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The Complete Guide to Trigger Points & Myofascial Pain


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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 • 900m 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.
Cartoon 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.

Photograph of the cover of an important text, Muscle Pain, by Mense and Simons.


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

  • Sep 22, 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.

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 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 (see below for more about the misdiagnosis of bursitis), 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:

Trigger point diagnosis is not reliable … but it also may not matter that much

Finding trigger points is tricky work for professionals and even harder for beginners. Consider this example from my inbox, from a husband trying to help his wife:

As I pushed down on the muscle knot, it literally moved from her lower to her upper back, ending up in the trapezius area. It looked like it was like out of horror movie. I’ve never seen anything like it: it was like the muscle picked itself up and rolled to another area on her back. I felt like I was playing a cat and mouse game with a muscle knot: it moved every time I try to apply pressure! When I finally cornered the knot I was able to successfully apply pressure, she stated when I did that she felt/heard a popping sound. Did I burst the trigger point?

I don’t know what he was chasing,62 but it wasn’t a muscle knot. They cannot be chased around under the skin like “a cat and mouse game.” They do not move or pop any more than a knot in a 2×4. Chant it with me:

Further along, I’ll explain exactly what trigger points are supposed to feel like, and what kinds of things can be confused with them, but the rest of this chapter is just about the problem of diagnostic reliability in principle.

It’s hard to treat what you cannot find

I go out of my way to warn chronic pain patients that trigger point therapy will probably not solve all of your problems. On the one hand, trigger points are surprisingly clinically significant and somewhat treatable, and thus they present a nice opportunity.

On the other hand, trying to find good trigger point therapy is like trying to find a good bagel west of Montréal.

Perhaps the biggest problem of all is that it’s tough to treat what you cannot locate … and it’s hard to find trigger points by feel, which is the only option most people have, most of the time. The reliability of trigger point diagnosis is in considerable doubt. A 2017 review of a half dozens tests of how well therapists agree on the locations of trigger points concluded that the “use of manual palpation for identification of MTrPs is unreliable.”63 Older reviews came to similar conclusions.6465 Ruh roh.

So are a lot of common diagnostic challenges, so “unreliable” isn’t actually as bad as it sounds — but it’s not easy, and probably only better practitioners can do significantly better than someone playing pin the tail on the donkey. With well-established official guidelines and proper training, diagnosis might be much better. But there are no such guidelines, and many professionals probably do not even know what the candidates are.

The review cited above, Rathbone et al, was forced to just “estimate” trigger point detection reliability from six studies, all barely adequate and too different from each other for pooling the data for a more stastically powerful answer (meta-analysis). A score of 0 is the same as random — diagnosis by coin flip — and a score of 1.0 is perfect. Trigger points came in at 0.36 to 0.54, or even a bit higher at 0.68 (when just looking for localized tenderness, the most reliable criteria they identified).

Those scores do technically mean “unreliable”! It’s far from perfect. And yet they are also not actually all that bad for a difficult diagnostic challenge. They represent “fair” to “moderate” reliability, even “substantial” for the best criterion.

The evidence strongly suggests that trigger point diagnosis is possible-but-difficult in principle and downright sketchy in practice: lots of misses are inevitable, which jibes perfectly with my observations in the wild. Despite the theoretical potential of trigger point therapy, few patients seem to be able to find good help for their trigger points, and the failure often starts with clinicians who don’t even know where to look for common trigger points, let alone a good understanding of best diagnostic practices. I have repeatedly encountered cases where well-trained therapists appeared to be oblivious to the most obvious of “perfect spots” for massage.

Clear proposals for diagnostic criteria exist and probably will, eventually, lead to better tests of better clinicians. A 1996 paper describes an (infamously) failed initial attempt to confirm that the diagnosis of trigger points is satisfactorily reliable, but reported greater success with practitioners who were better trained and prepared.66 Those authors also pointed that some diagnostic signs are more difficult to reliably detect than others, and some trigger points are harder to diagnose in some muscles than others. But, with training, therapists were able to achieve more reliable diagnosis. So maybe the reliability problem will ease over time.

Probably it will take a couple generations, though. If it happens at all. There’s been no major improvement in this department in the last 20 years.

Do we actually even need to locate trigger points precisely?

You need to know where a button is to press it. Some treatments for trigger points do depend on precision, dry needling especially and also the most common form of massage treatment, ischemic pressure (just pressing on the trigger point).

But there are other options, and just because it’s tough to confidently locate a specific trigger point doesn’t make it impossible to work with them in general. A steam roller driver does not need to know the exact location of every bump in his path to flatten them. You don’t have to know exactly where a trigger point is to treat it with massage. Heating pads, foam rollers, stretches, vibrations all cast a wide net.

You actually don’t even have to be certain that it’s there. A strong clinical suspicion of a trigger point can be enough reason to proceed with treatment. Indeed, as I’ve been telling patients and professionals for years, the best way to diagnose a trigger point is simply to try to get rid of it: if you treat a muscle as if there’s a trigger point in it, and the symptoms improve significantly, there’s your diagnosis! “Presumptive treatment” is fair game.


Where are the charts and diagrams of trigger point locations in this tutorial?

Seems like some diagrams would be a pretty useful tool for diagnosing trigger points, no?

Yes. And no.

If I had a buck for every patient who’s ever tried and failed to make sense of a trigger point chart … ! Trigger point reference materials can be useful, of course, but they also confuse patients as often as they help, and maybe more often. You can get lost fast when trying to find something in your anatomy based on a diagram and/or a description. Even the pros routinely get stumped by the complexity of the anatomy. Even if everyone’s anatomy was exactly the same — it’s really not — even the difference between hefty and skinny can throw you off. More about this below when we get into the huge challenge of identifying trigger points by feel.

So this tutorial is not an encyclopedia of trigger points and that is deliberate. My goal is to teach concepts and principles — the know-how, the skills, the tips and tricks that are flat out more useful than muscle-by-muscle descriptions of trigger points. I could tell you where the trigger points are … but I’d rather show you how to find them for yourself. It’s the ol’ teach-a-man-to-fish thing.

Precisely locating trigger points is somewhat over-rated anyway!67

That said … who am I to argue with market forces? There’s certainly a strong demand for trigger point reference material. Charts sell to therapists like hotcakes, and some of the most popular content on has always been my Perfect Spots series of articles. See Appendix A for overview of reference resources, and a quick reference guide to the Perfect Spots.


Slow checklist: a more detailed diagnostic checklist for myofascial pain syndrome

We can’t ever truly confirm a diagnosis of myofascial pain syndrome, because the condition itself is hypothetical. Any chronic pain that appears to be of muscular origin has other possible explanations (and less hypothetical ones). However, if there are enough of the right clues, it’s reasonable to suspect pain of muscular origin, and that suspicion can even be fairly strong in some cases. But “fairly strong” is about as good as we can get for a hypothetical pathology that has huge symptom overlap with other causes of chronic pain.

A “trigger point,” on the other hand, cannot be “diagnosed” (explained) at all: it can only be described. It’s just a sore spot, and only you can say if you have a sore spot! It’s just a symptom, a subjective experience. While it’s the most important symptom that suggests the diagnosis of myofascial pain syndrome, it’s only one.

This checklist is designed to help you decide how likely an MPS diagnosis is. As with the short list, check all that apply (but there’s no form to submit — the checkboxes are just a visual convenience). This can only be a guideline: there is (literally) no way to actually confirm this diagnosis. However, the more of these items sound like a good description of your experience, the more reasonable and useful it may be to accept a muscle pain diagnosis as a working theory.

If you checked off a bunch of these, congratulations: you have a little more diagnostic clarity! Myofascial pain syndrome is definitely maybe a possible explanation for your problem. And that’s about as sure as we can ever be.


Negative checklist: signs/symptoms that are probably not caused by trigger points

In the sections below I’ll discuss several explanations for pain that isn’t trigger point pain, but can seem like it. To start, here’s another simple checklist of symptoms that should lead you away from a trigger point diagnosis. The more these “sound like you,” the less likely it is that a diagnosis of muscle pain is meaningful, and a few of these items are deal-breakers that can eliminate a muscle pain diagnosis to a high degree of certainty.


Identifying your trigger points by feel: tissue texture and other palpable signs

It’s important to understand that you may or may not be able to feel a trigger point with your fingers, and it’s dazzlingly easy for beginners to get this wrong. Hell, it’s easy for professionals to get it wrong, as discussed above in the diagnostic reliability section. The only defense against this uncertainty is a lot of humility, and the best possible understanding of what you are looking (feeling) for, which is what this chapter is about. Two key points:

  1. If you can’t feel a trigger point, it doesn’t mean it isn’t there.
  2. If you think you can feel one, it doesn’t necessarily mean that it is there. It may be normal anatomy. Or abnormal anatomy but not a trigger point. Or your imagination!

Bear in mind, as always, that we’re dealing with a hypothetical critter here, the sasquatch of pathology. It may literally not exist as a palpable lump. Maybe not in everyone, or maybe not in anyone. We’re groping for the unknown here. But we’ll assume for the sake of practicality that there is, in fact, something there to find.

In any case, it’s important to try to link what can be felt with your fingers with symptoms and other subjective signs. A trigger point cannot be diagnosed by touch alone, but this section is mostly about “touch alone.”

Will muscles with trigger points feel tight?

You expect cacti and scorpions to be found in an arid environment. Similarly, tightness is the presumed natural habitat of the trigger point. Like most assumptions about the body, it’s not a safe one. The texture of muscle is not a great indicator of anything at all, trigger points or otherwise.

That sounds like heresy to most massage therapists, who are fond of telling patients that they are “really tight,” and the goal of all massage therapy seems to be to “soften” muscles, treating a firm muscle texture as the enemy. Early in my career I got interested in whether or not this made any sense, and, after a decade of experience and waffling, I decided that it did not. I’m not saying that muscle texture isn’t an indicator of anything ever — such absolutes rarely work out — but I don’t think it is a good or reliable one, and in particular it isn’t a reliable indicator that “here be trigger points.”

In a simple 2010 experiment, the hardness of the trapezius muscle (top of shoulder) was tested and compared with sensitive points, and before and after intense exercise.77 In a dozen healthy patients, sensitive spots were not just softer but the softest spots in the muscle — the opposite of the correlation that most people expect. In general, “a heterogeneous distribution of pressure pain sensitivity and muscle hardness was found.” So much for tightness or hardness mattering. Clearly muscle can be sensitive without it being obviously rigid. The conventional wisdom that “tight” muscles are a problem is probably a misleading oversimplification.

Different body types naturally have different textures that seem to be independent of myofascial pain syndrome or any other pain problems. I do have a Vague Professional Impression™ that lean and skinny folk are more likely to suffer from aches and pains than people with fatter and/or more muscular bodies, but it is vague indeed. Maybe it’s just easier to find trigger points in lean people, not that they are any more likely to have them.

A prominent trigger point can exist in a muscle that doesn’t feel the slightest bit “tight.” The trigger point itself may feel more like a denser patch of muscle than a hard nodule — a subtle difference! The tightened muscle fibers containing it — the “strap” — may not be an obvious “strap” or “cord” of muscle at all, but just an indistinct thickening. And that “signal” can easily be lost in the “noise” of the natural variability of muscle tone and texture.

For what it’s worth, I’ve also never observed any significant, lasting change in a patient’s tissue texture. People who show up for a massage with rigid cables of muscles often still have them as they walk out — even if they are delighted by a change in pain and sensitivity.

More detail about what trigger points might feel like

If it can be felt, it will probably feel like a lump of harder or denser tissue somewhere along the length of a tight “strap” or “cord” of muscle fibres, about the size of a lentil. The cord may twitch when the trigger point is stimulated. Subjectively, those signs will usually be associated with intense, distinctive, and familiar sensitivity… and relief after rubbing, ideally!

All of these details are variable, but the size is particularly unclear and unpredictable. The average trigger point seems to be about the size of a lentil, but every now and then you’ll get one that’s as big as an almond, and in rare cases in large muscles a trigger point may be walnut-sized. (Why such huge variation? Some ideas can be found below in the science sections.) However, in principle many trigger points may be just too small to feel — the size of a grain of sand, or even literally microscopic! Good luck finding one of those.

Trigger points can vary widely in size!

Some may be hidden in thick tissues, or under thick fat, of course. And others are surrounded by other bumpy anatomical structures that will throw you off. This may be an extremely common problem. When I massaged for a living, it was routine for people to ask me “What’s this? Is this a trigger point?” while pointing to a bone or some other completely normal anatomical structure. The normal structure could even be normally sensitive — or abnormally, for some other reason, confusing things further. A particularly common example are benign cysts, which often feel like they move a little between the skin and the muscle — definitely not a trigger point (see the negative checklist).

Some trigger points may be tiny, deep, and surrounded by larger, normal bumps! This makes them effectively impossible to identify clearly with your fingertips.

The key objective and subjective symptoms of a trigger point

Putting it together, here are the official key features, both objective and subjective:

Those are the four main things that can help to confirm a trigger point diagnosis: two symptoms that only a trigger point’s owner can confirm, and two signs that might be felt by whoever’s hands are on the job, yours or your therapist’s. I can’t emphasize strongly enough that these are guidelines, not firm rules, and none of them are diagnostic on its own.

That paradoxical “good pain” concept is particularly important. It’s not a euphemism or a joke. Trigger point pressure often really is both unpleasant and desirable at the same time: the “Ow! Don’t stop!” effect. Because of it, people often really crave pressure on trigger points — often much more than is wise, in fact. With sustained but moderate pressure or kneading, the tenderness usually gradually fades and the knot seems to melt or unravel. For better or worse, that imperfect and imprecise word “release” is usually used to describe this, and it is the goal of trigger point therapy. There will be much more about how to get so-called “releases” later. For now, there is more to learn about how to identify trigger points.

That’s no trigger point, that’s a ________

Thanks to reader SKY (her actual initials) for sharing this cringe-inducing tale of low palpatory intelligence, which demonstrates that even some professional massage therapists really have no idea what a trigger point actually feels like, and may fixate on any odd lump just like an amateur:

A massage therapist was giving a massage to a middle-aged man, and started working deeply on his upper ribs below his clavicle. She couldn’t get the knot relaxed at all, and kept working harder …

… until he told her she had found his pacemaker.

Oops. Many therapists wouldn’t have made that mistake, but unfortunately the story doesn’t surprise me much. For all the talk of “magic hands” and the much-touted palpatory prowess of massage therapists, this is hardly the only counter-example I’ve witnessed and heard of — it’s just one of the worst.

One more (really cool) example of a misleading bump: abnormal bone

There all kinds of things that can and do fool experienced therapists, because anatomy is simply chock-a-block with abnormalities. In fact, abnormalities are so common they probably shouldn’t even be considered abnormal. Specific anatomical variations are exceptions, but almost everyone has them: variation is the rule.81

For example: ossification, or the formation of bone where it doesn’t belong. (Technically an ossification is a genuinely abnormal pathology, a kind of benign tumour, and not an “anatomical variation,” but whatever — it’s just weird anatomy for our purposes.) In the CT scan image below, a portion of the patient’s quadratus lumborum muscle has been converted to bone.82 And not just any bone, but a substantial bone, about the size of a radius or ulna! It has grown between the pelvis and the spine, echoing the fibre direction of part of the quadratus lumborum muscle.

Holy unwanted bone, Batman!

Heterotopic ossification of the quadratus lumborum muscle. It’s surprising how often this kind of jiggery-pokery goes on in bodies.

This is an incredible image, and a dramatic reminder that not everything you feel in your body, or anyone else’s, is necessarily supposed to be there. And not every hard lump in muscle is necessarily a trigger point! This particular ossification was probably quite obvious to palpation, but I think you’d be surprised: what we think we feel is very strongly shaped by our expectations. It would not shock me if you gave such a patient to ten professionals to feel and an alarming percentage of them miss it entirely or misinterpret it: “Wow, you’re really tight in your right low back! Your quadratus lumborum is hard as bone!”

Yeah, literally!


“Out of nowhere”: a signature symptom of trigger points

Some chronic pain has an obvious cause and is relatively consistent: you know what’s wrong, and as long as it stays wrong, it hurts. Frozen shoulder, for example. Although we don’t know why shoulders “freeze,” the problem is definite, a diagnosable pathology. There are no “good days” when a shoulder is freezing: it hurts all the time, every time it moves in certain ways. It doesn’t come and go.

If it did, you’ve have to doubt the diagnosis.

Even when there is no known cause for chronic pain — which is typical with back pain, for instance — the pain is either constant, or predictable (hassling you predictably with certain activities).

Chronic but erratic pain is a major subcategory, and perhaps the hardest of all to understand. Why would pain come and go without rhyme or reason? Is there something wrong or ain't there? Some pathologies do act like that, and there are several reasons why pain might be erratic.

But in the absence of other obvious causes, trigger points might be the culprit. We have to beware of blaming any weird pain we can’t understand on trigger points, but sore spots that flare up unpredictably are a real phenomenon.

Trigger points have many intriguing clinical features, but the “out of nowhere” thing might be the most interesting of all: the tendency of muscle pain to both come and go without much rhyme or reason. Pain that surges without any obvious mechanism of injury. Pain you wake up with — common with neck cricks and back pain, and discussed more below. Pain that disappears for three days when, as far as you know, you didn’t do anything to help it disappear. And then it comes back, without doing anything to help it re-appear, as far as you know.

Trigger points lead to a lot of second guessing about what you could possibly have done to cause such a pain. Both patients and professionals often thrash around looking for “the” aggravating factor that supposedly explains flare-ups, whether they understand trigger points or not. For lack of a better explanation they often fixate on something relatively trivial that doesn’t really have much explanatory power. Whatever it is — stress, your golf swing, the phase of the moon — it usually can’t possibly explain all your bad days of pain. Instead it will “sort of” explain “some” incidents, but the bottom line is that you’re just not sure.

If you find yourself engaging in this kind of puzzled reaching for an explanation … you may have trigger points.

Erratic pain — the phenomenon

First let’s look at this only in terms of the clinical phenomenon: a description, not an explanation.

Whatever the cause, this is an extremely common experience, a pattern of symptoms that occurs much more frequently than diagnosis with any other recognized type of injury or pathology. If it’s explained by trigger points even some of the time, it’s important. So now let’s frame it in terms of our best understanding of what trigger points actually are: a micro cramp.

If trigger points cause pain like this, there are probably two main reasons why. First, they are probably irritated by many and/or unknown and largely uncontrollable factors — really just too many for mere mortals to sort out. (Which is hardly unusual in biology: we rarely have any idea what triggers an eyelid twitch, an outbreak of hemorrhoids, or ten thousand other problems large and small.)

Second, they are probably “sneaky” by nature, developing for quite a while before becoming symptomatic.

Sneaky trigger points: “latent” versus “active”

Trigger points can become quite clinically significant (sensitive only to pressure) before they start just hurting (painful without apparent provocation). When they are relatively young and minor, they are simply beneath our notice, a little sore to the touch, but otherwise painless. This phenomenon really helps to explain a lot of trigger point situations.

We distinguish between two kinds of trigger points, on either side of the threshold where they are impossible to ignore: “latent” when they only hurt when poked or otherwise provoked, “active” when they hurt without any obvious provocation.

Comparison of Latent and Active Trigger Points
Latent Active
stiffness, tightness stiffness, tightness
hurts only if poked hurts, period
sneaky, stealth mode “loud” and impossible to ignore, like your brother-in-law

Based on how common active trigger points are, it’s a good bet that latent trigger points are probably quite common. We grow them like little alien babies in our tissues.83 Most of them stay that way, causing only minor stiffness, and maybe not even that. Our population of latent TrPs is probably a factor in the creakiness we all feel as we age, even if we never get an active trigger point. But some of them … drum roll … in most people, sooner or later, some of them will become active. And when they do, it will usually happen quickly and with relatively little provocation.

It is when trigger points burst into activity that we have an episode of pain that seems to come “out of nowhere.” The thing is, it didn’t actually come out of nowhere: the trigger point was well developed already. It just woke up. It got pushed over a threshold.

The speed and ferocity with which trigger points “activate” is not always the same. Sometimes they become symptomatic slowly and erratically, minor at first, then worse and worse over time. At other times trigger points activate so fast that it is almost like an injury, and you could swear that you actually tore a muscle rather than just waking up a trigger point. In fact, both patients and professionals routinely mistake an activated trigger point for a torn muscle, but it’s usually clear that the onset of pain wasn’t nearly as sudden and severe as a true muscle tear. (More about telling the difference later.)

But most trigger points, most of the time, are in the baffling middle zone: they activate at moderate speed in response to unclear/moderate stresses, giving the appearance of an unreasonable amount of pain with no obvious cause.

Trigger points are irritated by too many factors to track

The other major reason that trigger point pain comes “out of nowhere” is that trigger points seem to respond to an incredible array of physical and mental stresses — so many that there is no way to know, on any given day, whether they will all add up to a problem. We don’t know what bothers trigger points any more than we know why sometimes muscles twitch or cramp at night (both fasciculations and night cramps are ubiquitous unexplained muscle behaviours).

A “rogue wave” is a rare type of large ocean wave that occurs when just exactly the right combination of other waves comes together to make a really big wave. (Satellite studies in recent years have proven that they occur regularly — and can be seen from space, yikes! Scary and neat.) Well, a bad flare-up of trigger point pain is sort of like a rogue wave: a bunch of aggravating factors coming together to make a really bad day for you.

There is no way to predict rogue waves … or trigger point flare-ups.

“The Great Wave off Kanagawa,” the classic Japanese woodblock print by the Japanese ukiyo-e artist Hokusai. Believe it or not, serious flare-ups of trigger points are a lot like rogue waves — the result of interactions between many complex variables.


Chasing pain: hurting in all the wrong places (referred pain)

I first heard the phrase “chasing pain” from Doug Fairweather, RMT, the owner and director of the school where I studied in Canada’s Okanagan Valley. Doug is tall and thin and speaks as precisely as an engineer but always gently, softly, and slowly.

“Chasing pain,” he explained to me, “is when you treat only the tissues where the pain is, and you forget to look for the source of pain in other places.”

It was an idea that I would return to many times over the years. The key to the surprising clinical importance of muscle pain is the somewhat spooky way it can cause symptoms somewhere else — a bit of neurological strangeness called “referred pain.” Referred pain makes trigger point therapy interesting and much more difficult.

Referred pain is felt some distance away from its cause, which can be any source of pain, like a trigger point. Or a heart attack! When heart attacks cause pain in the left arm, that’s the best-known example of this phenomenon: pain referral from the heart muscle to the arm. The problem is in the heart, and yet the pain is strongly felt in the arm. Interestingly, a trigger point in the chest musculature can cause the same referred pain, imitating a heart attack! I tell a story about a case like this below.

Referred trigger point pain usually feels like a wave of sensation spreading out from the trigger point, sometimes leading to an area where the discomfort is felt more intensely: the trigger point and a hot spot of referral, connected by a “bridge” of more diffuse pain. In some cases, there is no bridge at all, just the soreness of the trigger point and the aching in the referral zone, with no sensory connection between them — except that you feel the referred pain more vividly every time you press on the trigger point.

For instance, you might have a trigger point in the muscles of the forearm, near the elbow — but when you press on it, you feel pain in your hand and fingers! Like magic. Seriously: when you press on the trigger points near the elbow, pain spreads like a stain down the forearm and right into your hand … possibly feeling very much like annoyingly familiar symptoms in your wrist and hand. This is probably a common cause of a lot of so-called carpal tunnel syndrome.84 The symptoms are in the wrist, but their cause is in the forearm muscles (not the carpal tunnel).

Or, for instance, if I pressed on a trigger point in your neck muscles, you might feel pain behind your eye — a pain just like the headaches you get once every week or so. Trigger points are one likely cause of “cervicogenic headache” — headaches that are coming from the neck — which is one of the best common examples of referred pain. You might feel surprised or even alarmed by such a strange sensory connection, but it’s normal and common. Eye pain caused by pressing on neck muscles doesn’t mean there’s anything wrong with your eye.

Why does pain refer?

Although referred pain is odd, it’s quite easy to explain the basics of the phenomenon: the body is simply not wired for precisely locating internal irritation and injury. We literally just have a hard time figuring out where pain is coming from when it’s deeper than skin. The brain gets kind of confused, and interprets the pain as coming from a broad area of tissues. The science of it will be discussed in more detail later on.

Simple referred pain patterns. Most referred pain patterns are not all that interesting: usually the pain just spreads out around the trigger point, like egg white around a yolk. It’s often a bit asymmetric, spreading down and out to the sides (laterally and distally). I consider it simple as long as the referral zone is clearly “connected” and relativey close to the trigger point.

Consistent patterns. Referred pain patterns are surprisingly consistent from one person to the next. When people tell me that they get their headaches “behind the eyes,” I can show them a chart of the referred pain pattern that causes them so much misery. When I press on a common trigger point in the back of the shoulder and casually mention that it may cause pain in their elbow, clients are impressed.

“How did you know that?” they usually ask.

“Ancient Caucasian secret,” I tell them. “I looked it up in a textbook!”

Common referred pain patterns from trigger points were first published in 1953, and later in more detail. Exactly how this was determined will be revealed in the referred pain science section.

Bizarre patterns. Referred pain patterns can be quite bizarre. I have seen scores of peculiar cases. One women felt pain in her knee when pressing on her heel. Another had a hand that ached when I pressed on a trigger point in his shoulder. Time after time, pain in one part of the body turns out to be caused by a trigger point in another.

Chasing pain and misdiagnosis

Obviously referred pain can lead to misdiagnosis. Unfamiliar with referred pain patterns, all kinds of health professionals mistakenly assume that the problem is where the pain is. They “chase pain.” Either they don’t know about referred pain, or they underestimate it. One of the most dramatic cases of pain chasing I’ve ever seen was a massage therapist working on a severe anterior shoulder pain, for several weeks, touching only the front of the shoulder. The problem turned out to be entirely in the back of the shoulder, in a muscle called infraspinatus, which commonly causes anterior shoulder pain. (This case is described in detail below.)

Patients “chase pain” as well, picking at the site of pain like a scab, oblivious to the possibility that the problem might actually be coming from somewhere else. In the negative checklist section, I mentioned that an itch usually isn’t caused by a trigger point — but it can be. I know of a patient who suffered an itch between his shoulder blades so severe that he actually scratched an open sore on his back. After months of torture, it was finally completely relieved by massaging what appeared to be a trigger point just a few centimetres higher on his back than the itch. Talk about “scratching an itch!”

Trigger point pain routinely does not originate from where you feel it, and presents one of the greatest challenges for therapy. And so, referred pain will be explored in much more detail in both the science sections and treatment sections.

Referred pain from trigger points particularly leads to the most common of all trigger point misdiagnoses: mistaking trigger points for nerve pain


Nerve pain is overdiagnosed

  • Dec 26, 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.

How can you tell the difference between trigger points and nerve pain? Fortunately, it’s usually easy, because nerve pain is quite distinctive. Nerve pain is neuropathic pain, the symptoms that arise from damage to the nervous system itself, central or peripheral, either from disease, injury, or pinching.85 It usually causes more “electrical” sensations, much more tingling and numbness, and in much more specific locations than trigger points. This section ends with a reference chart comparing trigger point and nerve pain.

Usually. Not always.

In spite of these common differences, the number one general category of misdiagnosis for trigger points is probably nerve pain. Patients particularly, and poorly-trained massage therapists, are unaware that nerve pain is so distinctive and tend to assume that any strange, spreading pain is “some kind of nerve injury.” That assumption will often lead people to describe their pain with “nervy” language, which boosts the odds that health professionals will also be bamboozled by the difference. It all results in a great deal of barking up the wrong trees.

It’s certainly possible for trigger point like symptoms to resemble neuropathy and vice versa. I will discuss both. The next section is a case study of a woman with very “nervy” hip pain that responded brilliantly to trigger point therapy.

And one expert suspects that trigger points may actually be a type of nerve pain — that cranky nerves are actually the cause of myofascial pain syndrome — and I’ll discuss that much further along in “Quintner: ‘It’s the nerves, stupid’.”

But those are details. Our culture paranoia about neuropathy is the bigger story, and that’s what this chapter is about.

The fear of nerves (is stoked by pharmaceutical advertising)

This was a full-page advertisement for Lyrica in National Geographic magazine back in the 2000s:

“Do you feel burning pain in your feet?” the ad asks. “Or uncomfortable tingling, numbness, stabbing, or shooting sensations? If so, you may have nerve pain.”

Yes, you might. But there’s an excellent chance you don’t. Science says so!

This is one of the most common and understandable concerns that people have about pain, especially near any part of the spine. But it is also one of the most overblown of all common medical fears.

Neuropathy is less common than most people believe.86 Many other common causes of pain and altered sensation routinely fool patients and professionals alike into suspecting “some kind of nerve problem.”

And a large percentage of that so-called neuropathy is probably coming from muscle, and is relatively treatable.

Nerves are notorious

I once had a nice older Italian client who would ask me, over and over again, in a thick, sing-songy Italian accent, “So, it’s-a nerve, eh?” No, I would say, it’s probably just a muscle knot, not a nerve. And then — as if we’d never discussed it — five minutes later he would ask again, “So, that’s-a nerve, eh?” He was obsessed with nerves!

Like everyone else is. Sometimes it seems to me as if modern civilization is still getting used to the whole idea of nerves. When people talk about their nerves, it’s like they’re talking about something just revealed by science early last year. They speak with some awe about something barely understood … and feared. Nerves! It could be my nerves!

Nerves just make people nervous. The whole idea of nerves gets people anxious. Could it be a nerve? people are likely to wonder of any puzzling pain. Is this a nerve problem? What if it’s a nerve? Is something pinching my nerve? Something must be pinching a nerve!

The idea of a pinched nerve root particularly is deeply embedded in the public consciousness, but…

Nerve roots actually have a lot of wiggle room

It’s difficult to actually pinch most nerves, or nerve roots (as they exit the spine). Most nerves have generous “wiggle room.” In the lumbar spine, the holes between the vertebrae that nerve roots pass through can be more than a couple centimetres at their widest, while the nerve roots themselves are only about 3-4mm thick.92 If you stretch or compress the spine, the holes do change size a little — as much as 70–130% in the looser neck joints,93 a little less in the low back.94 But, even at their most compressed, there’s still plenty of room.

Schematic of nerve root wiggle room

On the left are the approximate proportions of a healthy nerve root & the hole it passes through (intervertebral foramen). When the spine is pulled or compressed, the holes get a little larger or smaller, as shown on the right … but there’s still lots of nerve root room.

There’s so much space for nerve roots that significant arthritic deformation and even major derangements of the spine (dislocations, spinal stenosis) can fail to actually cause trouble.9596

X-Factors: pinching in itself is not enough to cause trouble (seriously)

The idea of nerve pain is almost synonymous with nerve root pinching … but it shouldn’t be. Physical impingement is only part of the equation, and maybe it’s not even the biggest part. There are other factors.

Like oxygen. You need it. Your nerves need it. And both you and your nerves get cranky without it.

Fun fact: healthy, fully oxygenated nerves can be pinched firmly without causing pain, but oxygen-starved nerves are sensitive.979899100 Related: there’s also some good evidence that radiculopathy has more to do with blood supply than mechanical impingement.101

And why would blood supply to a nerve root be impinged? According to Jayson, “Vascular damage and fibrosis are common within the vertebral canal and intervertebral foramen.” Especially after surgery! But not only after surgery. The delicate capillaries around nerve roots seem to degenerate just like joints get arthritic, and that process is probably accelerated by biological factors like autoimmune disease, cardiovascular disease, and chronic low grade inflammation … which are in turn affected by diet, fitness, stress, sleep, etc.

Despite the fact that nerve-pinch pain is a thing, it’s clear that tissue health is probably the more important factor. The vulnerability of the nerve before it’s pinched is probably more important than the fact that it’s being pinched, or how hard. And how vulnerable the nerves are may be affected by factors that have nothing whatsoever to do with your back. Like your genes!

Nerve pain and sensitization

There are several mechanisms by which nerves can become pathologically over-sensitive after an initial insult, causing the pain to drag on and on. For a long time, no one had any idea why this happened to some people and not others, and it really does seem to be a binary phenomenon: either it happens or it doesn’t. Unfortunately, one likely explanation was identified in 2010: genetics102 That is not great news, but it is interesting and at least a little bit useful.

So chronic pain could be due to on-going irritation of nerve tissue, but it could also be entirely due to a malfunction of the sensory equipment itself. A fascinating possibility (and a rather bleak one).

The point: be wary of therapeutic wild goose chases looking for mechanical causes of pain. Neuropathy is definitely not just about pinching. The extended suffering could be caused by continuing irritation of a nerve root, or it could be entirely due to a malfunction of the sensory equipment itself.

The relationship to trigger points

Nerve pain may be about nerve vulnerability due to poor tissue health, what does that say about the role of trigger points? If anything? Maybe they are just another symptom of poor tissue health, or could they be a form of “poor tissue health” themselves. Could a nerve passing through/near muscle tissue rotten with trigger points be affected by that? I’m not sure how plausible it is, but it’s not inconceivable.

Maybe this is why treating trigger points sometimes seems to alleviate actual neuropathy.103 If so, it’s yet another way that a back problem that seemingly isn’t about muscle may nevertheless be helped by treating muscle. In this articulate passage, Clair Davies, author of The Trigger Point Therapy Workbook, discussed patterns he observed in private practice as a massage therapist. My experience has been similar over the years …

Interestingly, almost all the people who came to me had some kind of back pain along with whatever other pain complaint they had. Their previous treatments for back pain had always focused on the spine. I heard about injections of papaya or cortisone. People had usually been told they had arthritis or bad disks, or that their cartilage had been worn away. They’d been shown X-rays [or MRIs! — PI] that purported to prove it. Some had already had surgery, and frequently had as much pain after surgery as before. Typically, the surgeon’s last word was always that he was sorry but he’d done all he could. Then he’d renew their prescription for painkillers and dump them off on a physical therapist. I heard these stories over and over again. And over and over, I found that trigger point therapy gave them the relief they’d been seeking for so long. Had trigger points been the problem in the first place? Arthritis? Bad disks? In Travell and Simons’ Myofascial Pain and Dysfunction, I had read that you can have herniated discs and arthritis of the spine and still find that myofascial trigger points are the primary cause of your back pain.

The trigger point therapy workbook, by Clair Davies, p. 13

And here’s a neat thing: even if you do have nerve pain, treating trigger points may be a good way of helping it.104 This may occur because irritated nerves appreciate the improvement (stimulation) of tissue health in the vicinity.

Comparison of Nerve Pain and Trigger Point Pain
Nerve Pain Trigger Point Pain
often causes tingling and pins and needles almost never causes pins and needles
electrical, zappy, hot, burning deep, aching, stabbing
often causes true numbness may cause a “dead” or “heavy” feeling, but you will still be able to feel light touch on the skin
very specific pattern/locations sometimes quite variable
injured nerves tend to produce continuous symptoms, or symptoms that occur predictably in response to a certain movement or positiontrigger point pain, while it certainly can respond to position and movement, is usually more variable and unpredictable
only a few nerves in the body are commonly hurt although more common in certain areas, trigger point pain also routinely occurs everywhere else

I will explore cluneal nerve entrapment and meralgia parasthetica, both of which may be a little more likely to masquerade as trigger points than other neuropathies, but both of which also still often have clear symptoms of nerve botheration. And in the next section, an example of the reverse: pain that seemed a lot like neuropathy but probably was not.


Case study: a story about nerve pain that wasn’t really nerve pain

I once helped with a young woman who had “sciatica” — the mother of all nerve pinches. The sciatic nerve is the biggest single peripheral nerve in the human body. Allegedly, either her sciatic nerve, or one of the lumbar nerve roots it emerges from, was being pinched and sending hot zaps of pain down her leg.

That can happen, so it was a plausible diagnosis, and she came to me with it already accepted. She also had some tingling in her feet (much like in the magazine advertisement). The description of her symptoms did, indeed, sound a lot like nerve distress. On the face of it, it was likely that her sciatic nerve was irritated: true sciatica, a genuine neuropathy. Although nerve pain isn’t nearly as common as trigger point pain, it certainly can happen.

A couple things didn’t add up, though. For instance, she had no numbness at all — no dead patches of skin, which are highly characteristic of true nerve impingement. Instead, she had widespread “dead heaviness” in her leg, a different kind of numb feeling that is much more closely associated with trigger points than nerve pinches — and a lot more common.

I quizzed her carefully about the quality of her pain. She assured me it was “zappy” and “electrical” … just as you would expect of nerve pain, not knots. Yet something didn’t seem quite right. I couldn’t shake the impression that she was interpreting non-neurological pain as an electrical mainly due to her strong belief that she had a nerve problem. When you think a pain is nervy, you’re going to interpret, feel and describe it in nervy terms. Pain quality is an extremely flexible concept.

So I did some experimenting, and clinched the case:

This young woman’s “nerve” pain could be vividly reproduced by pressing on muscle knots that were nowhere close to any nerve tissue. Pressing on the side of her hip, on a gluteus medius trigger point several centimetres away from the sciatic nerve, she reported the same “electrical” pain flowing down her leg, even producing the weird, tingling sensations in her foot.

That largely eliminated a diagnosis of sciatic nerve impingement,105 and the symptoms were fairly easy to relieve. No more neuropathy.

A more likely story

In spite of spending most of my career trying to explain to people that pain has many possible causes, and that muscle pain is particularly common and sneaky, I was surprising myself — fooled, really.

The symptoms really did seem neuropathic to me at first. But the evidence was hard to argue with, and — in retrospect — I realized that I had been sucked in by “nerve anxiety” myself. In fact, her symptoms were strongly consistent with a diagnosis of muscle pain.

The only unusual thing about her case was that her muscle knots produced referred pain that was more similar to nerve pain than usual, and even that may have been a by-product of my leading questions when I still assumed it was probably a neuropathy. That is, I may have accidentally encouraged the use of terms like “electrical” by basically suggesting them to her: “Is it an ‘electrical’ sensation?” If allowed to describe her pain in her own words, she might have done so in a less “nervy” way.

I suspect that muscle knots are routinely doing this, fooling patients and professionals alike. Painful trigger points are definitely more common than neuropathy, and at least some of those muscle knots feel enough like nerve pain that they are easily mistaken for the more familiar bogeyman.

The take-home message of this section: do not underestimate the power of trigger points to cause pain that seems like a nerve pinch.


Morning symptoms: an uncomfortable daily mystery for many people

Lita Scruton of Ontario asked me for an explanation of her morning back pain:

Every morning I awaken stiff and have to get out of bed. No sleeping past 7am for me, ever! I can’t take the discomfort. So why during the day I can do anything, even exercise, and have no discomfort? Why do my muscles get so painful while I am suppose to be relaxed and resting? If I awaken during the night to use the bathroom they feel great, but any time after 6am, it is a whole different story. Can you help me solve this mystery?

You’re not alone, Lita! Countless people who are more or less pain-free during the day nevertheless experience significant pain and stiffness first thing in the morning, especially in the back.

People wake up with pain so much that it seems like sleep is almost dangerous. One of the top mechanisms of “injury” in my massage therapy practice over the years was, apparently, sleep! It is absolutely amazing how many patients came to me with a new pain and told me “it was just there one morning” or “I woke up with it.” Indeed, in many cases they are woken by the problem. I still hear this kind of story constantly from readers and friends. I’ve also experienced it myself many times.

There are four main ideas about what causes morning back pain, including trigger points and myofascial pain syndrome. (Of course! Why else would I be bringing it up here?) The other three are:

There’s also a lot of overlap with fibromyalgia in this sub-topic. Both known for their morning hijinks.106

Trigger points in the morning

Trigger points may be associated with morning pain in general, and back pain especially, because:

The paraspinal muscles seem to be particularly vulnerable to trigger points, for reasons no one understands. Just the way it seems to be.

And tissue stagnancy and postural stress seem to be a major cause of flare ups of trigger point pain, and both are an issue at night. We are often pretzeled into awkward positions in our sleep for long periods.107

Awkward positions (postural stress) can be quite painful, even injurious. Sleeping often involves slightly awkward positions held for periods long enough to cause sustained compression, pinching, and oxygen starvation of tissues (which may or may not have already been vulnerable or irritated). The dose makes the poison: it doesn’t have to be an obviously bad posture to cause trouble. Just a little awkwardness will do the job if you’re stuck that way for long enough. Although people can also carelessly tolerate postural stresses while wide awake, it’s more of a risk at night.

And awkward position or not, just being still is always inherently uncomfortable. We like to move, and sitting or lying down always gets unpleasant eventually. Forced immobilization is a potent torture method (as discussed in the chapter about the “bamboo cage”). Trigger points in particular may be aggravated by stillness.108 Morning pain could be a wake-up call (ha ha), letting you know that you have a bumper crop of mostly asymptomatic (“latent”) trigger points that flare up overnight. In Lita’s case, trigger points could account for the consistency of her symptom timing, and for the peculiar way in which she is fine at 6am, yet can’t stay in bed past 7am, but then is fine again by 8am as she gets moving and her trigger points calm down.

That’s the highlights of the role of trigger points in morning pain. I discuss all of these topics in detail in a dedicated article: 6 Main Causes of Morning Back Pain.


From the frying pan of injury pain to the fire of trigger point pain

If injury is the frying pan, trigger points are the fire. This section of the tutorial is important if you’ve been injured — or, in rare cases, if you’ve been injured and the only symptom of it is the trigger point pain in the region!

Trigger points seem to be a routine complication of most injuries. In the aftermath of an injury, pain and stiffness in the area often increase significantly. At first, this isn’t surprising: inflammation and sensitization are normal features of wound healing. Spasm and fatigue of muscles around the injury may also play a role, but already we’re venturing out on a scientific limb here (more on this below).

As time goes on, this halo of symptoms can get surprisingly persistent, severe, and sprawling. It gets harder to explain in terms of normal post-injury sensitization. It starts to resemble the phenomenon of TrPs: focal soft tissue soreness associated with aching and stiffness. And sometimes those symptoms can become so severe that the original injury becomes the least of your worries. In fact, trigger points can be such a serious complication of injury that they can overshadow it even in the early stages, obscuring the fact of an underlying injury and making it appear as though a patient has mysterious musculoskeletal pain.

This graph shows how trigger point pain increases & then dominates, even as injury pain is fading away.

Case study: a dislocated pelvis

I worked for a long time with a woman with a substantial pubic diastasis, or dislocation of the pubic bones: a serious injury that neither of us knew she had. All we knew was that she had an extraordinary amount of focal sensitivity in many muscles around the pelvis, with severe aching and stiffness. Her diastasis had never healed and was an ongoing source of pain, and yet she had no awareness of a primary problem at that location, which was just one of many sore spots, and not the worst one. Her widespread pelvic pain completely overshadowed the injury itself. I had been treating a complication, giving her temporary relief from the consequences of an injury — a game of therapeutic Whac-A-Mole, treating trigger points that were doomed to be re-excerbated by the unhealed injury.

Despite significant experience with severe trigger point complications, even personal experience, I never even considered the possibility of a serious physical trauma in the region as the ultimate source of her pain. I had underestimated the potency of trigger points as a complication of an underlying injury. Basically, her pelvic pain was so bad that I never dreamed that it had a single specific root. I feel bad about that oversight to this day.

I’m hardly alone in having made that mistake: patients and pros often don’t suspect that trigger points are a significant injury complication because they don’t think that trigger points (if they know about them at all) can possibly cause as much discomfort as the pain of an injury. But I have now come to the point where I believe that you should simply never underestimate the potential ferocity of a trigger point. This power that trigger points have to complicate and overshadow injuries is one of the most important things to understand about them.

When she finally got her diagnosis — with the help of a more experienced clinician than I was, plus some imaging — she was able to minimize irritation of the injury, finally giving it a chance to heal over the next 2-3 months. As it healed, it became possible to actually resolve the widespread muscle pain in her pelvis: every massage brought greater and more lasting relief, until finally one day she came in and said, “I don’t think we need to work on that anymore!”

How does injury trigger trigger points?

It’s an article of faith among trigger point therapists and experts that injury can “activate” trigger points — a trigger point trigger — along with almost any other source of stress:

Trigger points are activated directly by acute overload, overwork fatigue, radiculopathy, and gross trauma. Trigger points are activated indirectly by other trigger points, visceral disease, arthritic joints, joint dysfunctions, and emotional distress.

Siegfried Mense, David G Simons, and IJ Russell, Muscle pain: understanding its nature, diagnosis and treatment, 2000 p. 213

Like the Dude said: “Yeah, well, that's just, like, your opinion, man.” Unfortunately, it’s never clear what statements like that are actually based on. Probably because they aren’t based on much of anything.

There is not much direct evidence that trigger points are a complication of injury, let alone that they can be worse than the injury itself, as I have claimed. There is some weak/indirect evidence,109110 but mostly I’m willing to endorse the dogma based on my own personal and professional observations. It may be largely unsupported dogma, but it’s unsupported dogma that fits nicely with my own experience with this subject.

Here are a few possible explanations for why TrPs crop up around a healing injury and constitute a significant complication:

Whatever causes trigger points to form around injuries, we tend to underestimate their severity and their longevity. Never underestimate a trigger point! They can produce worse pain than most healing injuries, and for much longer. While some trigger points resolve spontaneously, or relatively easily with some treatment, they tend to last and last, especially around injuries — perhaps because even minor ongoing provocation from the original injury constantly “recharges” them. While most injury slowly but surely heals, trigger point pain often overstays its welcome.

How can you tell if the pain of trigger points has actually replaced your injury pain?

You should be suspicious when an injury doesn’t seem to be healing, with no other obvious complications, and the main persistent symptom is just simple pain, either the same or actually worse than the original.

Obviously there should be some obvious sore spots too, around and near the injury site (as opposed to the injury site itself112)

Most injuries improve steadily, even slow-healing sprains. In fact, healing usually accelerates: the better you get, the faster you get better. You should be able to detect that improvement from day to day with most injuries, and week-to-week at the worst. If you can’t, or if you are feeling even worse than before, then there’s a strong possibility that trigger points have formed and are now dominating the situation.

But there are exceptions, of course, other reasons why an injury is slow to recover:

But most of the time, an injury that seems to be hurting too much, months after it should have calmed down, has probably been overtaken by trigger points.

My own “into the fire” story (and a good example of the worst case scenario)

The worst outcome is that trigger points completely “replace” the injury, fooling everyone into thinking that the injury has not healed. And I have experienced this, unfortunately.

In addition to seeing countless cases like this as a hands-on professional, I also have lived it. In the summer of 2008, I seriously injured my shoulder. I tried to stop someone else from catching a Frisbee, which went badly. I was playing goaltimate (a variation of the intense Frisbee sport, ultimate, a sport that has wounded me many times). I leapt high in the air, tumbled clear over the other player who was catching the disc, and fell a couple of feet onto the tip of my shoulder … tearing my ligaments (an acromioclavicular joint sprain). It was a nasty injury. Unfortunately, months later, I was in more pain than ever.

And I was fooled by the persistence of pain. I thought the injury wasn’t healing. Ironically, after years of teaching this principle to my patients and readers, I failed to recognize that I had jumped out of the frying pan of injury and into the fire of trigger points. When I realized that was probably what was going on and I started presumptive treatment, the results were quick, dramatic, and lasting. Correlation is not causation, “but it sure is a hint.”114

The story of my recovery illustrates this fascinating principle of injury healing. For readers who are injured, please read about it — I can’t think of a better way for you to discover how this works. I tell the whole story in, Muscle Pain as an Injury Complication: The story of how I finally “miraculously” recovered from the pain of a serious shoulder injury, long after the injury itself had healed.


Could it be ________? Regional pains that trigger points get confused with

As mentioned repeatedly so far, trigger points are often mistaken for other problems. A toothache is probably usually caused by a cavity or some other genuine dental problem, but sometimes it is caused by trigger points in the muscles of the jaw. I have both seen and experienced clear cases of that phenomenon.

Many aches and pains are probably sometimes caused by trigger points instead of a more common and better-known problem.

But what about pain that is routinely blamed on the wrong thing, when the real explanation is probably a trigger point? Could your pain be caused by bursitis? A sciatic nerve pinch? A herniated disc? A little bit of time spent discussing these may help you clinch a trigger point diagnosis.

Here are some of the things trigger points are often and easily mistaken for:115

Could it be a muscle strain?

A muscle “strain” is any physical trauma to muscle caused by force applied along the length of the muscle: tensile force, that is, which is why they are also known as “pulled” muscles. Simple, right? You would think so, but there is a surprising amount of confusion, even among professionals, about exactly what “strain” means.116 Trigger points are often conceptually blended with “strain,” each one getting misdiagnosed as the other. Indeed, trigger points getting called “strains” may be one of most common of all trigger point misdiagnoses.

But for the purposes of diagnosis, the distinction is simple enough — and it needn’t even be controversial, because it doesn’t depend on any ideas about what a trigger point actually is. In fact, just the opposite: it’s the unclear cause and nature of a trigger point that distinguishes it from the extremely clear cause and nature of a strain. A strain is structural damage to a muscle with a clear, physical mechanism of injury. A trigger point has symptoms similar to a strain but without the clear trauma and damage. A trigger point isn’t defined by its mechanism, because we don’t know its mechanism. Indeed, we don’t even have to call those little painful mysteries “trigger points” — that’s just the most popular label.

But we can know a strain by its extremely physical cause, because we do know how that works. It’s terribly obvious. And if it’s not terribly obvious, that’s no strain!

Here’s a checklist of the signs and symptoms of a true muscle strain. If you can say, “Yeah, that’s me,” to all of these, then congratulations: you almost certainly have a real muscle strain, and you should probably stop reading this tutorial and go look at The Complete Guide to Muscle Strains However, many people who are diagnosed with muscle strain actually have trigger points.

But if you “woke up with it,” or the pain came on slowly over several days, or if it’s six months old, or if the pain isn’t consistently in one particular place … then we’ll be talking about other possibilities.

Could it be bursitis?

Probably not. If your doctor has told you that you have bursitis, I can practically guarantee that you don’t have bursitis. If it weren’t so disturbing, it would be amusing how often doctors diagnose any specific body pain they don’t understand as “bursitis.” But bursitis is quite a distinctive condition — it usually causes severe sensitivity to light touch, and often redness and/or swelling as well, and only in quite specific anatomical locations (where bursae live). See below for a nice little case study of bursitis misdiagnosis.

Could it be a herniated disc?

Probably not. This is the mother of all common misdiagnoses that scare people unnecessarily. Disc herniations are feared out of all proportion to their actual frequency or severity. The scientific evidence is strong that herniated discs are often asymptomatic,117 often absent in many people who do have pain,118119120 and recover spontaneously far better than people realize. They are clearly only one surprisingly minor factor in chronic low back pain. And yet doctors still overuse MRI to overdiagnose and overemphasize the power of herniations, despite an avalanche of official medical guidelines recommending against it.121

[Picture of an MRI machine.]

Medical care for the Jetsons?

For many years now, MRI scans have been the ultimate in futuristic medicine. But while these machines are miraculous in some ways, they can be worse than useless for diagnosing low back pain.

Most back pain should not be attributed to disk herniations. In many cases, trigger points in cranky lumbar paraspinal muscles are probably a more important factor and a more treatable one. They might be the entire problem, or they might just complicate an otherwise trivial herniated disc (or other relatively minor tissue issue). And treating them seems to be an effective way of indirectly helping other problems in the low back. Why? Perhaps, for instance, because healthy nerves in healthy tissues do not hurt (as previously discussed). Relieving trigger points may be a way of improving tissue health to the point where nerves are no longer sensitive to minor stresses.

If you have low back pain, please read The Complete Guide to Low Back Pain

Could it be a pinched sciatic nerve?

Or any other nerve? Usually not. Peripheral neuropathy can certainly happen, but it’s easily mistaken for trigger points, and will mostly have distinctive symptoms like sharper and shooting pain, tingling, numbness and weakness. As discussed in detail above, nerve pain is overdiagnosed in general — but in the back, buttocks, and legs, because the sciatic nerve is an extremely popular scapegoat. While it is possible for it to get painfully pinched by the piriformis muscle, there are three important considerations: (1) the piriformis muscle may stop pinching the sciatic nerve if its trigger points are relieved, (2) the sciatic nerve may be less sensitive to pinching if its muscular environment is healthier, and (3) piriformis trigger points themselves routinely cause pain to shoot down the back of the leg, a more diffuse pain than sciatica, more of an ache and a “dead, heavy” feeling instead of true numbness. But even if you’ve got zappy, nerve-pinched feelings, remember: relieving trigger points may still the best way to cope with it.

Could it be frozen shoulder?

Maybe, but trigger points are definitely a possible culprit. Frozen shoulder is not just “shoulder pain” — which often involves pathological joint contracture — but a lot of shoulder pain gets misdiagnosed as frozen shoulder. Even when shoulder pain does match the classic symptoms of frozen shoulder, it’s not necessarily a true frozen shoulder (that is, adhered or contractured). A significant percentage of cases seem to be caused by muscle dysfunction, which we know because it disappears under anaesthesia (which is fascinating).122 Trigger points are probably a factor in many of those cases. I could probably run out onto the street and find someone with this kind of pain before getting to the nearest intersection.

Frozen shoulder is most common among middle-aged women, and the biggest differences from trigger point pain are: a painful “freezing” stage during which pain gets inexorably worse over months, often with night pain, and then yielding to a relatively painless restriction of motion, especially reaching up and behind the back.

Could it be tennis elbow (tendinitis)?

There are cases of true tendinitis in the elbow, caused by overuse of the wrist and finger extensors, but there are also cases of unexplained elbow pain, many of which are probably just caused by fatigued and irritated muscles, which will usually means there’s some trigger points there generating most of the pain. Also, tendinitis and trigger points probably routinely co-exist. Things are complicated further by an especially distinctive, non-rare referred pain pattern from the anterior scalene muscle in the neck to the forearm, which can explain part or all of so-called tennis elbow.123 See Massage Therapy for Neck Pain, Chest Pain, Arm Pain, and Upper Back Pain and/or Tennis Elbow Guide for more information.

Could it be carpal tunnel syndrome?

Another difficult maybe. There is considerable potential for trigger points to lead to misdiagnosis of carpal tunnel syndrome. Yet again, trigger points causing CTS-ish symptoms are probably quite a bit more common than the genuine condition that they are imitating. And, as with the previous two items, trigger points are such a common complication of true carpal tunnel syndrome that it can be difficult to separate the two problems. “True” carpal tunnel syndrome involves impingement of the median nerve in the wrist with clear weakness in the hand, numbness and tingling in the thumb side of the hand, and nasty pain (especially at night). Yet many cases that actually have those symptoms nevertheless seem to respond fairly well to massage for trigger points in the forearms that refer pain to the wrist and hand, which raises the question, “Was it really carpal tunnel syndrome? Or was it CTS that was so aggravated by trigger points that treating them effectively solved the problem?” And then there’s the truly incredible number of cases of frank misdiagnosis, where the classic signs and symptoms of carpal tunnel syndrome are missing or barely there, but the patient gets diagnosed with it anyway. (And self-misdiagnosis is extremely common too.124) Such patients often obviously have strong referred pain, and a bit of forearm massage routinely solves the “carpal tunnel syndrome.”

Pain system dysfunction and malfunction (regional)

Complex regional pain syndrome (CRPS) is a terrible disease which causes extreme pain, usually mainly in one limb, due to massive and poorly understood dysfunction of the nervous system. The severity and general nastiness of this condition cannot be understated. I include it here not because CRPS is a possible diagnosis for less severe pain, but because — like many extreme phenomena — it tells us something about how the body works … or doesn’t work. It tells us that some pain is definitely caused by “malfunction” of the nervous system. Not a nerve pinch or lesion, but nerve failure. Many times in my career I have become convinced that a patient was suffering from some lesser form of CRPS, a neurological dysfunction severe enough to cause extreme misery, yet not bad enough to be diagnosed as true CRPS.

Trigger points invariably coexist with CRPS, and they probably coexist with any lesser form of pain system dysfunction. How can you tell if your pain might involve some “nerve freak out” in addition to trigger points? Since trigger points cause such an astonishing array of odd symptoms, unfortunately it is extremely hard to be sure of the difference between serious trigger points and neurological dysfunction. However, broadly speaking (and hopelessly oversimplifying), one of the key differences would probably be “allodynia” — the phenomenon of minor stimuli feeling much more painful than they should. If you are noticing things like cold, air movement, or the “pressure” of your clothing on your skin being painful, then there is a good chance that your problem goes deeper than trigger points.

Spatial summation and why some body areas might suffer more, like the neck and back

If five bees stung you all at once, in one small area on your back, you would probably think you had been stung by one super-bee (or maybe that you’d been poked with a cattle prod). Two sources of pain close together will be felt as one larger painful spot, a neurological effect called “spatial summation.” Pain perception is low resolution, and the brain can merge pains that are up to 20cm apart.125 This might explain why some areas of the body, like the neck and back, are more prone to pain: either the brain can “sum” more widely spaced sources of pain in some places than others, and/or some areas simply have more to sum up, more potential sources of pain. Just recently, research showed that we have roughly the same perceptual “resolution” for pain everywhere in the body,126 so the spine is probably not a common trouble spot because we cast a wider summation net there. This makes it even more likely that there’s just more to sum in the spine: lots and lots of tissues that often have minor problems, which get perceived as a smaller number of worse problems. This could also help to explain the chronicity of spinal pain: if you have “one” back pain problem that is actually coming from two nearby sources, you’re going to think you have the same back pain problem until both sources are relieved, which is probably going to take longer.

Claudication: the pain of impaired blood flow

Sometimes an artery gets narrowed or pinched off and causes serious pain. Although simple in principle, it tends to get missed in younger people, where it’s a relatively rare problem, and so the suspicion falls on other things. It also gets missed because “musculoskeletal” is a realm of medicine where circulatory function is rarely considered at all. But it should be an easy diagnosis: claudication tends to cause a deep aching pain exclusively with exertion (when tissues are demanding oxygen), which isn’t how most musculoskeletal problems behave.

Case study: a patient had sciatica-like leg pain for thirty-five years and was misdiagnosed many times until finally getting not only a definitive diagnosis but a cure.127 He had a narrowed artery (arterial stenosis causing “claudication,” the pain of impaired circulation). That’s it! Not even a difficult diagnosis in the end, really. There were some pretty glaring clues there that got ignored by a lot of people who should have known better.


Many other causes of chronic widespread pain that should not be ignored

  • Mar 25, 2022 — Science update: Added an interesting citation about the infectious roots of multiple sclerosis (Bjornevik).

In the last section, we looked at several ways that people can hurt or be injured in specific areas that are sometimes hard to tell apart from trigger point pain. In this section, I’ll review other causes of widespread chronic pain.128 As with any of the more localized pains, these can also be complicated by trigger points, or just co-exist with them, of course.

Trigger points often have something to do with unexplained chronic pain, but definitely not always. Sometimes trigger points are only a small part of a much more complicated picture, and sometimes they have absolutely nothing to do with it. The major premise of this book is that they are a likely explanation for a lot of cases of chronic widespread pain, and that treatment is cheap and safe enough that it’s worth trying before worrying about other possible causes.

But you shouldn’t ignore the other possible causes!

I am always delighted when people discover trigger points as a possible cause of their pain, because it gives them a legitimate reason for hope. But fairly often I am also alarmed to see people shoot past “hope” and into excited overconfidence. While trigger points can cause chronic pain, but there are quite a few other possibilities! It’s very important to bear that in mind as you troubleshoot a tough case.

What’s covered here?

I will review several possible culprits briefly, the ones that are the most likely to be confused with myofascial pain syndrome. For a more thorough and general review of causes of chronic pain, see 35 Surprising Causes of Pain: Trying to understand pain when there is no obvious explanation.

Topics covered in this chapter:

Topics covered elsewhere in the book:

And a few others that deserve at least a mention, but if I get into any more detail you will get bored, and no one wants that:

Pathological sensitization

Pain itself often modifies the way the nervous system processes pain, so that a patient actually becomes more sensitive and gets more pain with less provocation. It is basically a disease of hurting too easily, a basic cause of pain that can itself have a bunch of other causes and complications, including practically anything else discussed in this chapter.

Trigger points could actually be a symptom of sensitization. (This idea is closely related to Quintner’s hypothesis that trigger points are peripheral neuropathies: see “It’s the nerves, stupid.”) The only thing we know about them for sure is that they are sensitive spots. So how can you tell if tissue is “sensitized” but not crampy? There’s no way to know for sure, but the consistent absence of a taut band of muscle tissue would be one major clue (and there is no such consistent absence). Another clue would be a lot of sore spots that don’t seem to have anything to do with muscle at all (which is actually common).

See Sensitization in Chronic Pain: Pain itself can change how pain works, resulting in more pain with less provocation.

Psychological amplification

Not pain that’s “all in your head” pain, but pain that is seriously “aggravated by your head.” Sometimes the brain amplifies pain substantially as a consequence of stress, anxiety, and fear. Like an ulcer, there can be a physical problem, but one that is also sensitive to your emotional state.129 Sometimes, the brain’s interpretation of a situation becomes a major part of the issue, or even the dominant factor — still not “all” in your head, but “a lot” in your head. Like picking at a scab, the brain can become excessively focused on a pain problem. For more information, see Pain is Weird: Pain science reveals a volatile, misleading sensation that comes entirely from an overprotective brain, not our tissues.

Amplified pain exists near one end of a spectrum: acute pain with a clear cause is at one end, chronic pain driven entirely by the mind at the other. With a clear traumatic trigger, the diagnosis of “amplified” pain seems apt: there was a painful problem originally, it just got exaggerated by the power of the mind. The more disproportionate that amplification gets, the more like pure psychosomatic pain it gets…

All in your head: true psychosomatic pain

Pure “all in your head” chronic pain is probably quite rare. Unexplained chronic pain is routinely chalked up to psychology. “Patients often find themselves trapped in a zone between the worlds of medicine and psychiatry, with neither community taking full responsibility.” (O’Sullivan) But, in most cases, there’s a diagnosable cause that simply hasn’t been diagnosed yet, and that’s the main reason this article exists. Most pain patients need better diagnosis, not a psychiatrist.

But at least a few probably do need a psychiatrist. Pure psychosomatic pain probably does exist. Some tension headaches are good examples of how mental state can directly drive pain with no clear intermediate mechanism. Amplified pain is a much more extreme example, which makes it quite clear that psychological factors can dominate chronic pain. The phenomenon of functional neurological disorder (FND, formerly known as “conversion” disorder) makes it even clearer: seizures, paralysis, blindness, and other neurological symptoms in the absence of neurological disease.130131 Strange but true! If we can paralyze ourselves with our minds, we can probably make ourselves hurt too. In fact, pain might actually be one of the members of the FND family, just undiagnosable — because pain can have so many other causes (whereas seizures, paralysis, and blindness have relatively short lists of possible causes to eliminate, leaving only the power of the mind to explain the problem). No one really knows.

Even the most psychological of all cases of chronic pain very likely still have a seed, something that originally inspired the pain, making them extreme cases of “amplified pain” (see previous section), and not technically “pure” psychosomatic pain. But if the trigger is subtle enough, relative to the psychosomatic consequences, then it’s psychosomatic for all intents and purposes, and the trigger no more defines the problem than a grain of sand defines a pearl.

Pain with literally no specific cause

Some chronic pain is probably an emergent property of a big mess of synergistic stresses, with literally no one specific cause. The problem is having too many other problems! This is a good news scenario in the sense that it might be treated by relieving enough of the contributing factors … but bad news in the sense that it may be like fighting a hydra. Trigger points may just be one head of the hydra.

“Spasms”: cramps, dystonia, spasticity, etc

Trigger points are just one hypothetical muscle malfunction. There are others that aren’t so hypothetical (although they do remain surprisingly underestimated and underdiagnosed, as with trigger points). No one has any doubt about the cause of pain when they get a massive calf or foot cramp, but not all cramps are so obvious, and there are other types of insidious and uncomfortable muscle contractions. See Cramps, Spasms, Tremors & Twitches: The biology and treatment of unwanted muscle contractions.

Chronic low-grade inflammation and “inflammaging”

Chronic, subtle, systemic inflammation is a possible factor in stubborn musculoskeletal pain. It can have many underlying causes, from bad genes to mild autoimmune disease (including allergies), smoking or other severe biological stresses, chronic infections, and even just getting old (known as “inflammaging”). The greatest culprit is metabolic syndrome: a set of biological dysfunctions strongly linked to poor fitness, obesity, aging, and likely emotional stress and sleep disturbance as well. Along with sensitization, this is one of the major mechanisms by which other problems cause pain. See Chronic, Subtle, Systemic Inflammation: One possible sneaky cause of puzzling chronic pain.

Myelopathy and dysautonomia

An irritated spinal cord — usually irritated by being slightly pinched by a narrow spinal canal — can cause an astonishing variety of problems, including widespread pain, without ever clearly giving itself away. Symptoms can be in virtually any location in the body, if the location of the trouble is high in the spine. This can go on for years, bad enough to cause pain but never bad enough to be easily diagnosable.

Worse and weirder, intermittent irritation of the spinal cord may have some very weird side effects, “dysautonomia” — excessive sympathetic arousal, causing you to react as if stressed.132 Subtle dysautonomia from chronic mechanical irritation of the spinal cord is definitely a plausible, sinister, and thoroughly obscure explanation for some chronic pain and anxiety.

Referred pain

This tutorial has already discussed referred pain from trigger points in detail, but remember that referred pain doesn’t just come from trigger points! Anything that hurts inside the body — any tissue deeper than the skin — is difficult for the body to locate. Chronic, undiagnosed pain often involves referred pain from somewhere other than the location of the symptoms, and can have any kind of cause. Referred pain results in an amazing amount of barking up the wrong tree; this confusion will dominate your story regardless of whether trigger points or something else entirely is causing the referral.


Believe it or not, syphilis can fly under the diagnostic radar for ages, eventually manifesting primarily as chronic aches and pains. There’s often other symptoms too, but not always. It’s a rare cause of chronic pain, but it should be noted: some patients with unexplained chronic widespread pain probably have syphilis.

Facioscapulohumeral Muscular Dystrophy [early stages]

This is a fairly common and usually mild form of muscular dystrophy that often goes undiagnosed for decades, before it eventually causes enough weakness and atrophy in the shoulders and face to be identified. Until then, guess what it does? Makes your muscles sore! All of them! It specifically causes excessive delayed-onset muscle soreness. Biology is destiny, and this condition is a really good example of it. How many people out there are in that multi-decade period of wondering why they get so sore so easily, before finally being diagnosed with FSHD?

Autoimmune diseases [early stages]

The autoimmune diseases are a huge class of pathologies that can cause essentially any non-specific symptoms for a long time before diagnosis. It can take literally years for the situation to clarify. These are conditions like lupus, rheumatoid arthritis, celiac disease, inflammatory back pain (spondyloarthritis, a common cause of the phenomenon of morning back pain), and — the big one — multiple sclerosis.

There is a strong causal link between MS and Epstein-Barr virus, confirmed in 2022133 — so we know that the pathological wheels are in motion long before MS patients know they have MS. And we also know that weird aches and pains and other woes are extremely common in multiple sclerosis patients up to five years before diagnosis.134

The pains and spasticity of early MS are particularly likely to get mixed up with a diagnosis of myofascial pain syndrome. One particularly good and sinister example of an MS symptom that can seem like a trigger point problem: the “MS hug,” which feels like a painfully tight band around the chest. Although the feeling of constriction is the classic symptom, many patients also just experience widespread and erratic pain in the chest wall, probably from erratic, isolated painful contractions.

Cancer, especially lymphoma (cancer of the lymphatic system, lymph nodes)

Any cancer can manifest as a chronic pain problem, depending on the details of the disease (remember, cancer is a disease with many, many forms). But lymphoma is the most notorious generating extremely unpredictable symptoms for long periods before diagnosis. It will usually also cause other symptoms, like serious malaise and fatigue, but not always.

Fake diseases

Let’s wrap up with the silly stuff. There are literally dozens of bogus diseases that have basically been invented by cranks and quacks and the desperate-but-näive to explain chronic pain.

Whole books can and have been written about this, but here are a few highlights that are most relevant here, conditions that I consider to be unequivocal nonsense that are often invoked to explain fibromyalgia and/or myofascial pain syndrome. In a couple cases there might be a grain of truth somewhere under all the fertilizer, but too little to worry about here. Most of these are discussed briefly in my fibromyalgia guide, unless otherwise linked.


Hypermobility and Ehlers-Danlos syndrome

Some people are much more flexible than average — pathologically flexible. Hypermobile patients get hurt easily — especially repetitive strain injuries — and have a lot of chronic body pain135 Hypermobility seems be linked to all the bafflingly stubborn, strange medically unexplained problems: fibromyalgia, chronic fatigue syndrome, temporomandibular joint syndrome, and inflammatory bowel disease.

And there’s a lot of overlap with myofascial pain syndrome here too. Hypermobility could be one of the systemic issues that drives the formation of trigger points — perhaps just due to the exhaustion caused by constantly striving to stabilize joints, or just a neurological response to pain arising from other sources. We can only speculate: this has never been studied. All my comments on the relationship between hypermobility and trigger points are just educated guesses.

Let’s get a little more specific than “hypermobility.” There are many types of hypermobility, with a wide range of severity, from trivial “party trick” flexibility (“double-jointed”) with no apparent consequences — especially early in life — all the way to full-blown genetic disorders of the connective tissue with many serious medical consequences. There’s a huge grey zone in the middle of under-diagnosed and under-treated people, who are definitely having problems but may never figure out why or what to do about it.

Hypermobility spectrum disorders (HSD) are a group of conditions defined by joint hypermobility — unexplained joint looseness. HSD is a bucket diagnosis for people with symptomatic hypermobility, but without a connective tissue disorder that explains it, like Ehlers–Danlos syndrome or Marfan syndrome. Most connective tissue disorders are relatively obvious, but EDS can easily evade diagnosis, making it a prime suspect in many cases of chronic pain…

Ehlers–Danlos syndrome (EDS) is a closely related group of conditions with known genetic causes that includes hypermobility along with lax and fragile tissues that injure easily and heal poorly (especially skin), with many consequences. The most common form of EDS is hypermobile EDS(hEDS), and it is the only form of EDS without a known genetic cause. It’s tricky to distinguish hEDS from HSD.136 However, hEDS is probably associated with serious rheumatic diseases (i.e. psoriasis, ankylosing spondylitis, rheumatoid arthritis)… and this is fresh science and likely to be missed, “perhaps due to a lack of gravitas surrounding the hEDS diagnosis.”137

Given the musculoskeletal troubles that we know hEDS can cause, it is reasonable to guess that less severe hypermobility (HSD) may also be both clinically important and yet even less obvious.

So, hEDS/HSD is serious … but it’s not taken seriously. Even doctors who know about hEDS/HSD usually assume that it’s mostly a minor condition, and would definitely not refer patients on to a rheumatologist. And even if they did, many rheumatologists probably wouldn’t take it seriously either! They tend to be preoccupied with more obvious and dire cases.

To sum up, hypermobile-type Ehlers–Danlos syndrome (hEDS) is the most common major sub-type of EDS, a connective tissue disease without a genetic marker, which probably causes a lot of body pain but isn't well understood and is rarely diagnosed. And if you have joint looseness that cannot be explained by hEDS or any another connective tissue disease, that might be hypermobility spectrum disorders (HSD), which is probably almost as clinically important as hEDS but even less well understood and even harder to diagnose.

Taking hypermobility seriously

Collectively, HSD/hEDS are probably quite common. If you suspect that hypermobility could be at the root of your troubles, I strongly recommend that you do some more reading and pursue a diagnosis as best you can. Hypermobility is probably one of the major possible causes of extremely stubborn myofascial pain syndrome.

Or, much worse, the idea of trigger points could be completely unrelated, a red herring. I see a lot of people get very excited about the idea/hope that trigger points explain their pain, and might be treatable. In many cases that excitement is justifiable, and relatively harmless even if it’s wrong. But it could also send someone on a long-term detour from a correct diagnosis that they really need! Trigger points are probably a commmon complication of hypermobility, and so learning to treat them probably isn’t going to be a total waste of time … but for some hypermobile patients, chasing trigger points could be a pointless, harmful distraction.

Here’s a short checklist of reasons for clinical suspicion of HDS/EDS. This is not a comprehensive diagnostic checklist … just enough to give you a sense of whether you should be looking into this more deeply, and asking your doctor to take it seriously with you:

Obviously many people without hypermobility could check off at least a couple items on that list, and virtually every patient reading this book will at least claim the last one! But if you check off more than a couple, it’s probably time to learn more about hypermobility.

Manipulating hypermobile people is risky!

Massage for people with hypermobility has the potential to do real harm. While it’s possible that cautious trigger point therapy (de-emphasizing tissue stretch) could be safe and helpful, there’s still a hazard: joints may be too unstable to manipulate. Here’s an excerpt from a funny, poignant tale of a patient with Ehlers–Danlos syndrome who was injured by a massage therapist.138 (Great illustrations, too!)

So there I am, blissed out on the massage table. Zinfandel Blush has marinated me like a chicken breast. The whales are climaxing in the background, and I'm drifting off to sleep.

She runs her oil-covered hands down my arm and gives it a gentle tug to stretch out my stiff shoulder, but it just keeps coming, until pop! It comes clean out of the socket. Dislocated.

Now I am very much awake. Zinfandel Blush is screaming. She has literally just pulled a client apart with her bare hands.

The door is flung open and the manager comes running in.

The therapist's face is covered in tear-streaked mascara and her blonde top-knot is flailing around like my dislocated arm. The manager slams on the lights, hits the fire alarm and yells about an ambulance.

I am too preoccupied to explain that I dislocate frequently. That my jaw fell out in Costa just the other day. And that this, whilst being painful and understandably alarming to innocent bystanders, is a regular occurrence.

Obviously this patient was aware of the risk, and probably failed to warn her therapist just how vulnerable she was. (No massage therapist would ever incautiously manipulate a patient with EDS… right?!) But bear in mind that plenty of patients aren’t aware of their own condition, and halfway to an accidental dislocation is still a problem — certainly not therapeutic!


Case study: “Bursitis” strikes again!

Here’s an interesting anecdote from a patient misdiagnosed with bursitis:

I’ve had hip pain for three years, strong enough to keep me from sleeping at times. Usually it’s on the side of the hip, but now it’s gravitated to the front of the hip, the top of the leg, and to the tail bone area. The diagnosis has always been “bursitis,” but I’ve started to wonder about that, especially now that it’s spreading — bursitis doesn’t spread, I don’t think! I’ve had steroid injections, extensive massage and chiropractic therapy, sessions with a movement educator, even intramuscular stimulation therapy, and nothing seems to work, and no one has ever challenged the diagnosis. It was when the doctor told me to set up an appointment with his receptionist to “rip out the bursa” that I knew it was time to seriously look for another explanation.

Melinda Alltree, Vancouver

Bursitis misdiagnosis is particularly common in the location Melinda describes: right on the bony bump on the side of your hip. The bump is the greater trochanter of your femur, a sturdy anchor of bone just under the skin that most of the hip muscles attach to and pull on. There is indeed a bursa between the greater trochanter and skin, and it does indeed sometimes get inflamed.

However, actual bursitis as the primary problem is fairly rare, and when it does occur it tends to have the focal sensitivity of an infected hangnail. It is extremely sensitive. People with this kind of bursitis often have a hard time even wearing pants.

Pain in this area is usually more aching and diffuse, with no single clear cause, and we call this “greater trochanteric pain syndrome.” Like so many chronic pain problems, it is probably caused by a combination of several overlapping factors: maybe a little bursitis, but more likely gluteal tendinitis, referral from deeper structures, minor peripheral neuropathies, and/or (my contribution) … trigger points! It routinely co-exists with back pain, and so it also likely shares some roots of back pain, like … trigger points!

In my experience, almost everyone with trochanteric pain has a lot of sensitivity in their low back and gluteal musculature, as well as the trochanter itself. Referred pain to the lateral hip is common in this population of TrPs. My guess is that the trochanter is at an intersection of multiple referred pain patterns from several common trigger points, which goes a long way to explain the way the trochanter is always the epicentre but never the only thing that hurts in the area, always surrounded by a halo of more diffuse pain.

I’m pleased to report that Melinda sent me a happy update, letting me know that after seeking trigger point therapy, she enjoyed substantial and lasting improvement in her pain:

As for my trigger points, we worked for an hour on perfect spot no. 12 and perfect spot no. 6! It gave me great relief around the tailbone within two days. The pain is not totally gone, but almost. I still have the pain in the ‘bursitis’ area but have been able to lay on my right side every day now.

Remember, that’s after three years of hip pain! Another typical trigger point therapy success story, for whatever it’s worth.


Predictably unpredictable: trigger point symptoms are erratic by nature

Another predictable feature of sore spots is their un-predictability. They are predictably unpredictable, consistently inconsistent, and even inconsistently inconsistent. Trigger point pain may remain “stable” for two days, two weeks, two years … or forever. The spot that was sore yesterday may be fine tomorrow, or never fine again. The pain and stiffness associated with trigger points may waffle between annoying and disabling three times per day, or per week, or it may be maddeningly unrelenting.

Such diversity might make us suspect other causes and factors, and that is surely possible, but the core clinical feature of trigger points may be quite constant.

The uncertainty is baked right in. Myofascial pain syndrome is a syndrome — a collection of related symptoms. A trigger point is the theoretical cause of most MPS symptoms most of the time, and trigger points themselves behave strangely according to rules and properties no one fully understands. But there are also other common causes of pain that come and go and make MPS appear to be even more varied and colourful.

By contrast, injuries and most other common musculoskeletal conditions like tendinitis tend to be much more predictable: they more or less hurt in the same place, in the same way, in response to the same stresses. A tentative diagnosis of myofascial pain syndrome can sometimes be made on this basis alone: the symptoms are not like other common pain problems.139

Stubborn persistence and maddening consistency can also be a cardinal feature of trigger points. Once fired up, trigger points are quite capable of lasting literally for the rest of your life. Trigger points can be forever, in some rotten cases. Pain that lasts far longer than the healing time of any ordinary injury is one of the main things that should make you suspect a trigger point, because injuries get better and trigger points routinely don’t. They are one of the things that drives pain chronicity (and/or they are a major symptom of it).

But trigger points are equally capable of resolving at the same pace as a tissue trauma … or disappearing hours after appearing … or remaining exactly the same for seven weeks and then switching to the other side of your body … or driving you nuts for three years and then “suddenly” yielding to a new treatment attempt.

Getting the idea here? Myofascial pain syndrome could be called “uncertainty syndrome,” and trigger points can be quite flamboyant. For instance, they can also cause strange sensations. You can mostly thank your fallible brain for this: it struggles to make sense of internal pain without an obvious cause, and more or less literally makes stuff up, colouring the discomfort with our anxiety, confusion, and even creativity. No one gets poetic about the weirdness of a toe stub — the nature and location of the pain is straightforward — but they certainly do when trying to describe muscle pain.141 But with muscle pain, we don’t know what’s going on, and in many cases we literally can’t figure out where it’s coming from. Consequently, they can be felt almost everywhere, or even in patterns that shift from moment to moment or day to day. And it doesn’t help that they also come and go without apparent rhyme or reason.

Patients with myofascial pain syndrome often crave the “solid ground” of a concrete and specific diagnosis of damaged tissue, and who can blame them? The strangeness of trigger point symptoms can cause a lot of consternation and wild speculation. While doctors misdiagnose, patients worry. It is not uncommon for people to ask me if I think there’s any possibility that their trigger point could actually be a tumor or some other ominous condition. In their minds, only something rather serious could cause such strange and strong sensations.

Fortunately, it’s straightforward to eliminate most of the scary possibilities — not many behave much like trigger points.142 Serious medical problems can cause and aggravate trigger points, of course, but they also usually cause other, nastier symptoms that give them away. If your main problem is body pain, chances are good that there is nothing medically dire going on.


All the noise! Trigger points and crepitus (joint popping and more)

Active trigger points are associated with crepitus — a fun word that means tissue noise. Crepitus can refer to any crunching, crackling, popping, snapping or grinding noise or sensation in the human body. There are three common types of crepitus (at least):

  1. “Rechargeable” joint popping, as in classic knuckle cracking. Joints seem to pop more loudly, and more often, in painful and injured areas. This is by far the most common and obvious of the three types. Note that no one really knows, despite some commonly floated theories, what the $!#@&! joint popping actually is. It is fairly well established that it’s harmless, fortunately. In 1998, Dr. Donald Unger won an “Ig Nobel Prize” for diligently cracking the knuckles of his left hand only — never his right — every day for more than sixty (60) years. What did he find? “There was no arthritis in either hand, and no apparent differences between the two hands.… there is no apparent relationship between knuckle cracking and the subsequent development of arthritis of the fingers.”143
  2. Tendon snap — tendons may cause a snapping noise as they move over projections of bone or other bumpy anatomy. Common places for tendon snap are the shoulder and the hip. It’s possible that tendons snap more if the muscles attached to the tendons have abnormally high tone, and muscles in the state may also be more likely to harbour trigger points.
  3. Harmless breaking of adhesions between layers of connective tissue. Nothing important is actually breaking, but it can sound and feel strange, kind of like pulling up carpet. See the adhesions section for more information.

The increase in joint popping in troubled areas is fascinating, and I have an extraordinary example of it:

In February 2010, my wife was in a terrible car accident — while travelling alone in Asia no less — and she had a great deal of healing to do. One of the most obvious effects of the accident has been a spectacular increase in joint popping, particularly in her spine, near the vertebra she fractured. It’s impressive! And it has lasted for many years so far since.

She had never really popped her spine before the accident.

I have plenty of personal experience with this too. Not only am I a “triggery” person, but my joints are extremely noisy as well. Virtually every joint in my body pops regularly and spontaneously, some of them very spectacularly.

And many patients and readers have reported this phenomenon to me over the years. But I have yet to see anything in a medical journal and text about it; there is no scientific evidence about this, and not even really any theories. My own guess — and it truly is just a guess — is that the popping is linked to inflammation.

Don’t worry about it, or make it the least of your worries — simply consider it an interesting partial diagnostic sign of trigger points, something that crops up in the same conditions, perhaps for the same reasons. Wherever you have pain, you are likely to have both extra trigger points and extra crepitus.


What are the worst-case scenarios for myofascial pain syndrome?

Sometimes people have a hard time believing that their pain could be caused by trigger points because it’s just so bad. How could it be caused by “just” muscle? It’s important to understand that nearly any amount of pain and misery is possible with trigger points, and with the human nervous system in general. There are three typical types of worst case scenarios that I will cover in the next three sections:

  1. unusually numerous and/or severe trigger points (being a “triggery” person)
  2. rare but extreme cases where trigger points seem to “take over”
  3. isolated but fast and savage trigger point activation

Given the global reach of this tutorial and the ease of digital communications, I have had the opportunity to talk to people suffering from more horrible trigger point problems than I would ever have guessed existed. Working in relative isolation here in Vancouver in private practice, I might well have never come across such cases, even after decades of clinical work. But, thanks to this bustling website, I have now heard many tales of the worst of the worst. And the extremes are surprising and instructive…


Worst Case Scenario 1: Being triggery

Some people get more and worse trigger points than other people. If it gets bad enough, we have to start questioning the diagnosis: either it’s not MPS at all, or it’s “just” a severe complication or symptom of something else (and I’ll talk about that in the next chapter). But before it gets that bad, there’s a grey zone populated by people with seemingly classic trigger point pain… just rather a lot of it. I call these people “triggery.” They seem to be quite vulnerable to trigger points for unknown reasons.

Triggeriness by severity

I recall a reader from one of Canada’s eastern Maritime Provinces who, after giving birth, developed an alarming collection of hard, tender nodules in her abdominal musculature which seemed to have the typical diagnostic signs and symptoms of trigger points. But there was nothing typical about their severity! They weren't just tender: they hurt badly, constant superficial abdominal pain and cramping, her muscles so shortened that she could barely stand up straight, as though her body was doing a permanent sit-up.

These fierce trigger points didn’t go away in response to any therapy she tried, and she had certainly tried a lot of therapies before she spoke to me. She had been in pain like that for more than three years when I spoke to her.

In all other respects it seemed like a typical case of trigger point pain. For instance, the problem remained “regional” (confined to one region, not spread throughout her body) and her trigger points behaved like trigger points, just really nasty, stubborn ones.

There was probably some X factor in her case, something about her that predisposed her to this fate. But her doctors had certainly cleared her of any obvious diseases, and most cases of myofascial pain syndrome are probably aggravated and sustained by mysterious variables.

Her case remained unsolved for as long as I was aware of it (a couple years).

Triggeriness by quantity

The other way to be “triggery” is to just have more trigger points. Instead of being bizarrely intense, trigger points can also be bewilderingly numerous — an endless plague of more or less average trigger points. This is particularly striking when it occurs in the young: they seem prematurely aged by the profusion of pain and stiffness. I have seen many minor examples of this, and heard about more dramatic cases from readers around the world.

There are usually regional “themes” in these cases. The trigger points mainly affect an area like the low back, or the right side of the body. And yet there’s almost always a steady supply of unpleasant surprises in other areas of the body, and constantly shifting cravings for relief in different locations. One area dominates, but not entirely.

Such patients often present a great clinical challenge for a massage therapist: they seem to want to be massaged everywhere at once, and no sooner do you arrive in one area than they declare that the target has moved. In many cases, I suspect it’s not that therapist and patient are struggling to “find the right spot,” because there is no one “right” spot. Instead, the patient’s priorities and cravings are just shifting rapidly: as helping hands “take the edge off” one spot, the patient’s nervous system decisively announces the next-most-desperate area requiring attention.

An analogy: a back scratch can seem just perfect one moment, but then the next moment there’s a great urgency for the scratch to be “just a little lower.” I think the same thing happens in triggery patients, but the pain gives it a disturbing urgency. If you consider how strong the “just a little lower” feeling can be, how strong must it be in someone experiencing serious pain? No wonder it sometimes seems as though such a patient can’t be satisfied!


Worst Case Scenario 2: Meltdown cases

Pain can be broadly divided into acute and chronic pain. Acute pain is mostly an informative warning — “pull your hand away from the stove!” — and correlates strongly with genuine tissue threats. By contrast, chronic pain usually gets weird and noisy, an alarm blaring pointlessly — a problem with the alarm system itself, lots of noise and no meaningful signal.

No matter how the trouble started, a glitchy, “paranoid” pain system can take over and become the main problem. Another common way of putting this is that chronic pain may be a disease in its own right, a serious complication of any other kind of pain. There is no official name for this type of pain, but there are several candidates — discussed in The 3 Basic Types of Pain — and my choice is “primary pain”: pain where pain itself is the main problem, as opposed to being a symptom of the main problem. A lot of chronic widespread pain is primary pain.

But chronic pain can also be secondary, caused by an on-going tissue threat. The alarm blares on, but it’s not wrong. If the thorn is still in your paw, it’s going to keep hurting. Confusingly, this kind of pain isn’t “chronic” in the classic sense: it’s acute pain that never stopped. Technically, this would be called nociceptive pain,144 but that lumps it in with toe stubs and other transient acute pain. Again, there’s no accepted label for this sub-type of chronic pain. My choice is: “chronic-acute pain.”

So there’s this million dollar question for severe cases of myofascial pain syndrome: is it primary pain or chronic-acute pain? The worse it gets, and the longer it drags on, the harder it is to tell.

Severe primary pain where trigger points are not the main problem

At one extreme, there are many cases of severe chronic widespread pain that do not clearly involve trigger points. Trigger points are usually present to some degree in anyone with chronic pain, but they don’t always dominate, and sometimes they obviously take a back seat to a much more obvious primary problem — joint pain is a common example.

For unexplained chronic pain without a clear contribution from trigger points, MPS obviously isn’t a meaningful diagnosis. This is just a severe case of unexplained chronic pain where trigger points may be a trivial complication that would evaporate quickly if the true problem could be solved.

Most serious chronic widespread pain cases share many characteristics, regardless of their origins, known or unknown. As with any chronically painful condition, the pain of trigger points probably becomes difficult to distinguish from wholesale malfunction of the pain system — the sum total of all the neurology and psychology that controls pain perception. Speaking generally, then, what is strange and extreme and difficult about these patients might “simply” be the nature of primary pain. It isn’t so much that they have severe trigger points (though they probably do), but that their pain systems have been “fried” by the experience.

Severe chronic-acute pain driven by trigger points

And then there’s the opposite extreme: some severe cases of chronic widespread pain obviously are dominated by trigger points. That is, they started with regional musculoskeletal pain and no other obvious disease process but plenty of classic clinical features of trigger points, which eventually multiplied and worsened, but never changed character. Years later, there’s still no sign of any other explanation, and there’s still a lot of sore spots which might be continuing to drive the problem. Primary pain may have developed as a confusing extra layer of badness (sometimes called a “fibromylagic overlay”).

I would tentatively diagnose such a case as myofascial pain syndrome, just a nasty one: the worst case scenario, what I call a “meltdown” case. This is the overall worst example where an MPS diagnosis and the role of trigger points seems meaningful to me.

But of course that diagnosis would still be uncertain even with this clearest and nastiest of all possible cases of triggery chronic pain. Remember, we don’t know that “myofascial pain syndrome” is a valid diagnosis in any context! It’s just one of several possible labels for essentially the same medical predicament. For all we know there’s an undiagnosed, specific pathological process that is the true cause of all that distress, with sore spots just being a symptom all along. No one knows if it’s possible to have severe myofascial pain syndrome where a lot of trigger points are the main and only problem.

I will say this, though: some cases really seem that way.

But those are the extremes of clarity: for every case that obviously is or is not dominated by trigger points, there are many that are ambiguous.

“Someone is going to have to explain these patients to me someday”

In July 2009 in Las Vegas I encountered an interesting analogy to this puzzle at the Science-Based Medicine Conference. Mark Crislip, MD, an infectious-disease specialist from Portland and a former editor of, gave a superb presentation about “chronic lyme disease.” He made a strong case that it is a misnomer, a meaningless diagnosis, an overconfident attempt to label a pathology we don’t understand. On the one hand, it’s clearly not an active/chronic infection, not Lyme disease per se (because no bacteria). On the other hand, something is obviously wrong with these people. Dr. Crislip:

Some patients do seem to have some kind of post-infection meltdown. They don’t still have an infection any more in any sense that we understand infection. But someone is going to have to explain these patients to me someday.

And someone now has: ten years later, we do have a pretty good idea what causes so-called “chronic Lyme disease.” This horrible phenomenon, so mysterious and controversial for so long, is probably explained by toxins dumped into the body by the bacteria that causes Lyme disease. The infection is killed by the immune system… but its toxin persists, especially in our joints, causing arthritis and malaise.145

This is how I feel about patients with unusually severe cases of chronic pain where it’s just not clear whether the idea of “myofascial pain syndrome” is useful. Clearly they have had “some kind of meltdown,” and “someone is going to have to explain” them to me someday.

This has been just an introduction to the subject of severe chronic widespread pain. This tutorial frequently addresses the issue of myofascial pain that is more stubborn and severe than average. There are also some sections later that offer some ideas about management of these worst case scenarios — what on Earth do you do if you suspect that your “pain system” has been “fried”? — and about people for whom trigger points seem to be a biological destiny, an inevitable consequence of some other factor, known or unknown.


Worst Case Scenario 3: Quick-start trigger points

Worst case scenarios are not solely concerned with widespread, disease-like infestations of inexplicably severe and stubborn trigger points. As already discussed above in the context of the “out of nowhere” phenomenon, trigger points can also “activate” surprisingly quickly. Although not necessarily severe, occasionally — even in an otherwise healthy person, mostly free of trigger point pain — the onset can be both fast and severe.

Trigger points can fire up so fast that misdiagnosis is all but inevitable, especially if the severity is high, and especially if the pain is occurring in a vulnerable or “frightening” location.146 In my experience, the very fastest of these activations are effectively instantaneous, and the greatest intensities are enough to disable the region and cause more or less total mental distraction — enough pain to stop the show.

Of course, these fast-activators don’t conveniently strike when you’re actually on a massage table! And so I have had almost no opportunity to observe the onset phenomenon in patients. I have only seen the aftermath hundreds of times. After an initially savage peak of pain, most such trigger points fade down to being merely extremely uncomfortable, and are still throbbing away 2–5 days later when the patient finally gets to me. Back in the days when I was advertising my hands-on services, I would estimate that approximately “a lot” of calls from new clients were people in this predicament: recent, sudden onset of a nasty trigger point.

As always, my own “triggery” body gives me some good source material for understanding what life can be like for patients. To date, I have had two of my own quick-start trigger points severe enough to qualify as examples of “worst case scenarios,” so I know what they feel like.147148

Based on these two personal experiences — and on a handful of experiences with clients who experienced moderately fast/severe trigger point activations right on my table — I believe that it’s likely that fast-activating trigger points can also be fast-de-activating if treated immediately. The speed of relief may even be proportionate to how quickly you get to work on them. There is no evidence about this, of course, and probably never can be: such an ephemeral phenomenon would be effectively impossible to study.

Probably quick-start trigger points are most “dangerous” to the uninformed, who don’t recognize them for what they are, because of the fear they cause. Undoubtedly, the true worst case scenario is to not understand what’s happening, to panic, and to end up in the hospital sweating in agony and caught up in a diagnostic wild goose chase. I’m confident this does happen.


Part 3

The science of trigger points

It’s a little half-baked, but at least it’s not boring

What’s in a knot? Here’s the oversimplified conventional wisdom since about the late 90s: a trigger point is an unholy clump of contracted sarcomeres living in a nasty swamp of their own metabolic waste products. (Sarcomeres are the neato molecular machines that make muscles contract.) I’ll summarize with key references first, and then spell it out more formally in the next section, and then get into all kinds of interesting details.

Unfortunately, the conventional wisdom is an imperfect theory. Even healthy muscle physiology is still full of mysteries. For many years, this tutorial had an introductory section confidently titled “Triggers points are good, hard science.” Unfortunately, I don’t really buy that any more — the more you learn, the less you know. Trigger point science is still weaker and more controversial than the average trigger therapist realizes. Or is likely to admit.

Here are some of the pillars of trigger point science. They are not as sturdy as they could be, but they are also far from useless. (The footnotes here are particularly rich and creamy: carefully written summaries of the most important evidence about the nature and existence of trigger points, fully up-to-date as of early 2016. Quite a bit more detail on each key scientific paper is available if you explore the links.) This is the evidence we have so far that trigger points are a lesion in muscle tissue, and that the “contraction knot” idea is roughly correct:

That all sounds pretty good. Surely things like pictures and scans are great evidence? Smoking gun evidence, even? No, not quite as good as that, unfortunately: high-tech methods of imaging can be misleading.155 Like seeing Jesus in a piece of toast, even scientists striving to be objective still tend to see what they want to see, and find what they are looking for … so it’s all debatable. And it is being debated.

The pioneers of trigger point research still are and always have been medical specialists and scientists like Janet Travell,156 David Simons, and Siegfried Mense. Their famous textbooks were responsible for the first surge in awareness of trigger points in the 1980s.157 Trigger point therapy has respectable roots, especially as compared to many branded therapies and classic snake oils. It began as a medical idea, not a product,158 and many doctors specializing in chronic pain care are well aware of that.

Everyone agrees that something painful is going on, however. The science and nature of trigger points is interesting and sometimes controversial, but the existence and medical importance of a painful problem is not. Even the harshest critics of trigger points — and I know some of them quite well, and I respect them — are not denying that people feel like they have pain in their muscles, that there are sensitive spots. Muscles can certainly hurt. (That may seem like an odd thing to have to say, but “what actually hurts” is an important part of the controversy.159160)

Also, the reality of the bizarro phenomenon of referred pain is unquestioned: press here, but feel it there, sometimes rather dramatically. Detailed charts and databases of these patterns are widely available.161 The best online example is not very good, but here it is, for whatever it’s worth: The Trigger Point Symptom Checker.

But there are some extremely different interpretations of why people have these symptoms, and the main trigger point theory is much maligned by some truly smart critics. I have seperately published a freely accessible article about these concerns and controversies: Trigger Point Doubts. Its purpose is to take criticisms of the conventional wisdom about trigger points seriously — a respectful, thorough, and scholarly response. I am critically analyzing the “bath” to see how much and what kind of “baby” is really in there … but I am certainly not chucking the whole thing.

All that’s really at stake here is an etiologic model (how trigger points work) for a very real and unpleasant experience. My muscles hurt. My patient’s muscles hurt. There’s a world full of people with hurtin’ muscles! But there may also be some grave problems with how we explain and treat that phenomenon. If there are, I will report on them honestly — even if it undermines the living that I make from selling this book!

Despite all the doubts, for now the science sections below are going to stay mostly as they are: an exploration of the rather weird science of sarcomeres and trigger points as we have mostly known it over the last 25 years, the conventional wisdom. And that’s fine, as long as you know that it’s not holy writ, that “trigger points” are only an idea, and how they work is still ultimately a mystery. Almost no matter where the march of scientific progress takes us, it will be worth understanding trigger points in this way for many years to come (for the historical context if nothing else). And it will always be worth understanding sarcomeres themselves, because they’re just neat.

The dominant theory of trigger points spelled out in a little more technical detail

You could skip this section and it probably wouldn’t make any difference in your life. But it needs to be here, of course.

Until further notice, the most popular provisional explanation for the trigger point phenomenon is the “expanded integrated hypothesis.” It was presented in a 2004 paper by Drs. Robert Gerwin, Jan Dommerholt, and Jay Shaw.162 It is harrowingly detailed and technical. (Read the full jargon version just below, if you dare!)

When abridged and oversimplified, the “expanded” part disappears — it was mostly just filling in some details missing from the original integrated hypothesis (“a possible explanation”), which was put forward by Travell and Simons in the second edition of the Big Red Books in 1999, which was in turn an elaboration on the energy crisis hypothesis that debuted in the first edition in 1981. This has been a work-in-progress for quite a while.

Here’s a careful, finely tuned translation of the expanded integrated hypothesis:

Under some circumstances, muscular stresses can cause patches of poor circulation, which results in the pooling of noxious metabolic wastes and high acidity in small areas of the muscle. This is both directly uncomfortable, and provokes a section of the muscle to contract, powering a vicious cycle. This predicament is often called an “energy crisis.” It is a subtle lesion in the muscle. Research has largely been concerned with looking for evidence of a lesion like this.

And here’s the full-jargon version, quoted directly from Gerwin, Dommerholt, and Shaw. Brace yourself!

It can be hypothesized that the activating event in the development of the TrP is the performance of unaccustomed eccentric exercise, eccentric exercise in unconditioned muscle, or maximal or submaximal concentric exercise that leads to muscle fiber damage and to segmental hypercontraction within the muscle fiber. Adding to the physical stress of such exercise is hypoperfusion of the muscle caused by capillary constriction, which results from muscle contraction. Capillary constriction is increased by sympathetic nervous system adrenergic activity. The resultant ischemia and hypoxia adds to the development of tissue injury and produces a local acidic pH with an excess of protons. Acidic pH results in inhibition of acetylcholinesterase activity, increased release of CGRP, and activation of ASIC on muscle nociceptors. Acidic pH alone (in the absence of muscle damage) is sufficient to cause widespread changes in the pain matrix. However, the breakdown of muscle fibers results in the release of several proinflammatory mediators such as SP, CGRP, K+, 5-HT, cytokines, and BK that profoundly alter the activity of the motor endplate and activity/sensitivity of muscle nociceptors and wide dynamic-range neurons. Motor endplate activity is increased because of an apparent increase in the activity of ACh. This apparent increase in effectiveness is caused by several factors that include an increase in the release of ACh that is mediated by CGRP, presynaptic motor terminal adrenergic receptor activity, and by AChE inhibition caused by CGRPand acidic pH. AChRs are up-regulated through the action of CGRP, creating more docking sites for ACh, thereby increasing the efficiency of binding to the receptor. The taut band results from the increase in ACh activity. Miniature endplate potential frequency is increased as a result of greater ACh effect. Release of BK, K+, H+, and cytokines from injured muscle activates the muscle nociceptor receptors, thereby causing tenderness and pain. The presence of CGRP drives the system to become chronic, potentiating the motor endplate response and potentiating, with SP, activation of muscle nociceptors. The combination of acidic pH and proinflammatory mediators at the active TrP contributes to segmental spread of nociceptive input into the dorsal horn of the spinal cord and leads to the activation of multiple receptive fields. Neuroplastic changes in dorsal horn neurons occur in response to continuous nociceptive barrage, causing further activation of neighboring and regional dorsal horn neurons that now have lower thresholds. This results in the observed phenomena of hypersensitivity, allodynia, and referred pain that is characteristic of the active myofascial TrP.

So that’s the messy guts of the “working theory.” The next several sections all assume that it’s roughly correct.


Micro muscles and the dance of the sarcomeres

Muscle cells & the sarcomeres inside them, the potent little bundles of protein that power muscle tissue. Unknown artist.

A muscle is made of microscopic contractile units arranged in series and bundles: the sarcomeres, tiny packages of proteins (especially myosin II, a famous molecule). Muscles contract because sarcomeres contract. Sarcomeres are little microscopic muscles-within-muscles. Micro muscles. These molecular machines are the best example of how life is chemistry. Although proteins have many impressive properties and do many dazzling things, none is more defining of living things than this ability to generate movement.

Most molecular biology is amazing if you can understand it, but it’s hard to connect it to anything as familiar as wiggling your toes. Sarcomeres are an unusual explanatory bridge between weird science and ordinary experiences because they actually resemble the muscles they power. There’s something simple and beautiful about how they are so much like miniature versions of muscles.

You know how kids are so good at asking a chain of “why” and “how” questions? Sarcomeres are the deepest possible answer to the chain of kid-questions that starts with, “How do we move?” (Well, almost the deepest answer.163)

Sarcomeres are how chemistry lifts barbells. Without sarcomeres, your heart could not beat, your guts could not digest, your jaw could not flap. You would never blink, breathe, or burp. Sarcomeres are the ultimate source of all movement, and they are powered by the weird properties of mind-bogglingly complicated molecules.

And sarcomeres can probably screw up.

The clinical relevance of sarcomere mistakes

Understand sarcomeres and their failure, and you might be able to make sense of muscle knots. Specifically, troubled sarcomeres could explain four distinctive clinical characteristics of trigger points:

  1. why trigger points can be so stubborn
  2. why applying pressure often helps
  3. why stretching feels good (but also does not work any miracles)
  4. why they make your muscles weak and heavy

This sarcomere science here is a just a primer for beginners and a refresher course for professionals. I do want you to appreciate just how weird and wonderful sarcomeres are, but what we’re really interested in is how sarcomeres have a starring role in your muscle knots.

The size of sarcomeres

Cells are mind-bogglingly small compared to your hand, sarcomeres are mind-boggling small compared to your cells, and atoms and ions are mind-boggling small compared to your sarcomeres.

So sarcomeres are somewhere in the middle of the sizes of things.

They are long and thin. Wrap a few hundred of them together like a bundle of firewood, and then line that bundle up end-to-end with a few thousand other sarcomere bundles, and you’ve got yourself a single muscle cell or fibre. Even small muscles consist of millions of muscle fibres, and therefore millions of millions of sarcomeres.

Sarcomeres are much too small for microscopes. They are closer to the size of molecules than cells. Compared to a muscle cell, which is already crazy small — about 50 micrometres in diameter, so about 10,000 of them could fit in the width of a fingernail — a single sarcomere is like a grain of wheat in a silo.164

As small as sarcomeres are, they are actually quite large as molecular-scale structures go. Every sarcomere is a tidy little package of well-organized proteins, and proteins are massive for molecules, and sarcomere proteins are big even for proteins. And so: if you were the size of a water molecule, about a tenth of a nanometre, you could wander around inside a sarcomere like a mouse in Grand Central Station.165

How sarcomeres work

You wouldn’t think that a package of proteins, not even big proteins, could be all that clever, but never underestimate organic molecules: they have a way of being even more freakishly amazing than suspected by the last generation of molecular biologists — who were already pretty impressed — and sarcomeres in particular can make hardened researchers cry. People who study these things face the possibility of never really understanding their subject, of never even seeing a live specimen doing its thing — live sarcomeres cannot be directly observed.

Despite the limitations of observation, the internal structure of a sarcomere is reasonably well understood from decades of elaborate inference and increasingly sophisticated imaging, even at the nanoscale. We know they look kind of like forks:

A (ridiculously) simplified model of a sarcomere.

Imagine overlapping chains of proteins, like the tines of two forks meshed together. To contract the sarcomere, the proteins grab onto each other and pull, increasing the overlap of the tines. To relax, the proteins “just” let go.166

That’s the structure. What about the function? We do not fully understand how sarcomeres do what they do — we just know what they do in principle. The details of myosin activity happen at the atomic scale and at extreme speeds. It’s like trying to watch a fast-forwarded football game from orbit with a pair of binoculars. And so “the process by which myosin II generates motion is still not completely understood,” Hoffman explains in Life’s Ratchet, “but substantial progress has been made by structural (X-ray, electron microscopy), biochemical, flourescence, and laser tweezer studies.”167 It was the first molecular motor discovered, but “it remains [in 2012] one of the most enigmatic.” Many details of how the stuff works remain surprisingly controversial. And that’s all about pure myosin, a standalone molecular machine in a “test tube,” rather than the intense metabolic environment of living muscle.

Normally, sarcomeres throughout the muscle contract with amazing coordination, and they even sync up with the contraction of sarcomeres in other muscles — precise choreography of action spanning from the nanometre scale to the metre scale! That is, things that are happening at the molecular scale in your shoulder can be synchronized with sarcomere activity in your lower legs.168

Perhaps unsurprisingly, this system isn’t perfect. Sometimes, isolated patches of sarcomeres seem to contract independently of the rest of the muscle. They probably do so briefly all the time, the microscopic version of an eyelid twitch or a shiver. Or they may get “stuck” like that: a trigger point, a sustained, inappropriate contraction, a microscopic version of a long-lasting cramp or the spasticity seen in some diseases.

We don’t know any of this for sure, but it’s all plausible: almost anything that happens as a matter of course in biology can happen too much, too little, or at the wrong time. And we do have some evidence that patches of sarcomeres do indeed malfunction like this. Sometimes the proteins appear to grab onto each other, pull hard, and hang on — the tines of the fork jammed tightly together.

Many experts have speculated about the kinds of stresses that provoke such malfunctions — cold, overstretch, anxiety, trauma, pain, fatigue — but it’s all guesswork based on experience and speculation. No one really knows this stuff.

The next four sections will explore the four ways that the conventional science of sarcomeres and contraction knots could explain some of the clinical features of trigger points.


One: The vicious cycle (why trigger points are stubborn)

I once bit the inside of my cheek seriously while vigorously chewing a steak. I swore, rolled my eyes at myself, and carried on chewing … on the other side, carefully avoiding my bitten cheek, which was already swelling. It’s hard to avoid biting a swollen cheek, though. I hit it a couple more times that evening, and then there was a hard bite around 4am. I woke up with the inside of my cheek blaring pain at me. A flashlight showed a fat, mottled bulge deep in my mouth, back where the big molars are close together even with your mouth wide open: the hardest spot to avoid biting. The more I bit it, the more swollen it got, and the harder it was to avoid biting again.

That’s a classic vicious cycle: the worse it got, the faster it got worse.

It took five days to break the cycle. I chewed on dozens of ice cubes. I applied crushed up ibuprofen pills. I cut little pieces of plastic to wedge between the wound and my molars. I had a dozen infuriating setbacks where I bit myself again just as I thought it might finally be calming down. I finally won the battle of the cheek by upping the bite-avoidance ante so far that I basically stopped using my mouth for anything for several hours — I just did everything slack-jawed until the nightmare was over.

There’s a reason they are called “vicious” cycles. Positive feedback is a bitch.

The idea of a vicious cycle is the central pillar of the integrated hypothesis of trigger point formation. Trigger points are believed to behave much like that cheek wound: as they get more irritated, they become easier to irritate more.

Vigorously contracting patches of sarcomeres generate a lot of tissue fluid pollution, waste products of sarcomeres that are metabolically “revving.” Those “exhaust” molecules are then accumulating, causing pain and other symptoms, and exacerbating the trigger point even more. This is called a metabolic energy crisis, and it’s why I often refer to trigger points as “sick” muscle syndrome.

Of course, “the feedback loop suggested in this hypothesis has a few weak links,” wrote David Simons. Indeed, it does! He was well aware that several links in the chain of causation were simply guesses.

Diagram of energy crisis hypothesis diagram, very simple.

Extremely over-simplified diagram of the energy crisis hypothesis, which occurs in a tiny patch of muscle. Right or wrong, it’s been kicking around for a decades now.

Nevertheless, some research has helped the theory.169 Starting with a simpler study in 2005, and then a more thorough one in 2008, a group of scientists using “an unprecedented, most ingenious, and technically demanding technique” have confirmed that there really are irritating metabolic wastes floating in the tissue fluids of trigger points: “ … not just 1 noxious stimulant but 11 of them,” Simons explains. “Instead of just a few noxious chemicals that stimulate nociceptors [danger-sensing nerve endings], nearly everything that has that effect was present in abundance.”

Basically, the researchers analyzed tissue samples from in and around trigger points and compared them with healthy muscle tissue. The differences were readily measurable. The tissue of myofascial trigger points seems to be simply rotten with irritating molecules associated with inflammation, with pain, and with immune function.

No study is perfect. It has been criticized, but not credibly in my opinion.170

This vicious cycle isn’t infinite. Most are not. Something stops it, probably just the maximum contractile capacity of a few sacromeres. The worst TrPs are likely worse because of the involvement of more sarcomeres, rather than a vicious cycle that goes further.

Well there’s your problem

Many times I have worked with people and heard from readers who seem to have had trigger points in the same location for many years, even decades. The vicious cycle hypothesis may be able to explain that phenomenon.

Positive feedback also helps to explain why trigger points, even when they do go away, tend to come back. Any well-established trigger point probably has some reason to be there in the first place, a predictable response to some chronic biological stress or vulnerability. Even if it could be completely eliminated on Monday — the sarcomeres’ proteins restored to a healthy degree of separation, every trace of metabolic waste flushed away — there’s a good chance that the conditions that led to it in the first place will restore it by Friday.

But more importantly: it’s extremely unlikely that the swampy physiology of the trigger point can be completely eliminated in the first place. No matter what we do to it, there will probably be some excessive contraction left, the circulation at least a little restricted, and some junk molecules still floating around in that spot — which means that it’s still relatively easy for the trigger point to flare right back up again, just like a bitten cheek that has not quite fully calmed down yet.

This all squares well with the clinical experience of every patient and professional trying to help: it seems to be easy enough to make trigger points a little better, but extremely hard to make them go away completely. Trigger point stubbornness explained. Just like cheek bites.


Two: Good pain (why pressing on trigger points hurts like hell but feels like heaven)

Pressure on trigger points causes both good and bad sensations simultaneously because the trigger point is sensitive, but the pressure is (hopefully) helping it at the same time. It’s a weird mix. Good pain is an interesting subject because it’s a contradiction that somehow manages to make perfect sense when you experience it.

And it comes from inside of people. Therapists have not imposed the idea of good pain on patients the way that they have imposed many other common therapy ideas. Even massage newbies recognize the sensory paradox clearly. It’s always fun and interesting to listen to an inexperienced patient discovering good pain …

Oooh, wow … oh, that’s sensitive … but it’s good … but it’s definitely pain … but it’s definitely good …

typical patient discovering “good pain”

The contradiction between the good and bad parts of pain can be strong. Good pain may involve an undeniably nasty or gross or sickening component, a truly unpleasant quality, and yet still be accompanied by a distinct sense of relief, like an itch being scratched.

No one knows how a painful massage can also feel so good at the same time. This is a sensory phenomenon well beyond the reach of science: all we can do is speculate.

Taken at face value, the paradoxical sensation obviously implies that something good is going on despite the discomfort, and that we can feel the benefit. There are lots of painful-but-relieving analogies in medicine and biology.171 That’s certainly what good pain in massage feels like, but we can’t necessarily take that sensation at face value.

A satisfying sensation doesn’t necessarily imply successful treatment, unfortunately. Scratching mosquito bites feels great… but it’s not helping them! Trigger points may be like mosquito bites: it may feel terrific to massage those mysterious sensitive spots in soft tissue, but it may not be doing much to actually “release” or resolve them. It may be a purely sensory experience, the satisfaction of dealing with an “itch” that we cannot easily reach on our own.

Or, massage may actually improve tissue, directly changing trigger points, releasing and resolving them. There are many possible and plausible mechanisms for it, and some of them obviously could hurt and feel good at the same time. For instance, if the sarcomeres’ protein chains really need to be pulled apart, like children fighting on a playground, and focused pressure can do it, I can easily imagine how that would be painful-but-good, just like a stretch. Underneath thumbs and fingertips, trigger points spread like bread dough — a straightforward “mechanical” cure for trigger points, forcing sarcomeres to lengthen with overwhelming force, intense but helpful. “All right, proteins, break it up, break it up!”

Or it could be a mixture of changing the sensation and the state of the tissue. Changing sensation could feed back into tissue state. Trigger points feel like stuckness, but it isn’t obvious how to get unstuck. Deforming the tissue with focused pressure feels like a relief simply because it’s a change, like getting up to stretch after hours in an airplane seat. Anything that changes it — even painful pressure — is such a strong sensory relief that the trigger point becomes less irritated, which may be another vicious cycle buster. I think of this as “freshening” the trigger point — treating it with novel sensory input, basically. The trigger point changes because of the blast of fresh sensation, not because of any direct biological effect of the pressure.

Whatever’s going on, the intensity of the relief tends to generate some amusing comments. When you find a perfect spot in someone’s muscles and scratch it, people generally say things like:

Ah, the sounds of sarcomere separation! Clearly, trigger point squishing feels important.173

There’s one more likely mechanism of good pain …

Referred pain spreads the goodness: it basically just makes trigger point stimulation feel bigger, more important. Press on a small spot … feel it down your entire arm. Wow! Impressive! Even though it’s just a thumb on a trigger point, it feels as though that “itch” is being scratched throughout an entire region. Referred pain amplifies the good pain effect — or the bad pain effect, if the pressure is too intense!


Three: Tightness (why stretching is appealing but underwhelming)

This section summarizes an important basic concept about trigger points and stretching. There is much, much more information about trigger points stretching later on in the tutorial in the main stretching sections, including a more detailed version of this section. “Tightness” was already discussed in more detail above: If you have trigger points, will your muscles be “tight”?

Terms like “tight” and “stiff” are imprecise and do not clearly describe anything other than a sensation.174 But people with trigger points sure do feel tight and stiff and are forever trying to stretch it out. Patches of contracted sarcomeres seem to be an obvious and quite literal cause for that sensation. If we run with the mini-cramp theory, it has an obvious implication: a trigger point must actually reduce the elasticity of a muscle, like a knot in a bungie cord.

Killer analogy, right? If I stopped there, it seems like quite a compelling image that artfully connects the dominant idea of how trigger points work with an incredibly familiar human symptom. It “explains” how trigger points restrict range of motion … which in turn strongly implies the need to stretch them out. Such stories are the bread and butter of many professionals who want to put a little science sauce on their work. But if it sounds too good to be true, it probably is.

A knotted bungie cord actually still works well. Only a small segment of the cord is affected. Only at the extremes of stretch are you going to see any difference in the maximum length, and that much is probably true of knots in both muscles and bungie cords.

And good luck stretching the knot itself! The stretchiest parts yield, not the knot. Again, this is also probably true of muscle.

Indeed, the flexibility of muscles does not in fact seem to be much affected by trigger points, despite all the symptoms of stiffness and tightness, and it turns out that stretching is — although super popular — actually a surprisingly lame method of treatment that seems to have almost no consistent or lasting effect on trigger points. Probably because stretch probably can’t fix contraction knots. If indeed that’s even what a trigger point is!

Nevertheless, it’s still possible that more and worse trigger points in certain types of muscles could restrict range of motion, and stretching might help, especially if augmented in certain ways. Maybe. I’ll return to this bungie-cord analogy in more detail later, along with much else about stretching.

Meanwhile, there’s one more clinical feature to try to explain with sarcomeres …


Four: Weakness (why muscles with trigger points might be weak)

“Weak as a kitten”? This shameless use of cuteness highlights a common symptom of trigger points.

People with trigger points don’t just report feeling stiff and tight, they also report feeling weak. Their muscles feel “dead” or “heavy.” Just as with stiffness and tightness, it’s not clear whether this symptom is just a sensation, or if it represents measurably reduced contraction power. It could also be a co-morbid symptom: it’s possible that something that causes actual weakness/heaviness is also causing trigger points.175

Trigger points might cause muscle weakness. We have almost no hard data on the topic. A 2011 study did identify weakness in people with trigger points compared to people without … but the side of their bodies with trigger points was no weaker than their other side.176 That’s hard to interpret, and the study had flaws, chiefly that they only looked at people with latent trigger points (sensitive only to pressure). And that’s literally the only study on the topic I have found. So it’s basically still a scientific question mark with the usual “more study needed” disclaimer.

But it does suggest that weakness could be a non-specific effect, a suppresion of vigour throughout a region rather than reduced power only in affected muscles.

Speculating then, there are two clear mechanistic reasons why a contraction knot might weaken a muscle:

  1. Sarcomeres in the trigger point are already mostly or entirely contracted, so they cannot contract much more. At least that segment of the muscle might be knocked out of service.
  2. Sarcomeres on either side are a little more stretched out, and elongated sarcomeres have a harder time initiating contraction. Contracting over-stretched sarcomeres is like trying to pull away from an intersection in fourth gear. This is an easy phenomenon to demonstrate, and it’s well known to anyone who has spent any time in a gym: muscles are much less powerful when stretched out. For instance, a barbell that you can’t budge when your arm is straight may be relatively easy to lift if you pick it up with your elbow already bent. That’s sarcomere overlap working for you!177

These ideas seem tidy, and for many years in this book I presented them as fact rather than speculation. Eventually I noticed that I was assuming that a contraction knot can make a significant difference in muscle function … after arguing exactly the opposite with the knot-in-a-bungie-cord analogy just above.

A few small patches of contracted sarcomeres may have a negligible impact on the overall flexibility or power of a muscle. It could cause the feeling of a bit of weakness without having much practical importance: a 1% loss of strength perhaps, barely measurable. Any loss of less than 5% would be hard to confirm.

And it’s also possible — but pure speculation — that weakness does occur more profoundly when more and worse trigger points occur in shorter muscles, where their effect is less “diluted,” where the contraction knot constitutes a larger percentage of the mass of the muscle. Strength losses could conceivably be quite dramatic and easy to measure, if only someone did. This phenomenon could be going on every day for millions of people around the world... and we could go another twenty years without any researchers actually studying the right patients in the right way to confirm it.

Or maybe having gross, sensitive spots in your muscles just makes them feel weak, without actually being weak.

If trigger points cause muscle weakness (the feeling or the fact), should you try to strengthen your muscles? This question will be addressed much later in the tutorial, in the treatment sections: Strengthening: should you take your trigger points to the gym?


Everything we just discussed … in a few bullet points

  1. Trigger points may be kept alive by a vicious cycle of super-contracted sarcomeres producing lots of irritating waste molecules.
  2. Massage may help to relieve them by mechanically “squishing” the condensed sarcomeres apart, and/or by forcing waste metabolites out of the trigger point, and/or by relieving the sense of “stuckness,” and probably other factors.
  3. The contracted sarcomeres are like “a knot in a bungie cord,” which makes them seem like something you should stretch out—but it doesn’t really work out that way.
  4. Overextended sarcomeres might make muscles weak and unresponsive to stronger resistance training, but it’s quite unclear if this is actually the case.


Triggers for trigger points: what makes patches of sarcomeres go haywire?

Why would sarcomeres get into trouble in the first place? What is their “damage”? What’s wrong with the system?

The exact mechanism by which the tissue becomes dysfunctional is simply unknown, and it may be a long time yet before we do understand it. Yet again we must resort to guessing based on a pathetically imperfect combination of anecdote and speculation. There are many factors that may “trigger” your trigger points — forces and factors and physiological circumstances that seem to be associated with trigger point formation and aggravation. But I’m restricting this to proximate causes, rather than general biological vulnerabilities.

Obviously there’s more to discuss if we expand the scope to “slower” trigger point triggers, the general biological vulnerabilities, the perpetuating factors — “factors that make trigger points stubborn” — especially the the medical ones.


The all-powerful acne analogy

Trigger points are like pimples in many ways. If you have skin, you’re going to get pimples. Some people will get more and worse pimples than other people.

Likewise, if you have muscle, you’re going to get sore spots … maybe more and worse than other people.

I spoke to a reader on the phone about her severe myofascial pain syndrome. It quickly became clear that she was fond of speaking about everything in the strongest possible terms — a drama queen.

“I have five hundred injuries,” she said, for the third time in as many minutes.

“What do you mean by ‘injuries’?” I asked. “I’m not sure what you mean. What’s injured?”

“I have five hundred trigger points,” she said. Ah! She was defining a trigger point as an injury — what an interesting self-perception! But a trigger point is no more an “injury” than a pimple is an injury. Oddly enough, however, pimples and trigger points are surprisingly similar. Let me count the ways:

Both are common. Practically everyone has a few pimples, and a few trigger points. A few lucky people have very few of either. And a few unlucky people have a lot.

Both are pathological lesions. Just like pimples, trigger points are small dysfunctional (sick) patches of tissue. A pimple is a tiny infection, which is certainly quite different than a trigger point. But the infection occurs due to subtle dysfunction of the organ (skin is often considered an organ in physiology). Skin is mostly quite good at preventing pimples, but sometimes it fails. Pimples occur here and there when something goes a little bit wrong. If it starts to happen a lot, something has gone wrong: the skin isn’t working quite right, and bacteria take advantage of the situation. Similarly, muscle tissue is mostly good at not getting trigger points. But trigger points occur when something goes a little bit wrong. They are pathological lesions (if the integrated hypothesis is accurate).

Both come and go without much rhyme or reason. Some risk factors for both problems are known: muscle fatigue will provoke trigger point formation, excessive chocolate consumption may give you a pimple bloom. This book offers quite a lot of detail about why trigger points may occur. However, in both cases, no one really knows why some people get so many, and others get hardly any at all.

The take-home lesson is that trigger points are a more or less inevitable by-product of having muscle. They may be a natural consequence of the physiological trade-offs involved in having high-performance tissue that can’t possibly work perfectly all the time, under all conditions.

Both muscle and skin are much more volatile and biologically intricate tissues than most people suspect. They are “busy.” They do a ridiculous amount of work, just like the more obviously complex tissues. Nothing in the body is really inert or boring — and muscle and skin are much more complex than we can easily see, and muscle is a particularly extreme performer.181

Like computers, muscles work miracles … but they also have bugs.

The only way to completely eliminate acne from the human experience would be to ratchet down a bunch of other vital, delicately balanced skin functions — a cure worse than the disease. On the other hand, if you tried to make skin work any better than it already does, you might well end up with ten times as many pimples, and your purpose would be defeated! Evolution and biology are full of capricious compromises like this — if the system goes too far this-a-way or that-a-way, it falters.182

It’s amazing how much mileage I can get out of the acne analogy. 😃


The evolution of muscle pain: does muscle “burn out”?

Muscle tissue is full of evolutionary compromises, just like the rest of biology. It has gotten roughly as performant as evolution can make it — but at the expense of longevity. It can’t do what it does forever without some consequences. Performance with a price. This might be one reason why muscle pain becomes more common as we age. In short, we burn out.

It’s not the years, honey. It’s the mileage.

Indiana Jones

All high-functioning systems — both evolved and engineered — usually walk a fine line between performance and blowing up, and typically get glitchy with age. For instance, all flying machines tend to require intensive maintenance and are more or less constantly falling apart and being put back together. The SR-71 Blackbird, the world’s fastest jet throughout its career, tolerated such extremes of heat at full speed that its parts needed room to expand, and so they were engineered to be loose-fitting on the ground, resulting in all kinds of challenges and risks, such as leaking expensive and explosive jet fuel like a sieve — by design!183 Fortunately, most of us never have to try to fly that thing. But we all have to use our muscles. And muscle is probably just as volatile — performing on a razor’s edge between performance and vulnerability, and with potentially significant consequences even to relatively minor deviations from operational norms.

As a simplistic example, with a strong shot of adrenalin, you can get super-strength out of muscles simply by recruiting every muscle fibre to contract simultaneously, instead of only a few at a time as with the relay system we normally use, even with quite strong contractions.184 We only use that trick in emergency, because it’s more expensive than a rare Pokémon card: it’s possible only by paying a price of rapid and extreme muscular fatigue. Consider how sore you can get from just overdoing it a bit at the gym, from doing 20% more push-ups than usual. Imagine how sore you’d be if you completely exhausted all the fibres in a muscle group. Yikes!

So natural selection picked the balance point: if we were any stronger in general (via this mechanism), we’d get tired too fast and be food for big cats and such; any less strong, and we’d be too weak to run fast in the first place.

Never mind athletics or emergencies: every day, your muscles have got to pull off routine miracles of fast, responsive, intense function in the course of performing surprisingly ordinary actions. That function almost certainly comes with biochemical costs. In a general way, this is probably why we get trigger points — glitches in an impressive but imperfect system, nonlethal and uncomfortable trade-offs for having muscle that is rather amazing in terms of performance. If I’m right, we should expect to see trigger points crop up (activate) at their operational extremes. While hard data on trigger point risk factors doesn’t exist, anecdotally they do seem to form in response to things like over-exertion, cold, injury, as well as anything that challenges the system as a whole like stress, sleep deprivation, and smoking. Systems fail and misbehave when challenged.

Muscle performance, trigger points, and aging

This evolutionary theory of trigger point formation is also somewhat consistent with the age of victims: children don’t suffer from trigger points anywhere near as much as adults. Myofascial pain syndrome seems to get rolling in the 20s, peaks in the 30s and 40s, and then levels off, not getting much worse in subsequent decades of life. This generally follows the same trend as arthritis, except that it doesn’t get relentlessly worse like arthritis.

Why don’t the young get trigger points? Evolutionarily speaking, it would be a Very Bad Idea for your muscles to fail by your 20th birthday simply because of their high-performance in your teens! Not a good system! Nature would be hard on people born with that system, with the usual effect: more getting eaten, less breeding.

But past the age of 20? In the barbaric mists of history, your ability to survive into a third decade was largely a moot point, evolutionarily speaking: most everyone passed on their genes by that point (probably a few times), and you were worm food by 30. Evolution didn’t “see a need” for muscles that could perform miracles with no consequences for three decades. So we didn’t get them. And we never will. Broadly speaking, this is why aging sucks: once you are past breeding age, you are in biological territory that evolution can’t touch.185

And why would muscle pain settle down in the later decades of life instead of getting a bit worse every year, like arthritis? My hypothesis: because they challenge their muscles a lot less! Gravity and systemic inflammation carry on chipping away at joints even in the laziest octegenarian, but their muscles get a lot of rest.


Referred Pain Science (basic)

Referred pain is not just a muscle pain phenomenon. It occurs in many contexts in biology, and it’s a great example of how trigger points are not a quack diagnosis. The fact that trigger points “send pain” to remote locations sounds all spooky and weird, but is completely consistent with well-known referred pain phenomena that occur in other medical situations. For instance …

How does referred pain work?

Bear in mind that there are probably several answers. But the dominant theory of referred pain (and the one more or less adopted by Drs. Travell and Simons) is the “convergent projection” theory. I’ll summarize it here — just the basics, I promise. But then I will cover it in detail in the advanced section following this one, where it is contrasted and compared with many other theories of referred pain.

Convergent projection theory is based on the idea that there are usually more nerve endings in the tissues than there are receptors for them in the spinal column. Therefore, signals from several different nerve endings all pass their information on to the one receptor in the spinal column — that is, they converge. This results in a low fidelity of pain perception, in which your brain literally does not know exactly where the signal is coming from, because there’s more than one choice. Thus you experience a kind of “maybe here, maybe there” pain in an indistinct fog spread out over the area where all the source nerve endings are. That blurry area of discomfort is the “projection.”

Psychological context is important to referred pain, too: if you just stabbed yourself, then your brain knows that, of all the possible places the pain could be coming from, it’s probably the knife wound, and thus a sort of simulated accuracy is achieved. Thus referred pain tends to be much more pronounced when the problem is internal and non-obvious.

Fun fact! How trigger point charts are made

Referred pain patterns from trigger points were originally studied by injecting muscles with pain-causing substances. The strong pain in the muscle quickly and clearly “lights up” the area of referred pain associated with that muscle. When the signal is that loud, it’s pretty easy for the experimental “victim” to trace out the referred pain pattern! In this way, it’s been determined quite accurately what the typical referred pain patterns are for each muscle. Although there’s variation, the patterns are remarkably consistent. The studies have been repeated many times using a wide variety of pain-causing injections: bradykinin, substance P,186 capsaicin (the stuff that makes chilies hot!), and serotonin. It’s been done with electric shock as well.

They’d have to pay me quite a lot to participate in one of those studies … 😮


Referred pain science (advanced)

Professionals and keen patients will want to dive into the science of pain referral in considerable depth. It’s both fascinating and enlightening. Although convergent-projection theory dominates, there are actually several theoretical models of how referred pain works, and no doubt there’s some overlap.

Four Referred Pain Theories
Convergent-projection many signals, one receptor the dominant, simplest theory, but it fails to explain several key features of referred pain
Central sensitization irritated spot in the spinal cord explains much that convergent-projection cannot, but fails in other ways
Hyperexcitability combine the previous two theories and throw in a long delay in sensitization makes sense to combine the previous two theories, but the delay concept only explains the slowness of referred pain in animals, which doesn’t occur in humans
Thalamic-convergence complex brain misinterpretation of signals plausible, probably a factor, impossible to prove

Convergent-projection remains the most powerful explanation of referred pain. It dates back to the work of WA Sturge in 1888, when he noted that attacks of angina are associated with a persistent tenderness in the skin that remains after the attack, like an echo, and the idea has had a rich history of development since then.

There are just a lot more nerve endings than there are receptors for them in the spinal column, and so there simply cannot be a one-to-one mapping (but it’s a weirdly difficult “basic” thing to prove). Signals from many different nerve endings, with different physical locations in your tissues, all end up passing their information on to a smaller number of receptors in the spinal column — the “convergence.” This is a lower resolution of pain perception in which your brain simply does not know exactly where the signal is coming from. It’s like your brain is getting a multiple choice question about where the signal came from. We experience a kind of “maybe here, maybe there, not totally sure” pain in an indistinct fog spread out over the area of source nerve endings — the “projection.”

The brain has to use other information to narrow down the list of options. If you just stabbed yourself, then your brain can sensibly infer that, of all the possible places the pain might be coming from, it’s probably the knife wound, and thus a sort of simulated accuracy is achieved — sort of the way smartphones use both GPS and maps of local WiFi networks to increase accuracy.

Not only is convergent-projection the dominant theory of referred pain, it is the explanation of referred pain put forward by Travell and Simons in their famous texts, and then again by Simons and Mense as recently as their 2000 text, Muscle Pain. Certainly the convergent-projection model makes a bunch of evolutionary sense.187

However, there are some problems with the theory. For instance, it can’t explain why referred pain is often delayed by several seconds in humans, or even minutes in some animal experiments. If the theory is correct, there’s no reason why there would be any delay.

It also can’t explain one of the most important features of referred pain: it mainly goes in one direction. Referred pain tends to spread from the source in predictable directions (which is useful and important to know). For example, pressing on a trigger point in the tibialis anterior muscle almost invariably causes referred pain that spreads distally, towards the toes; referred pain moving in the opposite direction is virtually unheard of. If convergent projection was the only mechanism involved, then irritating nerves at either end of the referred pain zone should “send” pain to the other end — because the signals are all going to the same place.

Finally and vexingly, the threshold for the local pain stimulation and the referred pain stimulation are quite different! Convergent projection should not care; any pain should result in referred pain. But one of the most distinctive features of trigger points is that a trigger point can be extremely sensitive to pressure without causing referred pain, until you press harder. There’s no obvious reason why milder and stronger stimulation wouldn’t be equally subject to convergence.

Nothing’s ever straightforward, is it? The convergent-projection model clearly does not have all the answers. And that’s why there are multiple theories.

Central sensitization theory basically says that pain can drive greater sensitivity to pain — a vicious cycle.188 Interestingly, some types of pain may be more prone to doing this, and — so predictable — muscle pain specifically may be one of the culprits.189 The sensitization process is complex, and affected by many variables. For instance, once again, mental context probably has considerable importance: the brain can literally instruct pain receptors to be more or less sensitive to stimulation depending on whether or not your brain perceives a threat, like turning up the volume on an annoying radio station if you think the news might be important — or turning it down if it isn’t. If the brain wants more information, it can dictate greater sensitivity way out at the edges of the nervous system.

Pain is an opinion on the organism’s state of health rather than a mere reflexive response to an injury. There is no direct hotline from pain receptors to ‘pain centers’ in the brain. There is so much interaction between different brain centers, like those concerned with vision and touch, that even the mere visual appearance of an opening fist can actually feed all the way back into the patient’s motor and touch pathways, allowing him to feel the fist opening, thereby killing an illusory pain in a nonexistent hand.

Phantoms in the brain, by VS Ramachandran and Sandra Blakeslee

Brain-o-centric sensitization is probably a factor in virtually all chronic pain cases. It broadly explains the effectiveness of placebo and the importance of fear and reassurance in health care. But there are probably also dozens of other inputs to the equation, such as the presence or absence of numerous hormones and molecules around the nerve. The basic idea is that, if you have distressed tissue, not only do the nerve endings at the trouble spot have the potential to get “loud,” but the receptors for those signals in the spinal column may also get sensitized. In fact, an entire patch of spinal column could get sensitized — and thus you might start getting a bunch of amplified signals from the surrounding area.

This sensitization process would not be instant or consistent, so it may explain much about referred pain that convergent-projection theory cannot: the delays of referred pain, and the way referred pain often only kicks in with stronger pain. However, it does not explain the way referred pain spreads in predictable one-way directions.

Hyperexcitability as a mechanism of referred pain is a subcategory of sensitization, referring specifically to the phenomenon of sensitization of receptor fields in the spinal cord. It’s based mainly on animal studies showing minutes-long delays in referred pain, which has to be accounted for somehow. Humans do not experience such huge delays with our referred pain; we get fairly quick delivery of referred pain, within seconds. Delayed referred pain in animals still wants an explanation, but that key feature of the hyperexcitability theory really doesn’t seem to apply to humans.

Thalamic-convergence theory is an almost irritatingly simplistic way of just chalking up the whole business of referred pain to a brain fart, and then saying it in Latin. The thalamus is a sensory Grand Central Station — it is believed to both process and relay sensory information selectively to other parts of the brain. You could say that it “thinks” about your sensations, and then decides if other parts of the brain have a need to know. So, information about possible threats arrives (“converges”) on the thalamus — lots of information passing through a neurological bottleneck. It’s probably not a true bottleneck, not an actual loss of signal (like there is with a larger number of peripheral nerve endings than matching receptors in the CNS); but it still a bottleneck, because the whole goal of thalamic processing is sensory triage, to boil all that input down to what actually matters. Something’s going to get lost, which is actually the functional goal. Sometimes, what gets lost is some more spatial resolution.

Does the brain get confused by a bunch of pain signals and you get a not-very-clear impression of where your pain is coming from? Can the bewildering complexity of the brain explain these wacky referred pains? Maybe. Probably. But experimentally eliminating the other theories, and finding evidence for this one instead, hasn’t happened and it might never happen.

Bonus elaboration on the thalamic-convergence theory. The spinothalamic tract is a relatively well-understood nerve superhighway between the skin and thalamus with nerves that are neatly mapped to the geography of the body — somatotopic organization — and is responsible for our ability to precisely locate superficial pain. But it has a larger, lesser-known sibling, the spino-parabrachial pathway, which is not neatly mapped (stomatopically organized). It processes much broader receptive fields, and — this is where it gets cool — it sends those signals to areas of the brain responsible for aversive emotions.190 In other words, it loosely maps areas to our emotional reaction to pain in those areas. Or in still other words: pain in different areas may be associated the same emotional reaction. You can hurt in a specific location, and yet potentially react emotionally as though a whole area is being stimulated. Fascinating.

Body mapping errors are another possible source of referred pain related to thalamic-convergence. The brain has a “map” of the body, and that map can be indistinct or distorted. Convergent-projection results in not knowing where a sensation comes from in the first place, but even if the brain receives definite information about pain from a specific place it may still not know exactly where that place is. To the extent that the brain’s body map is a bit muddled (which is probably a thing that can happen, especially to chronic pain patients), then the brain cannot accurately “file” sensory reports with the correct anatomy. Something like this likely accounts for some more bizarre and remote experiences of referred pain.

And that concludes my survey of the state of referred pain science. Obviously you could write a book about this. Too bad no one has! It’s pretty interesting stuff.


Other ideas about the nature of the beast

Everything we’ve discussed about trigger points so far has assumed that the integrated hypothesis of trigger points is roughly correct, and that a trigger point is basically a tiny cramp, probably, maybe. Stranger things have happened in biology, no doubt.

But what if that’s wrong? What are the other possibilities?

There have been many hypotheses over the decades, and many clinicians have quibbles with the old Travell and Simons model191as they did themselves, importantly.192 No one competent has ever said it was perfect or settled. Once again, I’ve addressed all the major doubts about trigger points in a separate article: Trigger Point Doubts.

So, what are some of the other ideas about the nature of trigger points?

Like referred pain theories, several hypothetical mechanisms for trigger points may co-exist. However, most alternative ideas are even more flawed than the tiny cramp hypothesis. I’ll first list and then summarize all the ideas in this chapter; in the chapters to follow, I will dig a little deeper into a few of the more substantial ones.

And then, for fun and education…

It’s a normal spasm! The old pain-spasm-pain thing

Probably the oldest and simplest idea about how trigger points work is that they are simply the pain of excessively tight muscles, like a calf cramp but not as dramatic, either slower and gentler and/or in smaller muscles. I brought this up in the chapter about trigger points and injury, arguing that pain probably does not typically cause a vicious cycle of more spasming and more hurting in the absence of other variables. Quite the contrary, “muscle pain tends to inhibit, not facilitate, reflex contractile activity.”193 Of course “it’s complicated,” and we cannot rule out the possibility of pain and spasm driving each other around in a vicious cycle, but it’s got all kinds of problems and it’s entirely undocumented for something that supposedly happens all the time and causes a lot of trouble.

The most obvious problem is just that there’s no obvious experience of whole-muscle cramping associated with regional pain, which would presumably be fairly obvious. A calf cramp is a show-stopper. A contraction a quarter as strong as a typical calf cramp in a muscle a tenth the size might be uncomfortable but would probably still be an obvious cramp, much more like a calf cramp than a typical trigger point. For any less intense cramp, in any smaller a muscle, it’s hard to believe it would hurt much. Thus the spasm hypothesis runs into trouble at both extremes.

Dr. Sarno’s popular books are good in many ways, but Sarno never really admits that there is a well-established theory of muscle pain that trumps his! A common problem with myofascial pain syndrome — too many cooks in the kitchen.

It’s starving for oxygen! Dr. John Sarno’s “tension myositis syndrome”

Dr. Sarno (deceased 2017) was the author of several popular books about back pain and muscle pain, which were good in many ways… until he clearly started to suffer from an overdose of his own Kool-Aid later in his career.194 But it’s a serious annoyance throughout Sarno’s books that he never acknowledged myofascial pain syndrome in any way — either the name or the ideas it refers to — and instead only ever used his own idiosyncratic label for the same phenomenon, “tension myositis syndrome”… and attributed it almost entirely to tension-powered circulatory restriction. Tight muscles cutting off circulation. This is an embarrassingly simplistic hypothesis. Sarno was clearly just ignorant of other writing on this topic, and he never had more than a couple pieces of a much larger puzzle.

But he had great influence, and to this day I still hear people casually “explaining” trigger points as a problem with “restricted circulation.” I’ll get notes from readers saying, “Haven’t you heard of tension myositis syndrome? Don’t you realize that’s what’s actually going on here?” Oy.

It’s sticky spot! Adhesions, fascial distortions, and scars

This might just be the most common idea about what a trigger point is: muscle fibres that are stuck together, like spaghetti noodles that weren’t stirred enough. This is also often described as a “scar,” “adhesion,” or the more nebulous and pseudoscientific idea of a “fascial distortion.” Scars and adhesions are good generic scapegoats, and it’s common for people to equate trigger points with scars. This is also closely related to the idea of contracture, which is a legitimate but extreme tissue state which significantly limits movement and of which there is no sign in myofascial pain syndrome.

There is no evidence for any of this. I suspect one of the main reasons it persists is because it provides a goal for therapy: release the muscle fibres from their cage of adhesions and scar tissue! Shame it’s not there.

The whole adhesions/scar thing just doesn’t make much sense, but it’s such a popular line of thinking that I’ll dive deeper in a couple chapters coming up.

It’s a pinched nerve! Referred pain of peripheral nerve origin

No one has rejected the integrated hypothesis more than Dr. John Quintner. He has declared Travellian trigger points to be an outright fiction. It’s permissible to point out that the emperor has no clothes without suggesting a new wardrobe, but Dr. Quintner does have an alternative hypothesis: “It’s the nerves, stupid.” In 1994, Dr. John Quintner proposed that the referred pain from irritated nerves (peripheral neuropathy) is the main thing, and not a symptom.

It’s a perfectly good … totally unstudied guess. Its main problem is that it boils down to passing the buck to another tissue — irritated nerves instead of irritated muscle — and there are clues that support both guesses, and no strong evidence for either.

This is one of the most important trigger point theories, and so I will go into more detail about this in the next chapter.

It’s the muscle spindles! Like the integrated hypothesis, but with a different trigger

This is actually just a obscure and minor variant of the integrated hypothesis. The overall explanation is still “mini-cramp,” but the specific villain is the muscle spindle instead of a glitchy motor end plate. A “muscle spindle” is a specialized sensory nerve ending in muscle that mainly detects stretch. If they were too easily set off, it could result in chronic localized contraction and exhaustion, just like if the motor end plate signals too much. Simons debates this idea in detail and finally dismisses the theory in Muscle Pain, and I endorse his reasoning. This idea is obscure and not worth much attention at this time.

It’s starving for attention! Sensory under-stimulation

A root cause of trigger points might be the stress of sensory under-stimulation, rather than the stress of over-stimulation/irritation. I will expand on this idea below in The Bamboo Cage chapter as an interesting theoretical case study, exploring the depths of just how wrong the “story” of metabolic crisis might be.

It’s on fire! It’s inflamed muscle tissue

The kind of inflammation we know all too well — hot, red, swollen tissue around an infection or acute trauma — is just the tip of an iceberg of complex and subtle immune system responses to tissue insult. For instance, for many years experts proclaimed that chronic tendinopathy was not “inflamed” because it lacked classic signs of inflammation. Only recently in history, researchers have challenged that notion, finding evidence that there is indeed inflammation present in, say, Achilles tendinitis — but it’s subtle and different.195

So trigger points might be some kind of inflamed, and it’s just as great a general scapegoat as evil nasty scars. Inflammation is much more likely to be a response to the problem, rather than the problem itself. It’s highly plausible that trigger points are in some sense inflamed, just not like a pimple or the aftermath of stabbing yourself in the palm while trying to shuck an oyster with a screwdriver, not that I know what that’s like myself. It is not plausible that inflammation spontaneously crops up for no reason, actually causing a trigger point. There’s a full chapter on this below.

It’s an illusion! The focussing of sensitization

Sensitization is a diverse set of both changes in the nervous system that result in pain amplification, common in people with chronic pain. The intensity of the experience is the only thing that’s illusory about it for most people, but a few people probably do suffer from what appears to be nearly pure sensitization — pain that is all amplification, based on little or no signal at all. I’m not talking about psychosomatic pain, although that could be considered the most extreme form of central sensitization. But sensitization is usually more like a neurological disease: a dysfunctionally exaggerated response to stimuli.

Sensitization can cause a variety of pain patterns, everything from widespread diffuse pain, or pain in a specific region… or, perhaps, pain in the sore spots known as “trigger points.” The idea here is that the trigger points might form around relatively minor irritant, like a pearl around a grain of sand. It gets worse if the provocation gets worse, of course, but it can also just get amplified as we notice and react to it, the nervous system getting overly “worried” about that spot. And the grain of sand could even be so subtle and trivial that it doesn’t really even qualify as tissue lesion at all.

This might be a powerful model. The diversity of the “grains of sand” could help to account for the exceptional range of severity of TrPs, why they are so common, and why they can be so numerous in an individual — it’s a generalized response to nearly any noxious stimuli, no matter how subtle, which casts a wide net. It could also nicely account for why TrP-like sore patches do not occur exclusively in muscle.196 Or for the strong conceptual overlap with fibromyalgia’s “tender points.” Or for how predictably they crop up near other injuries (because all traumas are sensitizing at least temporarily). Or for how easily massage seems to disrupt the sensory equation. It can even play nicely with the integrated hypothesis! Mini-cramps could be plausible causes or reactions to sensitized spots.

I like this idea! The problem is that it remains in the realm of pure speculation, and isn’t really being studied.

It’s injured or worn out! Trigger points as a type of injury, especially “overuse”

No one actually has any idea if it’s possible to cause persistent muscle pain by overusing muscle. And even if we did, we wouldn’t know how. But, for perspective, we are still aren’t even sure what causes short-term muscle soreness! But the idea of trigger points as “some kind of exertion-related injury” is an extremely popular idea about trigger points, probably because attempts to classify the clinical symptoms often leads experts to look at injuries that are the most similar but better understood (somewhat): post-exercise muscle soreness and repetitive strain injuries, both of which involve excessive loading of tissue.

For instance, a muscle injury classification system defined by Mueller-Wohlfahrt et al in 2013 divides muscle injury into structural and functional.197 The structural injuries are the obvious traumatic injuries: partial and total tears and avulsions, injuries you can easily see with a microscope if not with the naked eye.

The functional injuries are divided into “overexertion-related” and “neuromuscular muscle disorders,” which are defined by their lack of clear physical damage. The neuromuscular disorders are about muscle being irritated by spinal cord lesions. We will cruise right by that and head for the land of functional, over-exertion related muscle injuries. And you couldn’t ask for a clearer example of that type than post-exercise muscle soreness: the muscle is clearly messed up and painful in a distinctive way, familiar to us all, but there’s nothing visibly wrong with the muscle (just an abnormal metabolic state).

So what about trigger points? I’m not referencing Mueller-Wohlfahrt et al’s classification system because it actually tries to explain trigger points as a type of injury, but rather because it doesn’t, because all they can do is surround it with other, clearer ideas about muscle injury — all the things that trigger points probably aren’t. That leaves a blank spot on the muscle injury map, a “here be trigger points” dark area in the realm of functional muscle injuries, something that causes symptoms that are very much like a muscle injury, but without anything obviously structurally wrong with the muscle. They speculate about a “fatigue-induced muscle disorder” that isn’t DOMS, but they don’t know how it works, but it isn’t a structural strain either. They don’t know, and all they do is dip their toe into the topic and mention a few ideas that barely scratch the surface.

Other experts respond to the idea of “functional” muscle injuries by pointing out that “it is possible that ‘functional’ lesions may in fact represent yet-to-be understood ‘structural’ pathology.”198 Amen! Just because we can’t see it easily doesn’t mean it’s not there. Almost everything interesting in biology happens at the astonishingly small scales of biochemistry. Even DOMS — such a familiar, ordinary-seeming problem — is incredibly hard to objectively diagnose, because it involves only some very specific and ephemeral biomarkers. Like tracking fireflies from a thousand kilometres away.

Similarly, repetitive strain injuries are well-understood clinically… but not biologically. There is still much to learn about how they work — like the gnarly question of whether or not they are “inflamed,” which only got some strong research light for the first time in 2017.199 Perhaps trigger points are more like RSIs?

RSI is almost synonymous with tendinitis and bursitis, with some exceptions and oddities (e.g. carpal tunnel syndrome is actually a peripheral neuropathy, no one’s sure exactly what’s irritated in IT band syndrome). And occasionally the definition spills over into myofascial pain syndrome territory. For instance, writing about chronic exertional compartment syndrome (one form of “shin splints”), Franklyn-Miller et al conclude that it’s probably usually “muscle overload,” not swelling and pressure in the compartment.200

It may well be true, but it’s also not very specific. That explanation can only go so far: it’s a hypothesis about a behavioural risk factor that implies that the biological mechanism is muscular without actually saying anything about exactly how or why. Even if it’s exactly correct in spirit — even if every trigger point forms because of overuse — we would still want to know how the trigger point itself works. But the idea of fatigue as a cause of trigger points is so widely believed that it is often treated as though it’s all the explanation we need. Overexertion is assumed to have such obviously harmful consequences for other tissues, like tendons, that surely it can “break” muscle as well. And anyone can feel that muscles suffer after an intense workout, so it’s a short logical leap from there to assuming that some of that soreness might well persist in small patches. And, if so, it probably would have a subtle and poorly understood biological signature — just like DOMS and RSI, only more so.

It’s [insert embarrassingly bad idea here]! A bunch of bad ideas about what trigger points are

These ideas come straight from the horse’s ass: from massage therapists, from the professionals who should know more about trigger points than anyone. But many MTs have some worrisomely low quality notions about how trigger points work. I’ve compiled some quotes for you here. Most of these are lifted straight from one public discussion in a Facebook group for massage therapists (such discussions are common). A few others are from my inbox. All of these are misguided in some way (or five ways). We can forgive some of them as poetic oversimplifications (with a lot of spelling mistakes, all preserved here), but in my experience the majority of these statements are actually intended to be meaningful explanations:

And one more that is notable for quite a different reason:

She’s afraid saying “I don’t know” is “probably unprofessional as hell,” when in fact it’s by far the most honest, ethical, and therefore professional answer possible for most therapists, most of the time. And although a couple dozen people on the thread provided “no one really knows” answers, which was refreshing, almost all of them also said something like this: “there are a lot theories.” Only if you include really implausible, muddled ones that no one serious takes seriously. Most competing explanations, even those with the best pedigree and plausibility, aren’t actually very competitive … and yet most of them are not even mentioned in the statements above!


Quintner: “It’s the nerves, stupid”

No one seems to hate the idea of “myofascial pain syndrome” more than the retired Australian rheumatologist, Dr. John “Trigger Points Are Dead” Quintner. In the 2010s, I could hardly go a day on Facebook without encountering his comments on this topic, which he sprinkled everywhere he could, with or without any clear relevance to the post. He never missed on opportunity to declare that “trigger points are dead.” Quintner is an absolutist activist, and there is no grey area in this for him.

In 1994, Dr. Quintner wrote a flawed but historically significant and influential critique of the conventional wisdom about trigger points — that is, a critique of Travell & Simons’ explanation for the phenomenon of trigger points (the energy crisis hypothesis). And then he and his co-authors proposed that peripheral nerve pain could be a better explanation. Specifically, they hypothesized that irritated peripheral nerve trunks are “a rich source” of pain, and may be the true cause of trigger points, rather than a clenched patch of muscle.201

Quintner has continued to actively study and write about this subject. He published a new version of his original paper in 2015.202 The two versions are strikingly similar: it’s the same argument, just a little more fleshed out. His criticism and theory make for interesting reading (required for professionals, I’d say). It might be a better way to explain at least some aspects of trigger point pain, and he could be correct.

But I doubt it. I suspect it’s only half-right at best. It is just another idea, after all — and one without much detail or support. In fact, the only source of support at all is a handful of citations to studies done by one of his co-authors. Not exactly compelling.

The main point of Quintner et al.’s work is that the conventional wisdom is wrong — not to replace it. Maybe they should have stuck to their main point, because I see little difference in the quality of these competing hypotheses: they are both flawed educated guesses. Later in her career, Travell showed signs of drinking a little too much of her own Kool-Aid, but she and Simons did routinely emphasize that their ideas about trigger points were just speculation, without much experimental support. Quintner’s writing has dramatically less support and much less humility: Quintner is quite absolutist in his dismissal of the integrated hypothesis. The simple reality is that neither has ever been validated, and both have a mess of puzzling loose ends and logical problems.

I can’t read Travell & Simons or Mense without thinking over and over again, “But what about ________?” Sometimes they acknowledged those gaps and sometimes they didn’t.

But I feel even more that way reading Quintner: there are glaring holes there too! One specific example: Quintner suggests that the locations of trigger points correspond to the locations of peripheral nerves. And yet there are lots of common trigger point locations that don’t seem to be located on any peripheral nerve pathway (perhaps a tiny branch, hard to avoid those, but nothing you’d find named in an anatomy text). And there are lots of large peripheral nerves that I can massage right over without ever provoking anything like typical trigger point discomfort. I spent a decade paying close clinical attention to trigger points and nerve anatomy without ever noticing any overlap. I could have missed it, but that seems unlikely.203

Let’s get specific: known peripheral neuropathies that can seem like a trigger point problem

When all you have is a trigger point hammer, you may see only trigger points to bash on. There are some peripheral neuropathies that could be mistaken for trigger points. Especially if you aren’t familiar with the neuropathies.

Lateral femoral cutaneous nerve (LFCN) entrapment on the front of the hip, AKA meralgia paresthetica, causes lateral hip and thigh pain and “can easily be misinterpreted and ascribed to other causes.”204 Massage therapist Whitney Lowe:

A client, who I will call Steve, was experiencing lateral hip pain around the greater trochanter of the femur. Some of the pain was extending into the lateral thigh region as a deep aching pain sensation.

One practitioner thought that Steve had trigger points in his gluteus minimus muscle and another thought he had a joint capsule problem. Treating the trigger points via direct pressure on the tissues gave some brief intermittent relief, but ultimately was unsuccessful in resolving the issue. In this instance an alternative explanation seemed necessary for Steve’s symptoms.

Meralgia paresthetica can be a serious and tricky problem. There are some books about it, or at least one anyway.205 But here’s the thing: as much as a therapist with trigger point tunnel vision is likely to miss the diagnosis, meralgia paresthetica usually involves relatively obvious symptoms of a neuropathy:

None of that is typical of a trigger point. Any competent professional will spot the difference, if they aren’t so obsessed with trigger points being the cause of nearly everything that it’s all they can see (which I have seen all too often).

Cluneal nerve entrapment is just around the anatomical corner and similar in character. Cluneal nerve branches pass from the low back and sacrum over the edge of pelvis and into the buttocks, completely surrounding a classic location of sensitive soft tissue in the middle, upper “corner” of the butt (perfect spot for massage #12). These nerves are somewhat vulnerable to injury and/or chronic impingement along that route.206 When irritated enough, they may cause back, buttock, and leg pain.

Fascinatingly, cluneal nerve impingement is even known for causing a sore spot in the buttocks, which radiates pain down the leg when pressed… so it can do a great impersonation of a trigger point. Maybe the classic sensitive spot at this location actually is usually cluneal neuropathy — if so, that would be a perfect example of a trigger point (sore spot) that is not a micro-cramp in muscle, but actually cranky nerve trunk.

And yet cluneal complaining is not a perfect impersonation of typical trigger point discomfort: as with meralgia parasthetica, there will probably be some symptoms of neuropathy. Consider this description from Aota’s case study:

Palpation on the LPSL [location of the impinged cluneal nerve] consistently induced LBP and leg tingling radiating from the buttocks to the calves on both sides. Injections around the LPSL were repeated every month. Each time, the patient reported reappearance of leg tingling during the block procedure and, soon after, complete improvement in LBP and leg tingling that continued for three days.

That’s a lot of tingling! Every bit of which is a strong clue that the problem is just classic peripheral neuropathy, not a trigger point.

Why so many grumpy nerves?!

So that’s now two examples of peripheral neuropathy that certainly could be mistaken for a trigger point … but probably only occasionally, and mainly by beginners who are not alert for the symptoms of peripheral neuropathy. These confirmed examples of nerve entrapment don’t seem unusually triggery to me, just potentially confusing for people who are still learning.

Meanwhile, there are many common sore spots in soft tissue that do not overlap with any known peripheral neuropathy. How would we account for all of those? That’s a lot of neuropathy that doesn’t present like neuropathy!

My main concern with Quintner’s it’s-the-nerves-stupid hypothesis is that it requires an assumption of way too many inexplicably irritated peripheral nerves. Sore spots are extremely common: are they all caused by injured, entrapped, or otherwise irritated nerves? Why would that be happening? To practically everyone, constantly? Are nerves really that vulnerable? There’s certainly no evidence of that. Accepting the hypothesis means embracing a world with a baffling amount of mild neuropathy. Seems like a reach.

Quintner describes peripheral neural tissue as “a rich source of local and potential referred pain,” but why so rich? He suggests “mechanically or chemically sensitized nociceptors within the nerve sheath” and “damaged nociceptive afferent axons” and “entrapment or metabolic insult” and others. Mechanical explanations (trauma, entrapment) are generally implausible because people are so obviously tolerant of strong massage, and indeed many find it quite relieving — which would not be the case if their peripheral nerves were easily annoyed. Even if physical insult to nerve trunks is a mechanism of trigger pointy pain, it seems like just half an explanation at best — for a whole explanation, we would still need to know why so many people have so many irritated nerves.

But educated guessing is really what this book is all about! Above I speculated in a general sense about why muscle tissue might be prone to discomfort. Now it’s time to turn to a rather morbid, poetic bit of guess work about the general trouble with nerves — broadly supporting Dr. Quintner’s ideas, despite my concerns.


“The bamboo cage” — lessons from immobilization torture

Imagine that “trigger points” don’t exist in a physical sense, as some critics have suggested. The problem might actually be in our minds, and not our meat, for instance. This may be more literally true than it seems: not “all in your head” in a psychological sense, but a thoroughly neurological phenomenon, a sensory malfunction.

Consider how uncomfortable it is to be immobilized. Being physically stuck quickly begins to hurt: tissue responds to stagnation with discomfort and then pain, and it can get horrible long before there is anything seriously physiologically wrong with your tissue. The tissue remains fine while the nervous system starts to sound a loud alarm about the looming threat.

Held too long against your will, being “stuck” becomes literal torture

Torture by immobilization, as in a cramped bamboo cage, is the most macabre and extreme example of how much we hate the feeling of being stuck. There is a memorable depiction of immobilization torture in The Bridge on the River Kwai, and unfortunately such methods are not just a Hollywood invention.207 (Weirdly, medieval torture devices — many of which also involve immobilization — are largely fictional. Most of them either aren’t real, or existed but weren’t especially “medieval.”) As with relentless drops of water, immobilization can cause great pain and suffering without doing significant physical harm at first.

Why? Such extremes of human experience are often instructive.

The same effect can be reproduced in a few minutes at home. Try this simple experiment:

Position yourself comfortably, but place one muscle group in a moderate stretch, something you can sustain without effort (for instance, your hand bent backwards, your fingers comfortably hooked onto something, stretching your forearm flexors). Don’t move. Wait. The stretch will become somewhat unpleasant for most people within a few minutes, and bloody awful within a half hour.

Again, why? The muscle cannot possibly be “damaged” to any meaningful degree — not that quickly.

Now imagine doubling or tripling the duration of the experiment.

Never bet against the importance of nerves and brains

Vancouver pain researcher Chan Gunn once suggested a mechanism for pain that could help us to understand why stagnancy is uncomfortable, and immobilization torturous. Here’s a translation of his idea from neuro-speak into English:208

Tissue health depends on a normal flow of nerve impulses. If nerves are impaired, tissue can become paradoxically super-sensitive. Once the sensitivity sets in, tissue may become over-sensitive to all kinds of stimulation, and not just injury. Ordinary stretch and pressure, for instance, could become painful.

Sound familiar? That is how many people feel when they have “muscle pain.” Whether Gunn is right or wrong about the particulars is not important to the point I want to make at the moment: it’s this kind of thinking that may be useful in understanding so-called “muscle pain.” If this is anything like how muscle pain actually works, you can see quite clearly that it’s not quite right to think of it as a “muscle problem.”

Gunn used his idea as a way to explain the phenomenon of sore spots. His explanation is outside the mainstream of trigger point science (not that there really is such thing) and was summarily dismissed by Dr. David Simons, who wrote: “Neuropathy can be, but is not always, a major activating factor.”209 Simons’ dismissal was basically, “it’s not the whole story, it’s too simple,” which is always easy to agree with. But I think his dismissal was too hasty, and ever since then pain science has relentlessly affirmed the importance of neurological dysfunction and central dysregulation.210

When it comes to pain, never bet against the importance of the nervous system, and especially how potent the brain’s contribution is to how we experience sensations.

What is immobilization pain trying to tell us?

Gunn’s idea depended on the phenomenon of “denervation supersensitivity,” in which muscles that have been cut off from their nerve supply become sensitive to acetylcholine, the neurotransmitter that triggers muscle contraction. They become sensitive to it because there’s hardly any of the stuff coming from the nerve! Muscle cells literally build more receptors, coating their surfaces with them — a vivid example of how nerves can actually change the tissues they are attached to.211 With all those receptors, the muscles are “listening” carefully for orders; they seem to be saying, “Hey, is this thing on? Where’s the acetylcholine?” And then they turn the sensitivity dial up to eleven and react too strongly to any that they do get. (The same thing takes place in many different contexts: we get more sensitive to all kinds of signalling molecules when there’s a shortage, or insensitive when there’s a surplus.)

This phenomenon occurs in response to obvious nerve injury. It’s possible — unproven but plausible — that something analogous to denervation supersensitivity could also occur when there’s simply a lack of sensory variety and stimulation, which amounts to sensory boredom. Muscles might become sensitive to nerve impulses as we stagnate, like an eager dog who lunges at the slightest movement that might mean a ball throw. That “itch to move” could start to burn like pain.

This makes good biological sense. Stillness is dangerous — a few days in a bamboo cage might cripple or even kill, and there are many more commonplace examples of dangerous stagnation (ask any nurse about bed sores). No doubt it’s a good survival strategy to have nervous systems fine-tuned to avoid it. The sensory boredom of stillness is a meaningful warning, and more meaningful still if there’s a drone of signals about stretch or pressure or anything whatsoever that is more likely to do damage if sustained — even if the same thing would be harmless in the short term.

As these signals pour in, we probably get squirmier and twitchier, over-eager to move, stretch, anything. The stagnancy alarm might lead to physical changes in the muscle and its subsequent behaviour — i.e. hypersensitivity to stimulation — or it might just be a matter of extreme psychological distress associated with the sensations of being stuck. Or both.

The urgency of that feeling — the loudness of the warning — will be dialed up or down by our brain, modified by our knowledge of the situation, how long we expect it to last, whether panic and thrashing about is not such a bad idea … or if it would just ruin the meditation.212 Sometimes people actually practice being still, and are actively resisting the urge to squirm. And sometimes they are actually being tortured. Or maybe they just have to work in a chair all day — which is a bit of both. Or maybe they are cuddling with someone they’re keen on and don’t want the moment to end.

Or maybe you can’t tear yourself away from this book? 😜

Context matters.

Breaking the cage

It’s easy to understand how a good massage might scratch that itch to move, a stimulation-seeking impulse satisfied by hands and thumbs that create sensations that signal the end of stagnancy and soften the alarm.

It is often easier said than done to “use it or lose it.” Accidents of anatomy and modern lifestyle make it difficult, even for a healthy person, to keep certain places in the body adequately stimulated — the low back, for instance. For chair-bound office workers, it is almost as though the low back is being tortured, locked in a tiny bamboo cage. Even when we get up to move, it’s hard to compensate for so many hours in a chair (although it certainly makes sense to try).

Injury, disease and even emotional constipation can pile on and block our efforts to scratch our itches ourselves.213 The problem becomes clearer in the elderly, where such factors have accumulated. When I worked as a student massage therapist in extended care facilities, I had the strong impression that I was lending a helping hand, stimulating tissues on behalf of my elderly clients, helping them do what they desperately craved but literally could not do for themselves. One fellow I remember well simply could not reach his swollen feet. Our help was an intense relief for them, like breaking the bars of the bamboo cage that had been built around their bodies by age, habit, tension, and long lists of medical problems.

This all adds up to a non-meaty vision of how muscles might seem to hurt and why massage matters to us. It’s one way that muscle pain might be a kind of illusion, that trigger points may not be what they seem to be, and that pressing on muscle doesn’t “fix” muscle per se. Instead, perhaps it “just” satisfies the organism’s intense craving for stimulation … a craving which may be far more urgent and important than we usually imagine it to be.

I am definitely not saying that this is how the phenomenon of trigger points actually works. But it is an interesting detour down Hypothesis Lane.


Muscle knots are not clearly inflammed

Inflammation & muscle knots are a complex stew of biochemistry. But they are not the same stew …

A routine misconception about muscle pain is that it must be caused by “inflammation,” like a burn or a cut. That word is used almost interchangeably with pain, as though anything that hurts is inflamed by definition. By the correct definition, all (acute) inflammation is painful, but not all pain involves inflammation (acute or otherwise).

Muscular trigger points are one of the most common of all painful experiences, and are widely assumed to be inflammatory, and therefore also the basis for using anti-inflammatory medications or ice, neither of which seems to work very well. Trigger points do not appear to be inflamed, or not much, or not in obvious way.

Subtle inflammation might play a role, as it probably does in conditions like tendinitis. Experts have often declared that such injuries are not inflamed, just as I am doing now about trigger points, largely based on the absence of obvious signs of acute inflammation. Researchers started challenging that notion in 2017 (Dakin et al), finding evidence that there is indeed inflammation present in, say, Achilles tendinitis — it’s just more subtle.

But that kind of inflammation is so different from what we conventionally think of as inflammation that it’s almost a different thing.

Acute inflammation occurs prominently and predictably only in response to injury and infection. Damaged cells spill their guts into tissue fluid, triggering many other physiological responses. Blood vessels dilate, immune cells are attracted to the area, and dozens of molecules like bradykinin, histamines, and prostaglandins flow like Guinness in an Irish pub on St. Patrick’s day. This is the chemistry of tissue damage. Although painful, it is the result of the body trying to protect itself and heal, and it is medicated mostly just to make it more tolerable, not to stop it.

Trigger points also contain a complex stew of biochemistry — but it is a different stew. The chemistry of trigger points might be better described as the chemistry of exhaustion. There is no word for this tissue state, but there probably should be. According to the prevailing energy crisis model of trigger point formation — which is pretty solid — a trigger point is “revving” metabolically, contracting constantly and strongly, millions of mitochondria with the pedal to the metal. The result is certainly a toxic mess of cellular waste products — acidic and irritating, which was shown clearly in a nice 2008 study — but it is definitely not the same thing as inflammation around an infection, injury, or even a chronic tendinitis.

Trigger point toxicity is mitochondrial poop: This is a mitochondria, a cell organ. Millions of them in each cell provide the cell with power. The toxicity of trigger points is caused by their waste products — mitochondrial poop, if you will. The chemistry of acute inflammation is caused by cells spilling their guts into the tissue fluid — quite different!

Trigger point toxicity is mitochondrial poop

This is a mitochondria, a cell organ. Millions of them in each cell provide the cell with power. The toxicity of trigger points is caused by their waste products — mitochondrial poop, if you will. The chemistry of acute inflammation is caused by cells spilling their guts into the tissue fluid — quite different!

This is all a great oversimplification of the chemistry, but that’s actually part of the point: we don’t have to understand the chemistry well to appreciate that each situation is too complex to be the same. Each has a distinctive biochemical “fingerprint.”

Despite their differences, there is probably some overlap between acute inflammation (fairly well understood) and whatever it is that’s going on in cranky tendon or a trigger point (definitely not well understood). Several of the same molecules are present. But just because they share some chemistry does not necessarily mean the processes are actually similar. Every process in the body shares some chemistry, of course — a lot of the molecules have many jobs — but so what? Immune cells turn up in both tumors and paper cuts: that doesn’t mean that tumors and paper cuts will respond to the same meds. Even if some features of acute inflammation turn up in trigger points, it doesn’t mean much.

On the “bright” side, biochemistry-driven problems like trigger points are so complex that they are also unpredictable, which means we cannot rule out the possibility that anti-inflammatory treatments will help some people, some of time.


Adhesions and contracture: when trigger points freeze in place

Adhesions and contracture are on a continuum of soft tissue stickiness and shrinkage. An adhesion is just a slight, Velcro-like stickiness between layers of tissues — quite common, and easily broken by massage… or just movement. Contracture is a much more permanent state of tissue being “frozen” in a shortened position, usually caused by pathology or long-term immobilization.

Between the two is a large gooey grey area of unclear clinical importance to pain patients. This chapter is about that spectrum and its relevance to trigger point therapy. Are trigger points related to adhesions or contracture? If trigger points are micro cramps, do they eventually turn into micro contractures?

Scar tissue is similar to contracture, but different in principle, and I’ll cover that in the next chapter.

The science of adhesions: atoms stick to each other

Adhesions are caused by hydrogen bonds. Hydrogen atoms carpet the surface of the large protein chains that make up the primarily collagenous substance of all connective tissues. They have a slight positive charge, and so they are attracted to negatively charged particles — such as nitrogen and oxygen atoms, which are also extremely common in the body (in case you were wondering, you are about 10% hydrogen, 2.6% nitrogen, and — wow — 60% oxygen). When atoms with opposite charges approach each other, they are slightly attracted, like wee magnets.

Hydrogen bonds form, Velcro-like, between protein chains. The phenomenon is exactly like any other electrical attraction, as between the opposite poles of magnets, or a balloon stuck to the wall. Each bond is weak, but there are many of them.

That attraction is very weak. A single pair of attracted atoms barely stick together at all — just like a single tiny loop of Velcro hook just barely grabs on to a single bit of Velcro loop. However, there is strength in numbers! There are a lot of these pairs of atoms on the surfaces of connective tissues — billions of them. As more and more hydrogen pairs bond, the overall effect is sticky.

At this stage, the bonds can still be broken fairly easily. Any strong contraction or manipulation would peel them apart with no damage, and this is a stated goal of many manual therapy techniques. For instance, instrument assisted soft tissue mobilization (IASTM) involves strong scraping of skin and muscles with mean-looking metal tools, and this is partly intended to “break up adhesions.” Or consider skin rolling, from Swedish massage, which is primarily intended to pull skin away from subdermal fascia and the walls of muscles. Bizarrely, when you “roll” someone’s skin, you can often feel the skin tearing away from the underlying muscle, like pulling up old carpet — which is mostly less painful than you might expect.

Just like Velcro, if the bonding between layers is allowed to “settle” — if you work the two layers “into” each other — it can get stronger. You end up not only with many firmer hydrogen bonds, but other physiological processes begin to compound the problem as well, and mere adhesions can eventually be joined by contracture, a much more substantial and permanent kind of stuckness…


“Contracture” is a kind of super-tightness in which muscle that has been shortened for too long essentially freezes in place, just like your mother warned would happen to your face if you kept making ugly faces. The danger may have been more real than she knew!

Tissue can get literally hardened and “stuck” without movement.214 Muscles can get locked into a shortened position. Tendons and layers of connective tissue stick together and lose elasticity. It would be hyperbolic to call this “contracture,” but it’s halfway there.

True contracture occurs most dramatically in people with paralysis, severe chronic spasticity, or connective tissue diseases like Dupuytren’s Contracture (a mysterious contracture in the palm) and its more common cousin in the shoulder, frozen shoulder.215 Progression of contracture must be constantly battled, like a garden full of weeds, with a challenging regimen of exercise and physical therapy. Even the most vigorous efforts may still fail, depending on the cause. Regular stretching does not cut it for most contracture;216 more aggressive methods like splinting might work.217 Or they might not: splinting Dupuytren’s contracture might help a little, but some of the evidence is clearly negative.218

Adhesions, contracture, and trigger points

Adhesions probably occur microscopically throughout entire muscles, between their cells and layers and subdivisions: not just stickiness between entire muscles, but between all the parts of muscles. Every part of a muscle is wrapped, like a sausage, in a layer of connective tissue. The entire muscle is wrapped; several large subdivisions are wrapped (muscle compartments); subdivisions of subdivisions of subdivisions are wrapped, and so on, like a Matroyshka (Russian doll). Even individual muscle cells are wrapped! In theory, all of these wrappings can stick to each other a little, and maybe it can add up to something that matters.

A trigger point may in time get “locked” into place by adhesions between the wrappings surrounding it and inside of it. Just as trigger points themselves may be “micro cramps,” a patch of adhesions around it may be a “micro contracture.” It might be why some trigger points are more palpable than others. (Or not — there are definitely other possibilities.)

And a muscle full of many trigger point for a long time might become more “stuck” on a macroscopic level — less flexible, like a hardened rubber band.

These are all reasonable things to wonder about, but we cannot do much more than wonder, because there’s not a lot of relevant research. There’s no clear evidence that this seizing up process even exists, or — if it does exist — that it is occurring to a significant degree in anyone who isn’t sick or very old and unfit, let alone that it has anything to do with trigger points or chronic pain. Adhesions probably form and dissolve constantly, and are mostly easily brushed away, like cobwebs, by any reasonable amount of movement.

And yet we also know, from extreme examples, that it is possible to get adhered and contractured if movement is restricted enough, for long enough. There’s probably a wide range of severity, as there usually is with pathology. The process of “seizing up” is probably more aggressive in some people than others, because of subtle pathology, genetics, or physical stresses.

Could it work the other way around? Could adhesions actually cause trigger points?

It’s not inconceivable. Tissue stagnacy → adhesions → irritation, maybe a small-scale circulatory impairement → sore spot. It is broadly compatible with the use-or-lose-it principle of all life. It could be one of the mechanisms that tissue stagnancy causes trouble. But there’s also no specific reason to believe that’s how it works, and no science. It can only be a guess at this time.

The speed of stickiness

If trigger points get stuck to a clinically significant degree, it’s bound to be a slow process. Many people worry about getting adhesions long before they need to. My guess is that it would take at least ten years, and maybe much longer, if it even happens at all. If adhesions around a trigger point get disturbed (broken) even once per year, they might never have a chance to become much of a problem.

On the other hand, in the worst case scenario, a serious trigger point could, in theory, develop meaningful adhesions in a matter of months if you did nothing to break them up — no movement, no rubbing ever.

However, many people do live with trigger points for decades — and they may slowly harden, thicken, and stiffen, and that may make them much more difficult to treat. There are other reasons why old pain is more entrenched too, but this could be part of that recipe.

Can you feel adhesions and contracture?

Adhesions are probably mostly difficult or impossible to feel. There is the skin rolling phenomenon, mentioned above — the weird sensation of breaking subcutaneous adhesions — but that doesn’t seem to have anything to do with trigger points.

Certainly pathological adhesions are often palpable. The knotty crud in Dupuytren’s contracture is downright obvious; in fact, you can actually see it.

But some lifelong, profound contractures do not have a distinctive texture. Consider one patient I worked with for years who had torticollis, a congenital contracture of the sternocleidomastoid muscle. One of his SCMs was about 3cm shorter than the other, his head tilted for his entire life. His facial bones remodelled themselves so that his eyes are level with the horizon. If he straightens his neck — which feels crooked to him! — his eyes are disconcertingly lopsided. But when his neck is bent to the side, he looks and feels quite normal — just a slightly head-cocked posture.

And yet his profoundly shortened SCM had a normal firm texture. His short-side was tender, but so was his long-side (and so are most people’s SCM muscles, really). If they’d both been the same length, I wouldn’t have had any clue that they were different based on their texture alone. And yet that was a truly, obviously contractured muscle.

Naturally, many masssage therapists will claim to be able to feel adhesions, contracture and alleged “scar” tissue (see next chapter), based on a particularly hard and ropy muscle texture. But a ropy texture does not necessarily mean that there are adhesions, contractures, or scars — muscle can feel that way “naturally,” just by having a high resting tone (tension)219 and non-adhered trigger points. A muscle with a lot of adhesions might feel that way, but it also might not.


The scar tissue issue — are you scarred for life?

There’s no good reason to suspect that every sore point arises from, or causes, anything that is like a “scar” in any sense. For me, the whole topic boils down to sloppy use of the term.

Many times in my career I have heard people equate their trigger points with scars, as in, “I have a bunch of scars,” when what they really mean is, “I have a bunch of sore spots, pain, and stiffness, and I’m making a really uninformed assumption about the nature of those spots.”

It’s a strange assumption to make. In most people, trigger points are quite numerous, so… if those are “scars”… oh dear! What exactly happened to those poor people?! What would cause such widespread scarring in the first place? Were they stabbed three dozen times and then forgot about it? Did they suffer some kind of infectious or inflammatory disaster? Are they like chicken pox scars, but under the skin? It seems like if such a thing happened, it would have been a major medical event!

Occasionally I hear from someone who is pretty clearly suffering from a combination of medical paranoia and ignorance who does not just equate trigger points with scars, but believes that they have widespread “scarring” and trigger points “everywhere” due to some accident or medical meltdown (often just as muddled a story as the alleged consequences). Such patients are undoubtedly in pain, but probably almost everything about their story is muddled. But it’s tragic how they have become fixated on the idea that they are literally “scarred.”

Now where would patients be getting an idea like that? Hmmm…

Scars! A fine way to justify expensive therapy

Unfortunately, it’s an extremely popular concept in the world of massage therapy and chiropractice to “break up scar tissue” — even when there’s no scar to be seen. Or maybe even especially when, because an invisible scar is a spookier scapegoat! And so patients are often actually told that they have scars they can’t see or even feel, due to “subtle” or “internal” traumas. Therapists may claim to be able to feel scars that the patient was oblivious too — probably because they don’t have them! Or there might be something there, but it shouldn’t be called a scar.

I think it’s extremely misleading — downright unethical — to talk about scar tissue in the context of most chronic pain. It’s marketing language, melodramatic and inaccurate. It has emotional appeal — the appeal of a clear problem that can supposedly be solved — rather than scientific accuracy. It’s not completely wrong — some adhesions and localized contractures are a bit like scar tissue — but they are not actual scar tissue, and the using the term “scar tissue” to sell treatments for “breaking it up” or “softening” it is just bullshit.

This is all on about the same level as a mechanic telling an old lady whose car needs an oil change: “Your car has bad oil. Big job to fix! Very expensive.”

Therapists: you need to “watch your language” and talk like professionals, not salespeople.

True scarring is worse than anything most people with myofascial pain will ever face. Scar tissue is highly disorganized connective tissue — tissue that’s been severely disrupted by trauma, and “patched” by a messy, dense, tough bit of “gristle,” a spackle of pure connective tissue. It is nearly impossible to fix a scar. Treatments that claim to soften or remove scar tissue are all bogus as far as I know. It’s like claiming to be able to melt cement.

Contracture is a little more like scar tissue, but still quite different. Contracture involves large quantities of severe adhesions and other adaptive and pathological changes spread throughout an entire muscle or even muscle group. Muscles are significantly and permanently shortened by contracture. Imagine if your elbow was immobilized in an extreme position, bent as far as it will go, and you could never straighten it out ever again — that’s going to cause contracture. After six months like that, your elbow would probably never move again.

So you can see why it might bug me when therapists casually throw around the terms “scar tissue” and “contracture” as if they have anything to do with trigger points — it’s not a fair representation of what’s going on. Those terms should be reserved for the people who actually have those problems.

Adhesions are much more common than proper scarring, and potentially more clinically relevant and treatable. Even the worst adhesions are not as tough as actual scar tissue or contracture. Instead of large patches of dense, disorganized connective tissue, tissues afflicted with serious adhesions are still more or less “organized,” but have lost their ability to stretch out or move relative to each other.

Adhesion, Contracture, and Scarring Compared
DefinedWhat is the worst case scenario?
Adhesions “Stickiness” between layers of connective tissue Almost all adhesions can be easily broken. Only clinically significant as a potential but unlikely precursor to contracture.
Contracture Near permanent fusing/shortening of soft tissue Contracture is much more severe in people with true paralysis or spasticity than anything faced by people with trigger points. The most ancient and severe trigger points could be linked to mild contracture, but even that is speculative.
Scar Tissue Extremely disorganized, thick, indestructible “patch” of connective tissue at a lesion site Mostly or entirely irrelevant to trigger point therapy. Scar tissue, by definition, only forms after messy tissue trauma; it never occurs due to trigger points, no matter how bad they are.


Trigger points in animals

This is an odd topic that does not clearly belong anywhere in this tutorial, but readers have often asked about it, so I’m wedging it in here at the end of the “science” part. The questions asked are usually: “Do animals get trigger points?” and “Can animals be helped by trigger point therapy?” The answers I give are probably and maybe. There are also some interesting implications and tangents. Very little of this has practical value, but I think it provides some useful perspective.

Trigger points are primarily defined as a subjective phenomenon — sensitive spots — because the objective signs are a bit sketchy. Since animals mostly can’t tell us which spots hurt and how much, it’s really hard to know whether they suffer from this like we do. I also think it’s difficult to infer the location of a trigger point from behaviour (a limp, for instance, might narrow it down to the leg, but no further).

However, some of the objective evidence of trigger points that we do have has been obtained by studying animals, so there’s that. And mammalian muscle biology is all mostly quite similar. Humans are animals! If we get trigger points, other animals probably do too.

And it is also possible that humans have much more trouble with muscle knots than other animals. Many things distinguish us in the animal kingdom. Our psychology is a lot more complex, for instance, and emotional stress is probably a factor in myofascial pain syndrome.

But mostly I see no reason in principle why trigger point therapy couldn’t be helpful for animals, just as we hope it is for humans. But in practice…

I don’t trust animal therapists

I don’t trust human therapists with egos and vested interests to accurately judge how helpful they can be. There are many animal massage therapists out there who claim to work with trigger points in animals, for whatever it’s worth, which probably isn’t much. It’s easy for humans to succumb to wishful thinking and selective perception, and it’s even easier when working with animals.220 There’s a maze of complications most animal therapists aren’t aware of, and they tend to remain blissfully unaware of them because they can pretty much do what they do without the slightest critical scrutiny.

Yes, there’s an entire book about animal placebo.

And so people who do animal massage tend to have obviously overconfident views about it. They often fail to give credit to the animals for being extremely suggestible, and just as capable of a placebo effect as humans are.221 And they give themselves too much credit, failing to recognize their own biases. People simply claim that animals feel better after a treatment because that’s what they want to believe. They over-interpret animal responses to their treatments in a self-serving way. They project and anthropomorphize like crazy, just as most people do with their own pets.

Example: it’s classic animal behaviour myth that dogs feel “guilty” when they’ve done something we think is wrong, when all they are doing is detecting and reacting to our judgement and disapproval.

It’s impossible to palpate trigger points reliably in humans, and undoubtedly harder still with animals. There are more variables, and stranger variables. For instance, domestic animals are super responsive to human attention and subtle non-verbal cues, to the point of amazing defiance of our expectations, which is bound to confound. The famous horse Clever Hans was so sensitive to non-verbal cues that he could answer any simple math question simply by paying attention to the reactions of humans to his hoof taps.222

I have no doubt at all that a dog or horse might benefit emotionally from a hopeful human taking charge and confidently trying to help. This is not a stretch! And that will definitely make it hard to tell if they’ve actually been helped physically as well.

Here’s a good rule for life: give animals some credit … and give humans less. 😉 Animal massage is probably a good thing for a variety of reasons, but calling it “trigger point therapy” is a bit rich. Trigger points may get treated, but even less reliably than in human massage. What is “experimental” and uncertain in humans is more of a total crapshoot with animals.


Part 4

Basic Trigger Point Therapy (Mostly Self-Massage)

What can you do about garden variety trigger points?

Most of the rest of this book is devoted to treatment: first basic and then advanced trigger point therapy. There are several chapters for the basics, and then many chapters for advanced refinements and troubleshooting. The basics are good enough for most people, most of the time, but the recommendations in the advanced sections will be of great interest to anyone who has already tried basic treatment methods and failed to get relief — which includes a lot of people who buy this book.

But don’t skip ahead! The basics are an important foundation, and few people are doing the basics well. In many cases, the “advanced” therapy that people need is simply doing the basics well for the first time.

Dr. Janet Travell wrote that “almost any [physical] intervention” can relieve a trigger point — nearly any stimulation. And indeed it does seem like a lot of trigger point pain can be relieved with a surprisingly small amount of simple self-massage with your own thumbs, or with the help of some cheap tools. So self-massage is probably the simplest, cheapest, and most effective way to experiment with trigger point therapy, and it dominates the basics.

How could such a trivial treatment work? It smacks of being a bit too-good-to-be-true, but there are plausible explanations, consistent with some ideas about how this kind of pain works.If trigger points are a purely sensory phenomenon without much pathological substance, if there is no actual lesion in the tissue, if the problem is more about how the nervous system is mis-interpreting sensation in the area… then massage might be able to easily inspire a “reinterpretation.” So not much to “fix” in that scenario; more like changing a dysfunctional sensation.


If trigger points are caused by slight nerve entrapments — tunnel syndromes, slight snagging/entrapment of nerves inside their tubes, as discussed in the chapter “Quintner: “It’s the nerves, stupid”” — then it makes sense that even gentle, subtle manipulation might free them up and solve the problem, and all the intense sensations are superfluous.


If we work within the micro-cramp hypothesis, the vicious cycle of contraction and exhaustion taking place inside a lesser trigger point may not be especially difficult to disrupt, similar to taming a macro-cramp with a quick stretch (which is absolutely a thing, not even slightly controversial). The knot may not be all that tightly contracted in the first place. The hypothetical accumulation of metabolic wastes might be relatively minor and easy to flush out,223 as conceptually simple as popping a zit (also a real thing, also not controversial).

And one final point that might account for the apparent efficacy of simple treatment…

Isolated and new trigger points are generally much easier to manage — they are probably neurologically simpler and/or the tissue state is much closer to normal. Basically, their bark is worse than their bite, and they are not pathologically “entrenched” in any way.

What does basic trigger point therapy consist of?

It’s almost entirely about self-massage, which mainly consists of learning the key features of TrPs so that you can find them, and then a few refinements beyond just random rubbing: how long to rub, how often, how hard, with what, etc, and some common mistakes to avoid. Tools like balls and rollers and canes and “guns” are also a key part of self-massage: all the usual creative alternatives for delivering pressure and stimulation to different tissues.

The basics notably exclude practically everything else: getting professional help, addressing medical factors, medications, injections, exercise therapies (especially stretch), ergonomics, and much more. You could argue that many of these things should be included in the basics, but it’s part of my manifesto that an experimental therapy like trigger point therapy should be DIY as much as possible.

I think learning self-massage for trigger points is more than enough to start with for most people.

Downloadable quick reference guide

Starting with the basics and then moving on to advanced treatments, there are many tens of thousands of words of information ahead about all the possible ways that you can attempt self-treatment of your trigger points! That’s a lot of words — a large-book-sized number of words, still to come. Fortunately, you don’t have to memorize it all.

This book includes a handy cheatsheet that summarizes all the diagnostic tips, basic treatment instructions, and advanced therapy tricks — on a single page. This is the Quick Reference Guide (QRG) to Trigger Point Diagnosis and Treatment. The QRG is in the PDF file format, which can be displayed and printed on any computer (which probably 99% of people know, but I never assume with tech). Click the links or the thumbnail below to display the QRG. They will open a new tab, and this tab will still be here. Any PDF displayed in a browser can then also be saved. Maybe not a bad idea to print it out and have it handy while you’re reading through the tutorial.

The quick reference guide condenses all key diagnostic & treatment points, tips & tricks into a single page. Laminate it, put it on the fridge!

Open in new tab/window.

Basic self-massage instructions

You can’t treat it if you can’t find it, but finding trigger points is the hardest part, even for experts. It is the exact opposite of an exact science, as I have emphasized in detail previously in the diagnosis chapters. However, I’m going to recap the highlights for self-massage in a practical way. So how do you try to find trigger points?

First of all, you don’t sweat it too much: sure you try, but you also just cast a wide and pleasant net. The first rule of massage for trigger points is that any good massage is probably better than bad trigger point therapy.

But of course you still look for them! And mostly you just grope around stiff, sore muscle tissue with fingers and thumbs and find small, acutely sensitive spots.

You may or may not feel a slight bump or twitch when you hit a trigger point, but those are inconsistent and unreliable signs. Do not put much stock in them.

More importantly, the soreness of a trigger point should feel “relevant” — that is, the soreness of the spot should feel like it is related to the discomfort you are trying to treat, rather than some other kind of discomfort that just happens to be in the same area.

It should also feel good — a paradoxical combination of soreness and relief we call “good pain.”

You can limit your exploration to a fairly small area of muscle tissue around the “epicentre” of your symptoms, but some trigger points are surprisingly far from the pain they cause, usually closer to the center of the body. For instance, wrist pain may be caused by trigger points in the forearm muscles up near the elbow. (But trying to figure those out is going beyond the basics.)

How do you rub a trigger point when you hope you’ve found one?

It’s not rocket science. “Rubbing” is really all there is to it. But rubbing exactly how? There are some specifics to consider…

Rub in what way? For simplicity, either simply press on the trigger point directly and hold for a while (10–100 seconds), or apply small kneading strokes, either circular or back and forth, and don’t worry about the direction of the muscle fibres. Really, anything that feels good is fine. But, if you happen to know the direction of the muscle fibres — sometimes it’s obvious — then stroke parallel to the fibres as though you are trying to elongate them, because that might be more effective.

Rub how hard? Massage is mostly about having a conversation with your nervous system, so you want it to have the right tone: friendly and helpful! Not shouty and rude. You’re not trying to “kill” it, you’re trying to soothe and “scratch” it. The intensity of the treatment should be Goldilocks just-right: strong enough to satisfy, but easy to live with. Too much intensity can backfire, and a just-right intensity may actually be a key to success. So, on a scale of 10 — where 1 is painless and 10 is intolerable — please aim for the 4–7 range, and err on the side of gentle at first. Beginners are often much too aggressive. (And the pros too!)

And rub very gently, too! Regardless of your maximum pressure on any point, always make sure there’s some light pressure as well. Specifically just gentle tugging of the skin to and fro. It’s important to include this because it might be more effective, depending on the cause. We cast a wide net with technique as well as locations.

Rub how much, how often? Start small—a single session of about 30 seconds might be enough, give or take depending on how helpful it feels. Five minutes is roughly the maximum that any trigger point will need at one time, but there is not really any limit — if rubbing the trigger point continues to feel good, feel free to keep going. As long as you aren’t experiencing any negative reactions, you should massage any trigger point that seems to need it at least twice per day, and as much as a half dozen times per day. More is probably too tedious and involves too great a risk of just pissing it off.

Rub with what? Rub the trigger point with your fingertips, thumbs, fist, elbow … whatever feels easiest and most comfortable to you. Simple tools are really handy for spots that are harder to reach. And I don’t mean specialized massaging tools — just a tennis ball, or other handy household objects. More information about massage tools is coming soon.

And what if rubbing backfires? It probably won’t. But if your symptoms worsen in the hours after treatment … simply ease up and use less pressure, less often. In basic therapy, you can always count on trigger points adapting to stronger pressures over the course of a few days of cautious experimentation. If they don’t, either the problem isn’t really trigger points, or they are simply worse trigger points than you thought!


How do you know it’s working? Getting a trigger point to “release”

The goal of self-massage for trigger points is to achieve a “release.” What is trigger point “release” and what does it feel like? It mostly refers to an easing of sensitivity of the trigger point, and/or a softening of the tissue texture.

But release is a painfully vague term with no specific scientific definition. It’s a label for the unknown, for whatever is going on when the trigger point seems to go away. Maybe it refers to the literal relaxation (or even the violent disruption!) of the tightly clenched muscle fibres. Or maybe it’s “just” a sensory adaptation, which might be a kind of healing (it just stops hurting), or trivial and temporary (like scratching a mosquito bite).

A release may not be obvious. In fact, things could even feel worse before they feel better: tissue might remain “polluted” with waste metabolites even after a successful release. Release might even require some damage to the tissue of the muscle knots — that is one theory. If so, the area would probably still be quite sensitive even if you’ve succeeded.

Again we can use the acne analogy: like popping a zit, some harm may be done in the process of helping.

In my experience — both treating and being treated — it’s a weird mixture of these possibilities: initially there’s a satisfying but profound sense of scratching an itch, but the tissue is actually more sensitive afterwards, not less.

Don’t worry about the details: just stimulate the trigger point, and trust that you probably achieved a release, or a partial release, and then wait for the trigger point to calm down. If you were successful, you will notice a reduction in symptoms within several hours, often the next morning.

The role of good pain

Generally speaking, with easy trigger points, successful release is usually associated with “good pain” — that clear, strong and satisfying sensation that is somehow both painful and yet also relieving. It is positive in the same sense that throwing up is positive: it’s not exactly pleasant, and yet your body “knows” that it needs and wants the pressure. Usually, if you feel “good pain,” a trigger point release is likely.

On the other hand, if you are wincing or gritting your teeth, you probably need to be more gentle. Ease and comfort is an important component of successful treatment. If you can’t massage the trigger point without wincing, either you’re being too brutal on yourself, or the trigger point is simply too severe. Sometimes a trigger point will feel nasty and hot and burning and still release anyway. But often such a rotten trigger point will need more persistent or smarter treatment.

In the advanced troubleshooting sections, I will talk about other clues to watch for that indicate that a release is in progress.


Basic tips and tricks for better, longer-lasting trigger point release

Trigger point massage often provides only partial and temporary relief. Here are several easy things you can do to improve your batting average:

Some of these are the beginnings of advanced approaches that will be discussed in much greater detail below.


Top 5 mistakes beginners make

The shortest path to success in a new endeavour is to simply learn about and avoid the mistakes made by beginners.

The main mistake beginners make is misdiagnosis: they shouldn’t even be trying to treat trigger points in the first place! But let’s set that tricky problem aside here, and assume that the diagnosis is correct and attempting treatment is a worthwhile experiment. How does that go wrong?

In trigger point therapy, beginners routinely sabotage their own results, getting only partial and temporary relief. There are several common mistakes in self-treatment that probably undermine results, or even make things worse. Avoid these mistakes! If you do, there’s a much better chance that your efforts will work much better, and your trigger points won’t come back.

  1. The wrong trigger points! Of all the things that can go wrong with your self-massage technique, this is the most common — simply missing the trigger point entirely. Sometimes it happens just because you lack experience identifying the feeling of trigger points (you miss them by a millimetre) but more often because of being misled by referred pain (you miss them by a mile, prodding muscles in the referral pain zone). But don’t feel bad: referred pain is a confusing phenomenon that can baffle amateurs and professionals alike. You just have to keep experimenting and learning — don’t be afraid to just throw a lot of massage at the problem, and try lots of spots throughout an area. And study referred pain patterns and try to understand where the trigger point might really be. There will be a lot more advice about how to locate trigger points in the advanced treatment sections.
  1. Excessive treatment intensity! It’s tempting to be brutal with a trigger point when you find it. Resist this temptation, especially at first, especially if you’re new to this. Strong intensity may be appropriate in time, but you must work your way up to it. Or high intensity could be the wrong approach altogether, and you can only ever achieve your goal with a gentle approach. Some trigger points need to be treated like a skittish horse.
  2. Ice and chills! Getting chilled or applying ice to trigger points may bring them roaring back. (A notable exception is that ice is probably harmless or even helpful when you’re alternating it with heat, “contrasting,” discussed below.) Drafts on the skin at night, especially on the neck, are one of the reasons why “I woke up with it” is such a common way for muscle pain to start (or return). Conversely, muscle pain mostly likes heat, and hot baths and heating pads will often aid trigger point treatment (or at least not sabotage it).
  3. Overexertion! Many beginners do not give themselves adequate time to recover from treatment. Intense muscular effort will usually aggravate a trigger point. The most common way that this happens is either with overly enthusiastic “weekend warrior” recreation, too soon after relieving a trigger point, or by going to the gym to try to “work out” the stiffness. See the footnote for another sordid tale of self-sabotage.225
  4. Awkward positions! Sleeping or working in awkward positions with muscles spending hours in an unusually lengthened or shortened state is another common way that people get trigger points flaring up … or coming back soon after releasing them. Plane rides are another one that I hear again and again. Spend long enough in a position, it doesn’t have to be particularly awkward to be a problem. There are a variety of reasons why awkward and sedentary positions can increase stiffness and soreness, so it’s not necessarily all about the trigger points — but flare-ups of those sore spots we call “trigger points” do seem to be one of the major reactions.

These factors will all come up here and there for the rest of the book, and I’ll also discuss other, more obscure mistakes that can sabotage treatment.


What about massage tools?

This is a massage therapy client describing an experience she’d had with an orthopedic physician:

He didn’t know about using tennis balls for massage! He asked what helped my back pain, and I told him I always lie on a tennis ball. He looked at me like he was going to refer me to a psychiatrist! How can an surgeon not know about the tennis ball thing? Doesn’t everyone know about the tennis ball thing?

Unfortunately, no: not everyone knows about the tennis ball thing. But it is a time-honoured simple self-treatment for chronic muscle aches and pains, much like “the hot bath thing.”

A tennis ball is just a cheap, handy, portable self-massage tool that you can use on suspected trigger points. It’s like a tiny little foam roller. It’s like a more accurate foam roller. And many people have one just lying around.

Basic technique for trigger point massage with a ball

The basic idea of any massaging with any kind of ball is to apply specific pressure to a stiff or aching spot in a muscle by trapping it between your body and something else: usually the floor, sometimes a wall, or another body part (or a few other creative options like the back of the couch, the bottom of the bathtub, and so on). The point is to use the ball to reach spots that you simply can’t get to with your hands, or can’t press firmly enough. And every other kind of massage tool is a variation on this theme.

This is in fact exactly like foam rolling, just less trendy and more precise. Both have their strengths, but if I could only use one of them for the rest of my life, I would definitely choose the tennis ball for the accuracy and versatility.

Tennis ball massage is the most useful in the muscles of the back and the hips: places where you can actually lie down on the tennis ball, pinching it between your body and the floor or wall. Many other locations are awkward (especially for beginners), and you may find it difficult or impossible to apply pressure effectively.

Lie down on a tennis ball, placing it in approximately the right location. You do not have to be precise. “Explore” by moving slowly and gently, until you’ve got just the right spot.

The limitations of tools

Tools are great for spots that you can’t reach any other way, and for spots that need more pressure than you can apply with your hands. But they aren’t perfect. One reader put it this way:

I have every knot remover gadget on the planet: the foam roller, lots of different balls, TheraCane, a 2-headed percussion massager, the Knobber, etc. However, in the end I find my fingers do the best job.

 Cindy Corriveau, Calgary

That has been my experience as well: no matter how clever, massage tools can’t touch the sensitivity and dexterity of your own hands. Always try to use your hands to reach a muscle knot first; resort to tools only when necessary.

That said, it often is necessary!

Don’t worry too much about what tools to get

Of course, it doesn’t have to be a tennis ball…

And of course there are now many, many kinds of therapy and gym ball available.

A simple selection of balls — I have had a “bucket o’ balls” around for many years now — gives great bang for your buck, and anyone who has a tough muscle pain problem should have one. Most of the balls in a good bucket o’ balls can be purchased in one trip to a sporting goods store and maybe a pet store. A bucket o’ balls and a bit of practice is like having 50% of a good massage therapist on call for the rest of your life, for the tiniest fraction of the cost of therapy. A ball certainly can’t do it all, but it’s a good start and an incredible value!

Use tools at your discretion. In the advanced troubleshooting sections, I will discuss tools in much more detail, both commercially available tools and free or cheap tools. I will recommend several specific ones, warn you away from pointless expensive ones, and suggest clever tactics for getting the most out of any massage tool.


Can you damage your nerves when self-massaging?

Is this a realistic scenario? Can you damage nerves with self-massage? Here’s the executive summary for this section: no. Case closed.

Yes, you can damage nerves by massaging, but it’s rare and rarely serious. I did it to someone just once in ten years working as a professional massage therapist — I tell the story below. Mostly nerve trauma is not something we need to worry about, but it’s a common concern anyway, driven by excessive “nerve fear” in our society (discussed above). I get a lot of questions like this one:

One thing that helps sometimes when my neck pain gets excruciating is to really dig my fingers hard into a couple of muscle knots in the back of the neck (not right on the spine but off to each side, below the occipitals), or to use a Thera Cane to do the same thing. Is there any chance of causing nerve damage from so much pressure?

reader Peter Spaeth, Boston

I’m going to answer this in detail so that you have good confidence about this issue. I’ll discuss the physical protection most nerves have, some of the potentially more vulnerable locations (endangerment sites), the toughness of nerves, and the extra caution needed with tools.

Why nerves are not very vulnerable to massage

If you are even slightly cautious, it is nearly impossible to damage your nerves with self-massage, because:

  1. larger nerves are mostly padded well by other tissues
  2. healthy nerves are not especially fragile or sensitive
  3. if actually threatened by trauma, nerves produce plenty of warning sensations that will stop any sensible person before much harm is done

Let’s look at those in more detail …

Larger nerves are mostly protected

The larger nerves and nerve roots — the only nerves of any concern — are mostly shielded by skin, fat, muscle, and bone. It’s particularly unlikely that you could harm yourself by massaging in the location Peter asked about, on the back of the neck (beside and behind the spine). The only prominent nerves in the back of the neck are the nerve roots, the bundles of nerve tissue that emerge from between each pair of vertebrae. But these are under at least a half inch of sturdy musculature, the meaty paraspinal muscles.

But not all nerves are well-protected, of course.

Endangerment, Will Robinson!

There are a few places in the body where nerves are more exposed and can be injured by stronger pressures. All of these sites are familiar to any well-trained massage therapist: we call them “endangerment sites,” but the danger is minimal. Perhaps a better thing to call them would be “unpleasant places to rub.”

Here are all of the commonly cited endangerment sites (nerves highlighted):

Endangerment sites
anatomic location (plain English) potentially vulnerable anatomy
Anterior Triangle of the Neck (throat) carotid artery, jugular vein, vagus nerve; under sternocleidomastoid
Posterior Triangle of the Neck (side of the throat) nerves of the brachial plexus, proximal; brachiocephalic artery; subclavian artery & vein
Axillary Area (armpit) brachial artery, axillary vein & artery, cephalic vein; nerves of brachial plexus, distal
Medial Epicondyle, Humerus (inside elbow) ulnar nerve
Lateral Epicondyle, Humerus (outside elbow) radial nerve
Umbilicus region (belly) descending aorta & abdominal aorta
lateral 12th rib (lowest rib) kidneys
Greater Sciatic Notch (buttocks, beside tailbone) sciatic nerve
Inguinal Triangle (groin) external iliac artery; femoral artery; great saphenous vein; femoral vein; femoral nerve
Popliteal Fossa (back of the knee) popliteal artery & vein; tibial nerve
Hollow under the earlobe parotid salivary gland, facial nerve

The endangerment sites are debatable and in some cases definitely misleading. Nerves are everywhere, and there are many locations where they are potentially just as vulnerable to pressure as some of the ones listed above … but no one has ever proposed them as endangerment sites.226 The idea that the sciatic nerve is “exposed” to any degree in the sciatic notch, for instance, is a bit ridiculous (compared to the ulnar nerve, say).

And you can easily massage the scalene muscle group (in the posterior triangle of the neck) without ever bothering a nerve fibre. Extra caution is justified in this area, but not because the brachial plexus is notoriously sensitive — it’s more because of the blood vessels.

If you massage these locations with reasonable caution, you might feel electrical, zappy, funny-bone-esque pains, but you will feel them before there is any actual danger. Healthy nerves aren’t particularly sensitive, but they will speak up if they are on the verge of being crushed or torn (like any tissue).

Nerves aren’t very fragile or sensitive

Most nerves, most of the time, can be firmly squeezed without producing any symptoms whatsoever. The ulnar nerve — the “funny bone” — is tolerant of almost any fingertip pressure, and only produces that infamous zing with much greater force.

However, there are almost certainly circumstances where nerves can be more sensitive. For instance, they may only be sensitive to pressure when oxygen-starved (or otherwise vulnerable). Which may be exactly what’s going on with some of the nerve tissue in your neck — muscles rotten with trigger points are measurably hypoxic, low-oxygen.227

And so, one way or another, nerve roots in the posterior of the neck might sometimes be sensitive enough that you may get some stranger, nervier sensations when self-massaging in the neck. However, this sensation tells you nothing you didn’t already know: your soft tissues are cranky. There is no cause for concern if the sensations are easily tolerable.

In my experience, however, blatant nerve sensitivity in the neck is rare in association with neck cricks, even quite severe ones.

Or maybe they are naturally sensitive? But not in a “zappy” way

Another intriguing possibility is that the sensitivity of nerves and trigger points are actually the same thing — trigger points might be the sensitivity of vulnerable nerves. This idea is thoroughly discussed in the section, “Quintner: ‘It’s the nerves, stupid’.”

If so, then pressing on them isn’t likely to injure them, or even cause clasically zappy nerve pain: just the familiar aching and burning of common muscle pain. The nerves are clearly vulnerable in some sense, but probably not to injury.

There’s another sense in which nerves might be “naturally sensitive,” and more vulnerable. There are several mechanisms by which nerves can become pathologically over-sensitive after an initial insult, causing the pain to drag on and on. For a long time, no one had any idea why this happened to some people and not others, and it really does seem to be a binary phenomenon: either it happens or it doesn’t. Unfortunately, one likely explanation was identified in 2010: genetics228 That is not great news, but it is interesting and at least a little bit useful.

So chronic pain could be due to on-going irritation of nerve tissue, but it could also be entirely due to a malfunction of the sensory equipment itself. A fascinating possibility (and a rather bleak one).

The point: be wary of therapeutic wild goose chases looking for mechanical causes of pain. Neuropathy, when it happens, is definitely not necessarily just about physical insult, but about our vulnerability to it.

What happens if you push your luck and push too hard on nerves?

Push hard enough, and you can injure a nerve, of course. In a 2017 incident, a woman’s radial nerve was crushed by an aggressive massage in her upper, inner arm. It’s rare, but it happens.229 Deliberately ramping up pressure on a sensitive nerve is hard to do, like sticking your hand into a jar of scorpions. And yet, surprisingly, sometimes people still do it! It’s amazing what we can put up with if we think it’s necessary, and the no-pain-no-gain attitude inspires a lot of foolishness.

Nerves can recover from a lot of abuse, up to and including being mangled in nasty accidents, or being pinched hard for years. For instance, many people who have severe carpal tunnel syndrome — years of disabling median nerve impingement — often recover just fine once pressure on the nerve is finally relieved by surgery.

In the unlikely event that you cause yourself a nerve injury, it would probably only result in annoying but trivial symptoms that would take a few days to resolve, or perhaps a few weeks at the worst. But I have rarely heard of this happening by self-massage — it’s just too unpleasant as you approach the point of injury to actually get there.

Please beware of tools

I’m sure that there are people, somewhere out there, who have hurt their nerves with self-massage. And I bet most of them were using a massage tool. When you use massage tools, it may be easier to apply too much pressure too quickly … before you have that “I’ve made a huge mistake” moment.

It’s harder to control tools, and hard to tell what’s going on when you’re sensitive fingers and thumbs aren’t involved. For example: you can easily feel the pulse of an artery when you are massaging with your fingers, but you can’t feel it at all when you use a tool.

So if you use a tool, use it with extra caution.

That one time I injured a client’s nerves

Once upon a time I pushed my luck, and injured a patient’s cervical plexus — this area where most people will probably never self-massage strongly. I injured him by applying strong pressures in a vulnerable area too quickly. It was one of my more reckless moments in a decade of mostly quite gentle massage.

He was alarmed and unhappy with me, of course, but his symptoms were minor: he had annoying flashes of moderate pain that slowly faded over about three weeks, and probably the worst thing about it was simply that he was less sure of his prognosis than I was. I knew he’d get better steadily, but he didn’t know if he could trust my opinion! Fair enough.


Don’t hesitate to recruit amateur help

Do not underestimate the value of amateur assistance! A creative and generous amateur can be just as effective a trigger point therapist as the average professional, certainly for easy cases — and even for difficult ones!

A helper — spouse, partner, friend, etc. — can be an incredible resource, and many people do have a willing helper available. Don’t hesitate to make it a family project. Back in massaging days, I sometimes invited helpers to my clients’ appointments to provide basic training. Adequate therapy could then continue outside my office, and the price was nice. Just as self-treatment is a realistic and affordable alternative to professional trigger point therapy, so is amateur help.

Another reason that amateur helpers are an important resource is that they are often better listeners than professionals. Whether it’s due to a lack of confidence, or simply being friendlier with you, or both, amateurs will often be much more responsive to your requests for changes in pressure or location than professionals are. Sadly, many professionals are too preoccupied with their own ideas and forget that therapy is an intricate partnership. Trigger point therapy with a helper invariably works better when there is lots of communication, because the patient can provide so much valuable information about exactly which location and how much pressure feels the most effective.

Of course, not everyone’s partners are helpful. Some just don’t want to do massage. Or they are willing but, unfortunately, do not listen well.

Another not-so-good scenario is when amateurs are too confident, and think they know what they’re doing and insist on imposing their ignorance. They may have misinterpreted ideas they got from competent professionals, or they’ve gotten bad ideas from incompetent professionals, or all of the above. When you encounter such a well-intentioned, overconfident know-it-all, you have to either educate them — give them this tutorial! — or fire them and find someone else.


A little more perspective on amateur assistance

Half the challenge of trigger points, maybe more than half, is simply recognizing their importance in the first place — getting to the point where you accept that trigger points are your problem, or a large part of it. Many people need a professional to help them get to that point, or a tutorial like this, or a popular book like Clair Davies’ The Trigger Point Therapy Workbook.

I have often worked with patients who seem to have readily treatable cases of muscle pain in the low back, but who have been given dozens of different diagnoses over the years, many of them scary. Such people are unlikely to believe, at first, that simple trigger point therapy might be all they ever needed. And no amateur can help them through that process: only a confident professional, putting the diagnostic possibilities in perspective, can guide a frustrated, cynical, and confused patient to that awareness.

But once you are there … the therapy itself can be quite easy! So easy that even an amateur can do it. As you’ve seen in the preceding sections, trigger point therapy is not difficult — most of the time it’s just a little rubbing.


How to get adequate professional help

All tutorials have a strong focus on self treatment, and on other solutions that minimize cost and dependence on expensive health care. I believe in empowering patients through education to do every possible thing for themselves. This is particularly a good idea in the case of trigger points, because so few health professionals are well-qualified to treat them, and because self-treatment really can work minor miracles.

But sometimes you really do need a little help. 😜 And in the case of trigger point therapy, it won’t be cheap to get help: rates start at USD $60/hour in North America, and can go much higher.

You don’t necessarily need help because your case is difficult.

It can make perfect sense to seek out professional help before attempting advanced self-treatment tactics. For instance, it may simply be a matter of an awkward spot, and a lack of a friend or family member available to help. Or it may be a relatively mild trigger point that you simply can’t locate — you know it’s there somewhere, but you’re having trouble figuring out where. So, even for mild cases, you may want to seek professional help.

I will address this topic in much more detail in the advanced troubleshooting sections below, suggesting a wide variety of therapy options. But for basic cases, my recommendation is that you simply find any massage therapist you like. Just as with locating trigger points themselves, you can largely trust your instincts.

Simply find a massage therapist who seems friendly, curious and responsive to your requests. After reading this tutorial, there is a really good chance that you will actually know more about trigger points than the therapist, so don’t be afraid to politely ask for what you want. Of course, you should also be open to their suggestions. But the scenario you want to avoid is the bossy therapist who puts all his or her energy into their own pet theories, completely neglecting what you asked for — a bizarrely common scenario, unfortunately.

Also, looking for a massage therapist who does “medical massage” is a reasonably good way of finding someone competent.


Common medications that might make a difference (and might not)

The commonly used over-the-counter medications are anti-inflammatories like ibuprofen, Tylenol, codeine, alcohol & muscle relaxants.

As anyone with anything more than a mild case of muscle pain knows, there are no over-the-counter pain medications that are going to make a significant, lasting difference. However, ordinary pain medications are the first line of defense for tens of millions of people. Patients often try virtually everything at their local pharmacy, sometimes stumbling on a medication that seems to make a difference for a while, but usually finding that medications simply don’t do any more than take the edge off.

In the spirit of “basic” treatment options, this section will only summarize the widely used and non-prescription drugs: ibuprofen, Tylenol, codeine, muscle relaxants and even alcohol. None work well, and none offers anything like a cure. All of these options are worth cautiously experimenting with. All of them are problematic and pointless in excess.

Anti-inflammatory medications are worth trying, but rarely work any miracles, probably due to the fact that trigger points are not really a problem with acute inflammation. When ibuprofen seems to work, it may just be because trigger points often co-exist with inflammatory problems, such as some minor tendinitis, for example. An interesting, related option is Voltaren gel: ibuprofen in an ointment, basically. Again, it’s not likely to magically eliminate trigger points, but it’s certainly worth a try, and is probably the safest of all medication options. See the Voltaren section for more information.

Straight acetaminophen (Tylenol) seems to do almost nothing for muscle pain for most people, and it’s infamously hard on the liver.

Codeine (mostly available in low dosages Tylenol 2s and Tylenol 3) won’t treat trigger points, but seems modestly effective because it’s deeply relaxing. Unfortunately, codeine also makes people so dopey that it’s just not useful except at the times of greatest need, and not all that much even then.

Alcohol is hard on your system in many ways, and hangovers obviously increase muscle pain. However, anecdotally, moderate usage seems useful for taking the edge off trigger point pain, probably via sedation and the “I don’t care if it hurts” effect. It’s hardly a cure, and you can’t go through life drunk any more than you can be constantly high on codeine, but it can offer some relief. Do beware of a particularly sneaky side effect: alcohol is well-known to compromise sleep quality.230

Muscle relaxants come in several varieties, but only one that is widely available without a prescription: methocarbamol, as found in Robaxin, Robaxacet and similar brand names. A muscle relaxant is the one drug in this section that seems to have the potential, in principle, to actually treat trigger points (as opposed to masking the pain of them). However, they just don’t work well. Methocarbamol is so surprisingly useless, in fact, that I’ve also included it in the treatment options hall of shame: the “Reality Checks” section. The unexpected uselessness of muscle relaxants is explained in detail below.

There are a few other medications, or medicine-like options, that are also in the “Reality Checks” section: the homeopathic ointment Traumeel, Epsom salts, and drinking extra water are three popular ones that almost certainly do not have any effect on trigger points.


Part 5

Advanced Trigger Point Troubleshooting

What can you do about severe and persistent trigger points?

There is a groan that unites men and women, rich and poor, in any nation. These [muscle] pains are “explained” in every culture, but the universal fact of this persistence must mean that no adequate therapy exists.

Professor Patrick D. Wall, FRS, DM, FRCP, in the Foreword to Muscle Pain: Understanding its nature, diagnosis and treatment

The basic advice given in the sections above is more than enough for most people, most of the time to deal with their trigger points well enough. But what if your case is more challenging? The second half of this book is devoted to troubleshooting trickier cases of myofascial pain syndrome — even cases involving many severe, active trigger points that seem to resist all forms of treatment and go way beyond “stubborn.”

What if you came to this book already familiar with the basics, but you’ve never really been able to do much better than just temporarily take the edge off? What if the book so far is all old hat to you? What if you already have some idea what to do about them (score one for you), but they just keep coming back (score one for the trigger points)? This is a common deadlock.

Many people who “discover” a trigger point diagnosis are initially excited by the possibility of relief … and then disappointed as self-treatment and therapy seem to go nowhere fast. Even when you are “correctly” treating the right trigger points, or even getting them treated by a professional, sometimes they just won’t go, or they come back so fast that you might as well have not even bothered!

Trigger points seem to be much easier to deal with below some unknown critical mass of numbers and severity. Above that line, things get much tougher. Many trigger points seem to reinforce each other: the more there are, the faster they all get worse, and the harder it is to deal with any of them. The tough cases feel like a sinister game of Whac-A-Mole.

You may get very little relief at all, or you may get good relief but only for a short time, or none of the above. Treated trigger points may come back in a day, a week or a month. Worse yet, treatment may even backfire — yikes! Some people do experience nasty negative reactions — aggravated symptoms, severe bruising, nausea.

The problem of trigger points that always come back, or never really go away in the first place, may or may not be fixable, depending on the details of your story and your body. In general, the only way to find out if it’s possible to beat such trigger points is to try a lot of things, and that is why the rest of the tutorial is so long. The tactical “secrets” to advanced trigger point troubleshooting are creativity and persistence — to throw everything at the problem but the kitchen sink. There’s no single magic bullet, but many small lessons that slowly accumulate into more of a cure than you used to have.

I’m always reassuring readers and clients that learning to deal with your trigger points (muscle knots) involves a long learning curve. In the vast majority of these cases, continued experimentation can still result in longer-lasting results. No one has “tried everything,” not by a long shot. Most people are not familiar with more than 2 or 3 treatment options out of the dozens of possibilities we will discuss here. For instance, I got through my entire clinical career as a massage therapist without ever once trying spray and stretch therapy — which is probably one of the most worthwhile things to try!

Even when trigger points can’t be “cured,” it’s often possible to learn to manage them to the point where they become no big deal. Compared to constant suffering, that practically is a cure. But the only way to get there is to keep trying new things. The sections ahead are designed to give you some hope, a sense of the possibilities, and every possible option — every tip, trick and useful perspective I can think of, after a decade of study and practical experience and constant exposure to extreme cases from every corner of the globe.231

But before we get into all the tips and tricks, I want to devote a section to another popular trigger point self-treatment manual, The Trigger Point Therapy Workbook, by Clair Davies, and why it is not actually suitable for helping many people with difficult cases of myofascial pain syndrome …

A brief detour: why not The Trigger Point Therapy Workbook?

This is an abridged version of my full review of the Workbook.

Clair and Amber Davies’ popular book is well-written and has many virtues. In particular, it is illustrated well, and offers detailed muscle-by-muscle reference material — something this tutorial actually deliberately lacks.

I used to wonder why I even bothered to create this tutorial! Why not just recommend the Workbook? Why reinvent the wheel?

It turns out there’s quite a good reason! More than I originally expected. Today, this tutorial offers a lot that you can’t find in the Workbook.

The strength of this tutorial is depth: the delving into the nature of the beast, particularly the science reporting. That strength has grown while the Workbook has fallen behind the times. The 3rd edition, published in 2013, not only promises too much to patients, but fails to explain the importance of many significant scientific developments and controversies.

The Trigger Point Therapy Workbook

The Workbook promises too much & neglects relevant science.

The Workbook has always promised too much. In the first edition in 2001, Davies tried to convince readers that trigger points are responsible for practically everything that ever hurt you or ever will, and — even worse — he certainly gave readers the idea that self-massage is a nearly infallible cure. That was absurd even then,232 but it was also more forgivable twenty-one years ago. The 3rd edition should have been much more cautious and humble. It should have explained that trigger point science has had many disappointments and problems, and that we have important new ways of explaining this kind of pain that have nothing to do with muscle tissue. It did not, and failing to even acknowledge the controversies is a deal-breaker in my opinion. This topic is too important for such neglect.

Fortunately, trigger point therapy based on the conventional wisdom still seems to offer people some relief. Massaging trigger points is no miracle cure, but it often helps. I have heard from many patients and readers who seem to have gotten some benefit from the Workbook … but it also gave them unrealistic and simplistic expectations. It did not help them troubleshoot their difficult cases. (How can it, when it doesn’t even admit that there are legitimate questions about what trigger points really are?)

My goal when I set out to perfect this tutorial was to offer people a more realistic view of trigger point therapy — to meet the challenge of difficult cases head on, and to offer you every possible option for treating them, and even the worst of all trigger points — even while explaining the limitations of those options. I believe it has been doing a better job of that than the Workbook for many years now, and it will only get better as I continue to update it and keep up with the science.


Some important things to keep in mind about placebos

A placebo is relief from belief: people often feel better simply because they believe they have been treated. More precisely, it is the appearance or illusion of a treatment effect that is not actually attributable to a biological treatment mechanism. It’s a fascinating phenomenon, but its “power” is over-hyped.

This is a standard section in most of my books, covering several key points about placebo that are important context for any thorough discussion of evidence-based treatment options. I do not substantiate any of these points here — all the references are in a more detailed article about placebo.

We have a word for medical treatments that only work if you believe that they will, and it rhymes with “gazebo.”

Book Review, Unlearn Your Pain [Schubiner], by Scott Alexander

Is it okay to pay for a placebo?

Many people claim to be happy to pay for a placebo. As long as it works, who cares how? And placebo can work! So why not? This is an extremely common sentiment, raised in most discussions about a treatment that failed to beat a placebo in a fair test (invariably overlooking the fact that neither the treatment nor the placebo actually work very well).

I have no problem with people paying for a placebo as long as their eyes are wide open, but the wider your eyes get the less likely you are to get even a minor benefit.

And paying for things is never completely harmless.

Treatments with unknown efficacy but some plausibility and low risks are the least objectionable placebos to pay for. I’ve tried many such treatments, knowing full well that any effect I enjoy is probably just placebo (or regression to the mean, or natural recovery)… but it might be an actual effect, and I’m willing to pay a little for that chance. I’m gambling on getting a genuine benefit, with a bit of placebo as a consolation prize. So, for me, the plausibility has to be there.

Comic strip of a man standing in front of shelves full of bottles and boxes. On the left, the products are labelled “Placebos.” On the right, they are labelled “Fast-acting, extra-strength placebos.” The caption: “Hmm, better go with these.”

Cartoon by Loren Fishman,

What I want readers to take away from this is that placebo is not therapy. It’s mostly just an over-rated curve ball that accounts for an awful lot of temporary “success” stories.


Fundamental limitations of trigger point therapy, and how to take advantage of them

Trigger point therapy can be pretty much hit or miss. If you do it yourself, you may be less effective than a professional, but at least you won’t go broke trying. It’s best not to pay upwards of a buck a minute for trial and error when you can experiment on yourself at no charge, and safely.

This is the raison d’etre of this website, actually: when the professionals are nearly as unreliable as you are, you might as well save yourself instead of paying for professional shots in the dark. Obviously there are limitations to self-treatment — some spots you just can’t reach! — just as there are limitations to professional therapy. The only dramatic difference between professional care and self-treatment is the cost.

The beauty of trigger points is that you can use the worst things about them to your own advantage. They may be tricky and stubborn and weird, but you have time to mess around. You can wait. You can experiment. You can fiddle. For free. For years, if necessary — as long as there’s evidence that you’re gaining ground.

This section covers the three most basic problems with trigger point therapy and how self-treatment is a generally good solution for them. (And some good examples of pointlessly expensive therapy are provided in the footnotes.) Two more sections after this cover more specific challenges with self-treatment: common mistakes, and more serious common barriers to success. But there are three really fundamental limitations to trigger point therapy to consider first, for both the pros and their patients:

  1. Locating trigger points can be tricky, and it’s hard to treat what you can’t find.
  2. Even when you’ve found trigger points, they don’t necessarily go away just because you squish ‘em, stretch ‘em, heat ‘em, or any of the other common treatment themes.
  3. And even if they do go away, they usually don’t stay away: trigger points have a nasty habit of coming back.

Fumbling around with diagnosis. Trigger points are really not at all easy to confidently locate, and (as discussed far above) research has clearly shown that even the professionals cannot really be counted on to find them for you. Thus, hunting for trigger points invariably involves a certain amount of expensive fumbling around. When I was a Registered Massage Therapist, I was painfully aware that $1.67 was flying out of my patient’s pocket every single minute as I hunted around for their trigger points — I ought to be damned good to justify that kind of expense, and the sad truth is that I wasn’t always.233

The right professional may be able to “fumble better,” and give patients a lot of good treatment ideas. But, as your own patient, you definitely have an advantage: you literally have all day to find the right spot.

Fumbling around with treatment. And then there’s the mystery factor, the overall scientific cluelessness about why trigger points form in the first place — not what they are, but why they happen — the impossibility of being confident about exactly what flavour of treatment is going to make them go away. Professionals are definitely not privy to the magic trigger-point-begone formula, and while extensive hands-on experience undoubtedly leads to somewhat higher quality experimentation, it’s experimentation nevertheless, and — once again — the experimenting is expensive.234 But patients can and should experiment with different approaches willy nilly. As a patient doing self-treatment, you might or might not get results, but at least the insult of a great expense is not added to your injury.

Fumbling around with perpetuating factors. The third basic problem with trigger point therapy is that a trigger point comes back, like The Cat in the Hat. The forces that tended to lead to them in the first place routinely result in their resurgence. Even “successful” trigger point therapy is notoriously prone to being temporary. But, once again, we can snatch victory from the jaws of defeat thanks to the logic of self-treatment: if your benefits are going to be brief, better that they also be cheap!

It’s also largely up to patients to make changes in their lives that make them less prone to persistent trigger points. A good therapist may have excellent suggestions for things to try, but an educated patient is nearly as capable. How hard is it, really, to guess that your crappy, uncomfortable office chair may be the reason your trigger points just keep coming back? If stress seems to be a factor in the stubbornness of your muscle pain, that’s not particularly difficult to figure out — certainly not after doing a bunch of reading on this website — and it’s also a deeply personal problem to solve, and the solution likely doesn’t have much to do with physical therapy or massage therapy.235


Several more treatment mistakes and problems (that you can fix)

In the basic self-treatment sections, I introduced the five most common treatment mistakes and reasons why self-treatment often fails. Unfortunately, it’s possible to avoid all of the most obvious errors and problems and still fail — because there are all-too-many ways to fail, some of which you can control (this section), and some of which you can’t (next section).

I will now introduce some more fixable mistakes and manageable problems. All of these will be discussed in more detail throughout the rest of the tutorial, and you can cherry pick and read more carefully about the issues that are most important to you.

Poor massage technique. I’m sorry to say it, but your self-massage skills may simply not be up to par yet! This problem is neither common nor uncommon. Good technique is actually not very important, because you can get away with poor technique when treating a typical trigger point. They just aren’t that picky — any kind of rubbing will do. As Dr. Janet Travell wrote, almost any kind of stimulation has the potential to help your trigger points.

But the other side of this coin is that, unfortunately, there is just not much scientific evidence to guide us in determining exactly what will work the best for most people, most of the time. Some of those trigger points just won’t respond to sloppier technique. And when mediocre massage tactics meet more severe trigger points, failure is almost inevitable. Figuring out what works for you is a personal matter of trial and error … sometimes quite a lot of trial and error. One of the main goals of the advanced troubleshooting sections is to upgrade your massage skills.

Too many trigger points. Remember, a trigger point is just a trigger point — but when you have a lot of active trigger points all at once, we call it “myofascial pain syndrome.” It’s the excess of trigger points that makes it a syndrome. In more serious cases of myofascial pain syndrome, trigger points may be so numerous that treatment becomes a logistical nightmare. Where do you start? It isn’t an impossible situation, but it does require more effort and tactical savvy than dealing with an isolated trigger point.

Slavish devotion to techniques that haven’t really earned your love. This one is from the Department of “If I Had a Buck For Every Time ______.” Irrational devotion to an iffy self-treatment technique is extremely common. With mild trigger points you can get away with it — your iffy self-treatment method of choice does the job temporarily, sort of, kinda — and you’re happy to have even a little relief. But too often I see people just hammering away on a more serious trigger point problem and not getting any meaningful results. This happens most often with stretching. “I have a regular stretching routine that works really well,” people will say. “Really?” I reply, trying to be gentle. “Has it solved the problem? Why are you still having regular episodes of severe pain? How effective is the stretching really?” If you have a pet self-treatment technique, and you still more or less have a significant trigger point problem, please face the obvious: it ain’t that good a technique!

Negative reactions and anxiety about them. If you have any ominously bad responses to self-treatment, and especially if it freaked you out, it can be difficult to get good results in the future. Fear and anxiety are powerful aggravating factors. If you don’t understand negative reactions or have any way to control them, there’s no way to deal with the fear, and everything is more difficult.

Avoidable perpetuating factors — Trigger points often quickly regenerate for the same reasons that you got them in the first place. These reasons are called “perpetuating factors,” and eliminating them is often the holy grail of trigger point therapy. This theme is spread out throughout the rest of the tutorial. There are many possible perpetuating factors, things such as insomnia, stress, and awkward working postures, or your entire job or career. Many of these are avoidable — even your career! The solution is to learn what causes and aggravates your trigger points, and work hard to eliminate those forces from your life.


More serious barriers to success

This is a depressing section, but necessary — and hopefully fascinating and strangely reassuring to those of you who feel like you are facing invincible trigger points. There’s just no getting around it: sometimes, trigger point therapy is not effective at all, or barely. The only thing worse than not being able to release your trigger points is not understanding why, not knowing what your chances are, not having a realistic view of the situation (see the sidebar for more about this). Here are some more reasons that therapy fails that you may not be able to do anything about:

Inaccessible trigger points. There are plenty of muscles in the human body that are simply not accessible without a scalpel, or some other extraordinary effort. Sometimes, muscles that are difficult to access can be reached by a skilled therapist with specialized skills. Massage inside the mouth, for instance, is not that exotic a technique — but it could be a real challenge finding a therapist with some experience with it. I rarely went there with my own patients, back in the day, just a handful of times. Or consider a more dramatic example: some of the muscles of the pelvic floor are nearly inaccessible, unless someone actually inserts a finger through your anus. This is a real thing. I am not making this up. And for a few people with pelvic pain, this is a vital medical service. (The rest of us might prefer to “unhear” that.) But there really are some muscles in the body that simply cannot be reached, by any means, through any orifice. If you have trigger point pain coming from one of these muscles, there may never be a way to prove it or to treat it yourself, or even with medical intervention. Sometimes this is the explanation for trigger point therapy that simply does not and cannot work.

Adhesions and mild contracture. Quick review: after a few years of clenching, trigger points may literally “freeze like that,” welded into place by connective tissues that have lost their elasticity and no longer slide freely across each other (see the main adhesions section). It’s much more difficult to treat such gluey trigger points. They literally can’t “let go” — not physically. It’s not an invincible problem, but it almost is, and it certainly is for self-treatment in awkward spots — in such cases, the techniques required will require an extra pair of skilled hands.

Trigger points caused by another health problem. In some people, trigger points are simply a symptom of something much “bigger” going on in the body, such as fibromyalgia, Parkinson’s disease, or an autoimmune disease. Obviously, if trigger points are being generated in this way, there may be little that you can do to treat them, or you may have to deal with numerous other more basic health problems first. Insomnia is a good example of an underlying problem that can make trigger point treatment virtually impossible until it’s treated. A serious disease like ankylosing spondylitis — an autoimmune disease that slowly destroys the spine — is a classic example of a health problem that generates so many secondary trigger points that it is simply not possible to deal with them all. The relationship between trigger points and some other diseases will be covered.

Unavoidable perpetuating factors. Some things that predispose people to trigger points are effectively or entirely unavoidable. Health problems are an obvious possibility, but we’ve just mentioned that separately. What I’m talking about is basic features of your life that you can’t change or won’t change because the cure would be worse than the disease. I will counsel people to consider changing careers and make other drastic changes that might help their myofascial pain syndrome. Almost anything you do with your life is theoretically avoidable or changeable, but there are limits to what people are willing to do.

The most straightforward example of an unavoidable perpetuating factor is always parenthood, which can directly and indirectly aggravate trigger points in a dozen different ways — stress, insomnia, and piggy back rides, for instance. Yet parenthood is a burden that is nearly impossible to put down. Families sometimes actually disintegrate under these pressures, but most people, of course, will not and should not leave their children just to make it easier to cure their trigger points.

The majority of severe cases of myofascial pain syndrome occur in people who are trapped in circumstances that set them up for failure. Insult is added to injury by therapists who continue to offer false hope, and charge for the trouble. In these ways, advanced trigger point therapy can go way beyond “technique,” and involves challenging personal, social, and even philosophical issues.

But don’t give up too easily. There are so many things to try that might still work. Let’s now dive into an almost ridiculous number of tips and tricks!


Massage efficacy according to science

Trigger point therapy is experimental, as I have emphasized repeatedly throughout this book. There may be some half decent science about the nature of the painful phenomenon, but when it comes to proof that the little monsters can actually be fixed it’s all about as nailed down as the Loch Ness Monster or Sasquatch. But just like the cryptozoology cranks who believe in those critters, in this section we will make a mountain out of the molehill of evidence that we do have. For fun and edification.

This section is about the massage evidence specifically and exclusively. What little science there is about using other techniques to treat trigger points is covered in sections devoted to those techniques — and it’s usually just a study or two, except for needling/acupuncture, which is the only category with a fair bit of research.

Even more specifically, this section is about the science of applying direct pressure to trigger points. Pressing them, like little buttons. This has always been the main massage technique for treating trigger points, and it is the most basic and important method recommended in this book (specifics on technique will be explained below). In life, and in a massage therapy practice, it seems obvious that sore spots in muscles often get less sore when you poke and prod ‘em. Alas, what seems “obvious” to the fallible human mind is often surprisingly wrong. You have to check carefully, in controlled conditions, eliminating as many variables and sources of bias as possible — a clinical trial, in other words. Science!

But it’s never been checked properly. There’s not enough science.

And so, despite using and recommending pressure on trigger points since the late 90s, I actually have had no idea if it’s truly an effective way to get rid of a trigger point. For shame.

Even regular (Swedish) massage for back pain is understudied, the most basic and popular massage treatment of them all, with only a few dozen mostly terrible studies available to review, and a true “more study needed” non-conclusion236 — and that’s as “good” as it gets. Why so little? The main problem is the massage profession doesn’t have a research culture, and other kinds of scientists don’t have the interest. The professionals who have studied massage are usually setting out to prove that massage works, a strong bias that often wrecks a trial.237

16 mostly shabby little studies

As of mid-2017, I am aware of only 16 scientific tests of trigger point squishing that one might cite. I have read and reviewed all of them. I will describe a few below thoroughly, highlighting some common issues and problems. The section concludes with a complete list of them, with links to my analyses of every single one — for the truly keen reader!

So what does all that half-arsed science say? What’s my impression, after having my head down in those weeds for many, many hours?

It says little. My impression is “meh.”

All of these studies have serious flaws. All show signs of a high risk of bias. All claim to be positive … and yet the actual data isn’t so sure. Most report only minor effects, a couple are clearly negative, and just a single one (Aguilera et al) reports a more robust effect … but that was based only on a single measurement taken immediately after treatment (an effect that could evaporate within seconds for all we know).

If you squint optimistically, you could call some of this evidence promising. You could say that where there’s smoke, there’s fire. But it’s like the smoke from last night’s campfire — more of a smokey smell than a smoke that can hide any fire.

Dial up even a mild cynical impulse, and the evidence collectively looks more like a damning failure to produce any clearly good news.

But mostly there’s just no conclusion at all, and I am not writing about these studies because they actually add up to anything. I’m doing it to fulfill one of the basic promises of this book: to rigorously, thoroughly, and critically examine the science of trigger points, such as it is. And because I’m an obsessive dork. Maybe someday there will be enough evidence for a real conclusion here, but I doubt that will happen in this decade or the next, not even if we’re lucky.

So, a few selected examples …

2002: A controlled study without the control

Let’s start with the oldest test of the efficacy of pressure for trigger points that I’m aware of, a 20-year-old Chinese randomized controlled trial of 119 people with “palpably active238 myofascial trigger points.”239 They checked simple pressure alone at two intensities and three durations (nice variety), measuring changes in pain, sensitivity, and range of motion (among other things).

They detected a barely statistically significant effect from some of the intensity/duration combinations, and none at all for others (the lighter, briefer doses). They concluded:

Ischemic compression therapy provides alternative treatments using either low pressure (pain threshold) and a long duration (90s) or high pressure (the average of pain threshold and pain tolerance) and short duration (30s) for immediate pain relief and MTrP sensitivity suppression.

Sounds good on its face! But where’s the “control” in this supposedly controlled trial? They did not compare these treatments to anything neutral. A control group was present in the other part of the study, where they tested combo treatments, but it was absent from the “does pressure work” part of the study we care about. The researchers treated this part of the study as if the efficacy of pressing on trigger points was a given and they only wanted to nail down the details. That’s a bad assumption that makes for bad science!

A controlled trial compares treatment to non-treatment (either no treatment at all, or a fake treatment like pressure near the trigger point). In this trial, all they did was measure the sensitivity of trigger points before and after applying pressure to them. Even if everything else was just right, this would nuke the validity of the study. But not everything else is just right.

They also split their subjects into so many little groups that each one of them was like its own underpowered experiment. From that data, they got results that were technically “statistically significant” — that is, the results were not a fluke (oversimplification) — but only just barely (P-value <.05) — which is a perfect example of why “P-values” have gotten such a bad reputation.

Even if the results had been more statistically convincing, they still lacked clinical significance: that is, the actual improvements were trivially small. For instance, the largest improvement in the entire data set for pain was a drop of about 2 points on a 10-point pain scale. That is just not enough. The best number should be better! This flips their good-news conclusion to a bad-news conclusion. I really would have liked to see quite good numbers here. They might not have been trustworthy good numbers for the other reasons discussed here, but you at least want your numbers to be as large as possible before you start listing all the reasons why they may not actually be as good as they look.

And here’s the last nail in the coffin: before this study and several times since, it’s been established by other studies that identifying trigger points by feel is unreliable. So there’s really no way to be sure that they were actually testing treatments on trigger points in the first place. If they could have been far more accurate somehow, perhaps they would have gotten better results. But we’ll never know.

Too many problems! This study tells us nothing except that brief bouts of pressure did suspiciously little to a bunch of putative trigger points.

2008: pressing this-a-way instead of that-a-way

Hugh Gemmell, Peter Miller, and Henrick Nordstrom — three UK chiropractors — seem like unusually competent researchers to me. Their 2008 paper240 is both readable and expert, and is admirably focused on clinical significance (an important concept neglected by most researchers, which exasperates me). I was also charmed by the way they pointed out the glaring flaws in other similar studies done to date (echoing many of my own thoughts about other studies in this section). Seems like these fellas actually understand something about science!

And yet I still think they put a face-saving spin on results that were actually bad news.

They were interested in testing two hair-splittingly different ways of applying pressure to a trigger point:

  1. Ischemic Pressure — Sustained deep pressure for 30-60 seconds or when there is “decreased tension” or its “no longer tender,” whichever comes first. This is the technique originally recommended by Travell and Simons. Reminder: “ischemic” is “low-oxygen.” The idea is to starve the trigger point of oxygen, to shut it down.
  2. TrP pressure release — Slowly increasing painless pressure up to a “tissue resistance barrier,” holding until that barrier softens, and then adding more pressure, repeating for up to 90 seconds or until there’s no more sensitivity. This is the method T&S recommended in the second edition of the Big Red Books.241

I have never endorsed one of these methods over the other because I think the difference is silly. That was my opinion before and after reading Gemmell et al. Trying to feel a “tissue resistance barrier” when pressing on a TrP is hopelessly vague and unreliable. There is no way that different therapists will ever find the same barrier at the same “place” (pressure) in the same patient — it’s just too vulnerable to palpatory pareidolia (feeling what you want/expect to feel, like seeing faces in clouds).

But Gemmell, Miller, and Nordstrom decided to put it to the test, and that’s the scientific spirit: why not just find out? They measured the immediate effects of both methods on forty-five chiropractic students with non-specific neck pain and shoulder TrPs. They divided the students into three groups of fifteen — rather small, unfortunately, but small sample size isn’t a deal-breaker in itself — and compared each of the two pressure methods to sham ultrasound. A decent control group, hallelujah!

Another way the study stands out is that their “primary outcome was clinical improvement, which was defined as a reduction of 20 mm on the visual analog scale for pain.” Bravo again! They baked the idea of clinical significance right into their experimental design, which is refreshing to see.

Except, uh oh, in this case, the difference between the improvements in each group was clinically significant … but not statistically significant, so the clinical significance doesn’t matter. One might even cynically wonder if this is why they decided to take the unusual step of reporting clinical significance (because otherwise the answer would have been a straight-up negative). Regardless, the raw data is just all bad news. There were no important differences between the two treatment methods and sham ultrasound. There is only one fair plain language interpretation of this: treatment did not work at all. Neither type of pressure worked better than the other, and neither worked better than sham. But the researchers soldiered on, pluckily framing their conclusion in terms of “improvement” and “number needed to treat,” in a gambit to say something, anything nice about their results:

In patients with non-specific neck pain, a single treatment with ischemic compression to an active upper trapezius TrP is superior to sham ultrasound. For one patient to improve with a single treatment of ischemic compression three patients would have to be treated compared to sham ultrasound. A patient treated with ischemic compression is five times more likely to improve compared to a patient treated with sham ultrasound.

That sounds like something, but don’t be fooled. They got there by using the numbers of people who “improved” (by their definition of a minimum 2-point drop on the pain scale), and ignoring exactly how much they improved. In all groups, some of the students improved, even the ones who just got bogus ultrasound.

The difference in those numbers was attributable to statistically insignificant differences in more detailed measurements. In other words, those who improved were almost identical to those who did not. But by categorizing each subject as either improved or not improved, of course everyone fell just slightly to one side of that threshold or the other … and there happened to be more on the happy side, and suddenly you’ve got a difference that looks much better!

This is a really excellent example of how statistics can lie convincingly by misleading without being technically wrong. Their conclusion is one legitimate way to interpret the data. But it’s lipstick on a pig! This is a negative study, folks. Pressure just failed. Boo.

(And yet this study has been cited extensively as evidence that massage works for trigger points.)

2011: Tool assisted knot squishing looks good in one small study

In 2011, Dr. Dawn Gulick of the Widener University Physical Therapy Department compared the sensitivity of trigger points both with and without a simple treatment of pressure242 — squishing them, that is. It’s about as direct and focused a trial of trigger point therapy as you could hope for. It’s a good design. This is the kind of experiment I think we need — now we just need more and bigger, better versions of this.

It’s particularly notable because Dr. Gulick et al. tested the effect of treatment applied repeatedly over several days. It was also controlled to some extent: a second nearby trigger point was left untreated for comparison. They measured the sensitivity of these TrPs before and after in 28 people, specifically “the minimum pressure required to cause pain.” The results:

There was a significant difference between the pre- and post-test sensitivities of the treated and non-treated trigger points. The results of this study confirm that the protocol of six repetitions of 30-second ischemic compression with the Backnobber II rendered every other day for a week was effective in reducing trigger point irritability.

Sounds great. Now for the inevitable enthusiasm reducers …

Of course it has one of the main problems faced by all trigger point studies: it’s so tricky to accurately locate them in the first place that it’s hard to be sure that they were actually testing real trigger points. I think they did a good job of trying in this case,243 but it’s still a blight of uncertainty. Especially with such a small group of people.

Worse, there is not one word in the paper about clinical significance — a stark contrast with the rare papers that do (eg Gemmell et al.) — and the authors place a predictable emphasis on “statistical significance” but not the actual size of the treatment effect. This is nearly synonymous with saying “technically we found a difference, but it’s a not an exciting one.” I have rarely, if ever, seen an exception to this rule. Failure to report a big effect size almost always means there was no big effect size to report.

And, sure enough, the actual difference is modest.

For the treated TrPs, pressure tolerance improved by about 12 Newtons, give or take 13 N (2.7 pounds-force). In untreated TrPs, the improvement actually got worse by a couple N on average (give or take several times as many N) — so we can basically just round that to zero and conclude, as expected, that not treating a trigger point has no effect.

12 N of increased pressure tolerance was about 38% improvement for those patients. Since pressure tolerance is essentially a fancy way of saying how sensitive a trigger point is, you could also say “38% less irritable.” That’s neither bad nor good.244 And there was a lot of variation, from actually bad in the worst cases, to definitely good in the best cases.

My conclusion? They found modest, highly variable improvements in trigger point sensitivity. Slightly encouraging.

And this is small-scale science, and funded by “industry” no less — an obvious (though minor) conflict of interest.245

2013: Barely improving ankle ROM with trigger point therapy (or stretching, it’s hard to tell)

Another small but promising test of pressure was published in a 2013 paper.246 This is a much less useful experiment than Dawn Gulick’s trial, smaller, only considering ankle range of motion (not pain), and unwisely testing both pressure and stretch. But it is still interesting, because it was looking at the immediate effect of a brief treatment on people who have tight calves right now.

Rob Grieve and colleagues found twenty-two recreational runners with limited ankle range of motion, supposedly caused by tightness of the calf muscles, which also supposedly had latent trigger points, which were in turn presumed to be the cause of the limited ankle ROM. Half of these runners got a brief 10-minute session of trigger point therapy — pressure while stretching, basically — and their ankle range of motion was measured right before and immediately after.

The other group simply got nothing. After identifying their restricted motion, they just sat there for ten minutes with the researcher — “supervised rest” — and then their ankle ROM was measured again.

Treatment seemed to work better than doing nothing. Maybe, kinda, sorta.

Importantly, ankle ROM measurements changed even after doing nothing. Imprecision and actual changes produced an average increase of 3˚ more range, with no treatment. The largest changes were 6˚: three people had that number, and four more changed by 5˚. Meanwhile, treatment increased the range by … about 4˚. The largest changes in ROM from baseline were a couple people who got a 9˚ boost, but the mean difference was just a single degree more than the mean difference after ten minutes of sitting there.


And … they were also stretching. That’s quite a confounding factor. That factor really confounds! Absolutely no way to know if the tiny difference — if it wasn’t statistical noise — was made by the stretching or the trigger point pressure.

Based on this data, I do not think the authors’ rather cheery conclusion is justified: “The findings suggest that a possible treatment method for runners and non runners with reduced ankle dorsiflexion could be the MTrP therapy approach.” I think the findings suggest the opposite. Or nothing. The study has so many flaws — some acknowledged by the authors, plus several more that are not even mentioned — that I don’t think it’s capable of suggesting anything.

2017: Turns out pain relief is relaxing

Let’s start with a small 2017 test of treating trigger points associated with neck pain, using thumb pressure.247 Superficially, this is just the sort of study I’d like to see. But dig in a bit, and it turns out to be weirdly convoluted. In addition to pain, Morikawa et al measured “prefrontal hemodynamic activity and autonomic activity based on heart rate variability (HRV) were monitored by using near infrared spectroscopy (NIRS) and electrocardiography (ECG), respectively.” In other words, they were looking for biological signs of relaxation, basically.

They might have jumped the shark there.

Did I mention this study was small? So small it hardly seems worth bothering. Treatment was given to just ten patients. Their pain was modestly reduced compared to 10 control patients, and their relief correlated with increased parasympathetic nervous system activity — relaxation — which Morikawa et al measured in a couple of ways (brain blood flow, heart rate variability). They were testing the interesting but daring and dubious hypothesis that

compression at MTrPs induces pain relief through inhibition of sympathetic activity, which (1) might increase the peripheral blood flow and subsequent removal of noxious substances, and (2) might block the excessive release of acetylcholine.

Translation: trigger point therapy works by relaxing you, which flushes trigger points with extra circulation and dampens the release of acetylcholine. There’s so much wrong with that hypothesis it’s literally not worth getting into, because it doesn’t really matter. Their study wasn’t designed to show causation, and their idea is implausible for one simple reason: it’s obvious that relaxation rarely puts a dent in trigger point pain. Probably all this study does is confirm in highly technical way the common sense observation that “pain relief is relaxing.”

Which is actually kind of worth knowing, even though it’s also quite obvious. Forget the fancy hypothesis that relaxation is somehow the actual mechanism of trigger point therapy: that’s just window dressing. The take-home here is that there were measurable signs of relaxation in these subjects, which is cool.

Unless there weren’t, because this study was tiny and had a risk of bias off the charts. Have never yet seen a study of 10 subjects that proved anything.

All together now

There’s more science, but not enough, and you’ve already got the picture. Despite all the sweat and tears that undoubtedly went into them, these experiments simply do not actually answer the main question.

The table below summarizes all the studies of any kind of massage/pressure on TrPs that are remotely worth mentioning. Click on the name column to read the summaries in a new browser window/tab.

Studies of massage (mostly ischemic pressure) for trigger points
Hanten 2000
Hou 2002
Hodgson 2006
Fernández-de-Las-Peñas 2006
Gemmell 2008
Kostopoulos 2009
Aguilera 2009
Gulick 2011
Cagnie 2013
Oliveira-Campelo 2013
Grieve 2013
Takamoto 2015
Ameloot 2016
Ravichandran 2016
Sohns 2016
Amin 2017
Morikawa 2017


Upgrade your self-massage technique

“Just rubbing” often doesn’t cut it for difficult cases. Here are some miscellaneous minor improvements to your technique that could make a difference. These are followed by several more detailed sections, each focusing on technique and troubleshooting tips that need more discussion than we can cram into a paragraph.

Experiment with pressure. If at first you don’t succeed with massaging your own trigger points, you should first attempt to reduce the pressure. “How much pressure?” is one of the most common questions about massage, but unfortunately there are no firm rules, just rough guidelines and playing the odds. Stronger pressure may be exactly what you need, but put your money on “gentler” at first, because most people with difficult cases will usually get better results from a softer approach, and there’s less risk of negative reactions. Try dropping your self-treatment pressure to about 75% of what it feels like you crave, or 75% of what you were doing. Consistently use that pressure for at least 2–3 days — you have to give it a chance! If you still aren’t getting results after that … then it might be time to try stronger pressure. Self-treatment can be a really good way to experiment with higher intensities, rather than spending quite a lot of money on professional massage that may be much more painful and no more effective. Occasionally I’ve successfully treated one of my own trigger points by beating the crap out of it! I never would have wanted to pay for therapy like that, but I was willing to take the risk myself, and self-treating gave me good control over the experiment.

Experiment with dosage and frequency. Experience has taught me that most people get the best results from frequent but fairly brief dosages of pressure, up to several short sessions per day (1–5 minutes). But there’s only a little science — just the Gulick study discussed in the previous section — and a bit of common sense, to guide us in prescribing an effective “dosage” of self-massage, and the “ideal” is probably quite different in different people, cases, muscles. And if you find yourself using stronger and stronger pressures, you will probably require longer rest periods between treatments. So, you have to just experiment. But you could certainly start by duplicating the dosage and frequency that Gulick et al found to be effective: “six repetitions of 30-second ischemic compression … every other day for a week.” Note that this wasn’t their recommendation — another dosage might have worked better. But at least we know that it did work for the 28 people in that study — that’s a good starting place.

Experiment with less awkward positions. There’s usually a paradox in self-massage: you’re trying to relax muscles, but you’re also straining to reach them and press on them, using muscles to treat your muscles. It’s not always possible to be relaxed, but with creativity and determination you may find a way to press on a trigger point without tense or awkward contortions. Here’s a great example of a small positioning adjustment that can make a big difference: when trapping a massage ball between back and floor, most people need to tense many of their trunk muscles in order to “steer” the ball around the back, which can be somewhat purpose-defeating. But if you put your feet up (on a chair or an ottoman, say), you will be amazed at the greater ease and precision you will have — in that position, it’s much easier to steer and stay relaxed while doing it. These are the kinds of refinements that make all the difference over the years.

Experiment with time of day. I had massage therapy clients who would only make appointments at a certain time of day.

I don’t get massage therapy at night because sleeping really reduces the value of the treatment for me — I get all loosened up and then immediately seize half-way up again overnight.

But others felt precisely the opposite: that sleep was exactly what they needed to make the treatment stick. Anecdotally, this seems like the more common believe. Time of day, and emotional/physical context, may be important for massage results. There might be no point in tackling the challenge at certain times. Try to figure out what circumstances in your day help, and which ones are like a head wind.


CASE STUDY: Chronic hip pain decisively resolved by unusually intense massage

Alex is a massage therapist of my acquaintance, a reader, and healthcare professional with some credibility as a critical thinker:

I am a skeptic about trigger point therapy, probably even more than you, but I am still doing it for all the reasons you lay out in your book. I also consider it experimental and even a bit dodgy. I get some good results with clients, but I don’t really trust that. What really keeps me interested in it is the results I get with my own body.

And then he told me a great story. This is the kind of thing I have experienced myself many times, but it’s a particularly ideal anecdote: a credible source telling a clear and simple story of a serious pain problem and a complete resolution. Tidy and happy. My first thought was, “It’s too perfect—people are going to think I made this up.” But I am not making it up.

A pain in the hip that just kept getting worse

Alex developed an annoying hip pain, just a little nagging ache, so minor he didn’t even try to massage it at first.

But it just kept getting worse. After about three months, he noticed he was limping, and he started to try a little basic self-massage for it, which had no effect. He tried a few times and gave up: massage just did not seem to be relevant.

Then he started to notice the pain at night. By around the six-month mark, he was starting to avoid sleeping on that hip. It was still minor, but it just kept getting worse. By nine months it had become impossible to sleep on his painful side at all, difficult even on the other side, and the pain was nearly constant throughout the day.

Any five minutes of this pain was no big deal. It was like a moderate headache in my hip. But it never let up. Once it reached that stage, it was just ALL THE TIME.

Such long-term and progressive pain was a red flag, a bit worrisome. Alex went to a doctor and they started the process of eliminating scary causes. There was a whole saga there, but I’ll condense it down to just this: they found nothing.

Massage round #2

Alex returned to massage, resolving to be more thorough: he decided he would both work on it himself regularly for two or three weeks, while also getting some more thorough help from a colleague, before declaring it a failure. He put in the time, generally working his way up to quite vigorous massage. But it still didn’t do the trick.

It always felt like the right idea. It was always a big relief at the time. But practically the moment I stopped pressing on it, the pain was back. So I gave up again. It was a bit of a blow, because this pain just felt so muscular, and I’ve had so many minor successes with similar kinds of pain in the past.

The pain — and the story — entered its final phase, which was rough. For the last three months of the story, Alex just lost a lot of sleep and felt that he had become a chronic pain patient for the first time in his life, and the symptoms were starting to spread outward from the trouble spot.

Things got a bit dark. The pain got fairly bad as well as crazy stubborn. I was limping a lot, I was totally exhausted. I thought about taking time off work. I wondered how much longer I could ‘take it,’ but what was I going to do? That was my first real taste of how hopeless pain patients can feel.

Desperate times call for desperate measures

It's always darkest before the dawn. After about a year of constant discomfort, Alex drove it away with a single brief massage session, one of the most decisive victories over chronic pain I have ever heard of. What sorcery is this? What did he do? What was different?

The only significant variable he changed was pressure:

I basically just panicked one night. There was no skill or strategy in what I did. I was half out of my mind with frustration and fatigue. I just hopped on the hardest massage ball I had, a lacrosse ball, and went to town. I ramped the pressure way, way, way up... to the point where it was obviously reckless and probably doomed to failure or even self-injury.

But I kept going, because it felt so good. Like, fantastic. Like the best itch-scratching ever. I just attacked it as hard as I could, it was practically violent. And yet it also felt like exactly what I’d needed.

And it worked. 😮

Some follow-up questions

I asked Alex if it was really and truly completely gone on the first try. Not quite, but very close: the pain came back a little bit the next day, but only a little and easily chased away with another dose of strong pressure. The same thing the day after that, but even milder and easier. And then there were “several” days in the next month where the symptom was detectable for a while, but faint and it went away on its own.

He’s been truly symptom-free since then (eight months at this writing).

Was he bruised? Yes, moderately. The bruising felt superficial and unrelated to the trigger point. He had to “work through” it for the follow-up treatments, which was unpleasant but didn’t seem to interfere or do any further harm.

I also asked him if there was anything different about his location or technique, other than pressure. “It was exactly the same spot it always was. The same spot I’d rubbed dozens of times before. The only spot I ever thought was a problem.” And what spot was that? Exactly this one, the spot I first called “Perfect Spot #6” almost twenty years ago: on the side of the hip, gluteus medius and minimus, about midway between the greater trochanter and the iliac crest.

And finally I asked him to put on his best skeptical hat and entertain the possibility, however faint, that his cure might have been a coincidence, regression to the mean, or the effect of some other treatment that finally just happened to finally kick in.

I know why you are asking and I have wondered it myself. Lots of times, things just go away. We get credit for helping patients who were almost certainly going to be fine anyway. But I just can’t see it in this case. We’re talking about a year of constant pain, not a month. The change happened in a few minutes while I was doing something that felt •bleep• fantastic. And then it stayed gone. I’ve tried to believe that it might have been a coincidence, but I just can’t.

I still call myself a trigger point skeptic, but honestly I should probably stop after this experience.


Don’t get hung up on anatomy, and be persistent

It is amazing how much poking around it can take to find the right spot. Many times I have almost given up the search for one of my own trigger points, only to finally get that rush of “triggery” sensation that tells me my persistence paid off. “There we go,” I will mutter to myself. “I knew it had to be there somewhere!” And it was. But it took a lot of experimenting with different angles and pressures and just trying lots of spots.

Of course, I have experienced the same thing while treating patients many times as well.

I go through this process of experimentation even though I have advanced knowledge of the anatomy (I am pretty much a walking muscular anatomy textbook). But I still have to grope around, a bit awkwardly and blindly, looking not only for the right spot, but also the right method (angle, force, tool, body position, etc). It can take quite a while!

One of the most common mistakes I see in self-massage is that people become too hung up on locating a specific piece of muscle anatomy. Patients become preoccupied and frustrated with this technical challenge, and usually have no way of knowing if they’ve succeeded. Anatomy is not the key to finding trigger points.

So … don’t look for anatomy. Look for the sensations of a trigger point (there’s more about sensations in a section coming up below). And keep looking until you find them.

Thoroughly explore all muscle tissue in a problem area, until you find a spot that feels “important” or “relevant” to your problem. Look for that strong, clear good-pain signal that tells you that you have landed on a trigger point (and who cares what muscle it is). The vast majority of the time, all that matters is that it feels like the right spot.

Don’t give up easily. Keep trying.


Focusing on one trouble spot versus “a little bit of everything” — which is the better strategy?

Readers often ask me whether trigger point therapy should be focused on a key area, or if it’s better to work on “a little bit of everything.” Focus is usually the superior strategy, for two simple, practical reasons:

  1. The most obvious trigger points are often “primary” trigger points that are actually driving the formation of other trigger points throughout the region, and in adjacent regions. Helping them may help a lot of the others — a pretty big win. If you can help the worst trigger point, numerous secondary trigger points may simply disappear, or become so much less bothersome that they are much easier to treat, or don’t even need to be treated.
  2. It’s emotionally important — often critical — for patients to experience progress. With focus, the chances of enjoying definite progress in “only” a single area are greatly improved. Having proven that progress is possible, patients can then proceed with additional therapy with much greater confidence.

The value of focusing on a primary is easy to grasp. But that second point is under-appreciated, and particularly critical for both patients and professionals to understand. The effectiveness of working with trigger points must be established — or it must be eliminated as a therapeutic option — as quickly as possible. Respecting that economics and psychology are major factors in recovery from pain problems, there is no time to waste in therapy! It is in everyone’s interest to see results as fast as possible, even if they are “only” in one area.

The sooner you see results, the sooner you can make better, more confident decisions about how to proceed with therapy.

In contrast, one of the most reliable ways to fail at trigger point therapy is to do “a little bit of everything,” trying to scratch a dozen itches in every appointment, once every week or two. It may feel nice at the time, but it tends to make progress slow and subtle at best, and completely impossible at the worst. Massage therapy patients often feel slightly better for a few hours after each treatment, but never make any substantive progress. The persistently positive reactions encourage both therapist and patient to continue, but substantive recovery remains elusive. And then, three years later, the patient is not only still in chronic pain, but also (rather tragically) mistakenly believes that they have tried and eliminated massage therapy as a therapeutic option! Of course the truth is that such patients were simply never treated properly in the first place … despite the large investment! Ouch.

Focused treatments that deliberately, strategically neglect lower priority trigger points, are the best antidote. If you make progress with the top priority first, you can much more confidently justify continued efforts.

How focused is focused? Please note that “focusing” a treatment does not necessarily mean that massage or self-massage is annoyingly pointy and completely neglects all other tissues. Therapists should not spend an hour poking one spot! That’s too much focus! (And, yes, I’ve seen it done that way.) Even a focused treatment still spreads out some. “Focus” means that roughly 80% of a treatment is devoted to a small area, but with regular detours to “make nice” with surrounding tissues, or just take a break and do something else entirely (foot rub!).

So, therapists, make sure your patients are relaxed and happy in general. And, patients who self-massage, make sure you give some massage to other muscles in the area.

To sum up: soothe the region and then zoom in on the most important-feeling spot you can identify. That will give you the best chance of seeing some real progress.


More information about exactly how to rub (moving strokes)

In the introduction to basic trigger point therapy, you learned how to rub a trigger point with simple circles or back and forth movements, possibly with the fibre direction, or to simply press and hold. That’s good enough most of the time. However, it’s a bit ham-handed to just rub in circles with your thumb and fingertips. This section will discuss three improvements for moving strokes:

  1. Massage along the length of muscle fibres.
  2. Push tissue fluids towards the heart.
  3. Prepare the muscle with broad, easier pressures.

Remember you can also just hold a trigger point — see the next section.

About muscle fibre direction. For more effective trigger point release, determining and working with the direction of muscle fibres may be helpful. Trigger points are contracted along the long axis of muscle fibres. To elongate them — to push the sarcomeres apart — you want to push along the length of the affected muscle cells.

How do you determine muscle fibre direction? In superficial muscles, just under the skin, you can either feel it easily, and/or determine it logically. It’s easy in long muscles — the fibres usually more or less run the length of the muscle! The fibre direction in the biceps muscle, for instance, is pretty obvious: it parallels the long bone of the upper arm, the humerus.

Another great way of figuring out fibre direction is to find the tight strap of muscle that contains the trigger point you’re after. Trigger points are always located inside a tighter section of muscle, which feels like a cord or rope inside the muscle. That ropy texture is what makes therapists say things like, “You feel really tight!” And it’s always a dead giveaway of fibre direction: it parallels the ropes! Find the rope, and then instead of strumming across it, slide along it. Think of flattening the trigger point, steamrolling it!

Push towards the heart. In fact, when you stroke along the length of a trigger point, you want to limit yourself to a single direction — push tissue towards the heart, not away. Although the most microscopic vessels in and around the muscle knot run in every direction, the larger ones often lie parallel to the muscle fibres, nestled amongst them. The vessels that carry deoxygenated blood and excess tissue fluid back to the heart all have one-way valves — that is, they let fluid through on the way back to the heart, but they don’t let fluid go backwards towards the tissues it came from. Therefore, as long as you’re squishing tissue fluids around, you might as well work with that system instead of against it. Random squish will still work — but you’ll be more effective if you push towards the heart, and/or along the direction of fibres.

Prepare the muscles. Don’t just rush in with focused pressure with the fingers or thumbs (what we call “poking”). If possible, prepare the area first by pressing and kneading with the palm or heel of the hand, or simply by starting slowly. You can prepare the muscles for two minutes … or for two days, or for two weeks. If your trigger points are extremely sensitive, don’t “poke” them at all — instead, massage them with broad surfaces and softer tools only for a while. It’s a rare trigger point that won’t get at least a little bit easier to approach after a few days of this!


Yet more information about exactly how to rub (pressing and holding)

Your trigger points may respond well to either kneading strokes, or to simply being firmly pressed with an unmoving thumb or finger or tool.

Pressing and holding a trigger point like this is called ischemic pressure or blanching, and it’s the method of trigger point release used by most professionals. In a previous chapter, I explained that the scientific evidence that this method actually works is inconclusive. In this chapter, I explain in more detail how to do it anyway. We’re deliberately embracing an experimental treatment here, which is just fine as long as it’s not misrepresented as “proven.”

“Ischemia” is an inadequate blood supply to tissue. For a simple demonstration of what “ischemic pressure” does to circulation, just pinch your fingernail: it will go white around the pressure. When you release the pinch, assuming your heart is beating, the blanched tissue will quickly turn pink again as the blood returns to the tissue.

Hypothetically, when you press firmly on a trigger point, the same thing occurs to some extent in the deeper muscle tissue: swampy tissue fluid is pressed out of the trigger point … and then hopefully it refills with fresher, cleaner, more oxygenated blood. This highly localized tissue fluid flushing could be the mechanism by which this method works (if it works), but there are also several other possibilities. It could be the sustained and highly localized stretch of the fibres of the trigger point, for instance, or just a change in sensation, or a neurological “reset” effect. It could even be that ischemic pressure starves the trigger point of oxygen even more than it already is, the stress of which could help, in theory. But no one knows (of course).

In theory even a very brief application of pressure should be enough to squeeze the stagnant tissue fluids from a trigger point, but in practice no one seems to think that brief pressure on a trigger point is an effective treatment. As a rule, sore spots do not stop being sore just because you press on them for a couple seconds. Which is interesting. So the common practice is to press and hold a trigger point for at least 20 seconds, and it’s not unusual for professionals to apply pressure for much longer (2–3 minutes). There’s no clear justification for such long holding except a very basic “more is better” impulse. An experiment in 2002 showed some benefit to both quick, intense bursts of ischemic pressures and longer, more gentle holding.248

One advantage of longer, gentler holding is that it may give an opportunity for both patient and/or provider to feel changes: reducing sensitivity, and perhaps a shift in the texture of the trigger point.


Using “press and hold” to identify a trigger point release in progress

One of the best things about using still pressure on a trigger point is that it can help you identify a trigger point release in progress. In the basic treatment sections, I recommended a simple “wait and see” method — you treat your trigger point, and if it feels better a few hours later, you know you must have “released” it.

That’s not good enough when you need to get serious about trigger point therapy. You need to know if you’re releasing the trigger point while you’re working on it.

As you press and hold a trigger point, the sensitivity of the trigger point will almost always ease up. This indicates one of two things: either you are achieving a release, or you are simply neurologically adapting to the pressure (i.e. your brain is starting to “ignore” it as it becomes “boring”). In fact, it’s possible that adaptation actually aids trigger point release! (Pure speculation, that — I don’t know.)

So, here are some step by step instructions:

  1. Find the trigger point.
  2. Apply enough pressure to get a “clear signal” — clear but easily tolerated intensity, hopefully “good pain” with some referral.
  3. Wait up to 3 minutes for the intensity of the sensation to fade at least 50%. This indicates release and/or adaptation.
  4. Increase your pressure to bring up the intensity to what it was before.
  5. Repeat steps 3 and 4 at least twice.

In other words: add pressure and wait for release … add pressure and wait for pain to ease … and so on.

And what if it doesn’t ease up? It usually will. However, if it doesn’t, don’t be alarmed. Trigger points don’t always release on the first try, or the fifth try. If you have a trigger point that isn’t releasing, try again about twice per day, for about five days. If it still isn’t backing off at that point, you can start to feel sure that something’s wrong and it’s not going to give.

Unfortunately, there’s no one explanation for a “non-fader.” It might be fibromyalgic tenderness instead of a trigger point; it might simply be too severe, you might be “missing” it by a few millimetres; it might be a “satellite” trigger point that is constantly regenerated even as you try to release it by a more “primary” trigger point nearby. And so on.

There’s no defense against a non-fader except to just experiment with other strategies. Sometimes a trigger point that wouldn’t release at all last month suddenly starts to become responsive this month, thanks to known or unknown improvements in other factors.


Identifying your trigger points by feel

This topic was covered thoroughly above, see Identifying your trigger points by feel: tissue texture and other palpable signs. Rather than duplicating it here, where it is relevant once again, I’m just linking to it for the sake of readers who use the tutorial like a reference instead of reading straight through.


Referred pain is not a diagnostic feature of trigger points!

This finer point is one of those things that “separates the men from the boys” in trigger point therapy. A skilled, knowledgeable therapist knows this: there are far more points that produce referred pain than there are actual trigger points.

I didn’t know this myself for the first half of my ten-year clinical career. For quite a while, I treated my patients (and myself) with the assumption that “referral = trigger point.” There was no specific cure for my ignorance — it simply started to become clear as I studied, learned and practiced. Now that I have a strong grasp of the science of referred pain, it’s simply “obvious.” (And then, later, I also discovered that this principle is stated outright by David Simons, somewhere in his text, Muscle Pain.)

Referred pain is a feature of the human body’s pain system, and not specifically of trigger points. Anything that hurts can cause referred pain. If you push on a healthy muscle hard enough, it will hurt, and referred pain may occur in the pattern typical of muscle.

So just because a spot is sensitive and refers pain does not necessarily mean you are pressing on a trigger point. For the maximum possible diagnostic confidence you need the big three: (1) exquisite sensitivity, (2) pain that feels like a familiar symptom, (3) local twitch response. Not referred pain.

It’s easy to get fooled, because referred pain from healthy tissue and trigger points will be similar — they are all part of the same muscle, which has a single pattern of referred pain. You run the risk of pressing on something that isn’t a trigger point, but is intensifying the same pattern of referred pain that’s also being caused by the trigger point.

Fortunately, there’s also something working in your favour, even in ignorance: pressing on a trigger point is much more likely to produce referred pain, for the simple reason that trigger points are more painful than healthy tissue. Remember from the referred pain science section, referred pain has a higher threshold than local pain — referred pain only gets rolling after provoked tissue has already started to hurt. Thus, if you’re massaging here and there in a muscle, the healthy tissue is relatively unlikely to hurt much and cause referred pain — but the trigger point is. So, generally speaking, both therapists and patients are much more likely to choose to focus on actual trigger points, because they stand out.

This is one of the good reasons, by the way, why therapists shouldn’t use brutally intense pressures everywhere: you may provoke pain and referred pain in perfectly healthy tissues, creating the illusion of “trigger points everywhere”, when in fact you’re just causing a lot of pain and 90% of your effort is not actually affecting trigger points. Especially during the diagnostic phase of treatment, skilled trigger point therapy is characterized by cautious pressures not only to avoid negative reactions, but also specifically to help distinguish between healthy tissues (which will feel mostly painless with moderate pressures) and the trigger points (which will stand out in contrast).


Don’t be fooled by “reverse referral”

As if referred pain wasn’t confusing enough! Every time referred pain has come up so far in this tutorial, I have described it in terms of a trigger point in one place causing pain in another area, like this:

For most cases, this is the important relationship to understand — that the pain in Area B may be coming from somewhere else. But it can also work the other way around! Pain in the referral zone may actually represent a problem in the referral zone, something actually wrong with the tissues in that location. It’s not always wrong to look for a problem right where it hurts. Sometimes you are hurt right where it feels like you are hurt!

So, “reverse” referral doesn’t mean that pressing on the referral zone will cause pain where the trigger point is: it means that the causal relationship is complex. Depending on which tissue is actually worse off, treating the trigger point may or may not solve the problem. Area B may actually be in more trouble than Area A! “Referred pain” is causing the trigger point, rather than the trigger point causing the referred pain. Sort of.

Or … could it be both? Could there be a vicious cycle? Suppose there’s tissue damage in Area B, and then a trigger point gets fired up in Area A, and refers pain back to Area B. Not only is this plausible, it’s probably common — there are probably many scenarios where it’s hard to tell which area was in trouble first or worst.

Every trigger point has this vicious-cycle relationship with its referral zone. Recall that referred pain happens because the brain can’t quite tell where internal pain is coming from — we’re not wired for it. When Area A has a trigger point, the brain gets confused and thinks maybe the pain is coming from Area B. But what if Area B is actually injured as well? Well, then Area B really feels like it hurts!

Here’s another way to think about this: instead of thinking of the “direction” of referral or causation, simply think in terms of which area is in more pain. Which problem is the “real” problem, or the bigger problem? If there is a blatant injury in Area B, there’s not going to be any confusion. Area B is damaged, plain and simple.

Confusion will arise when Area B is damaged in a non-obvious way. And this absolutely happens! For instance, a mild tendinitis in the shoulder can be difficult to tell apart from referred pain. The infraspinatus muscle on the back of the shoulder blade can refer dramatic, well-defined pain into the front of the shoulder. And so can inflammation of the biceps tendon! A therapist can easily be fooled into thinking that the problem is coming from the infraspinatus muscle — all the more so because the referred pain from infraspinatus seems so intense. But, in this scenario, the intensity of the shoulder pain is not caused by the severity of the trigger point, but by the actual tissue problem in the referral zone.

A problem in Area B will make the trigger point in Area A feel all the worse. That’s “reverse” referral. And this is exactly how a lot of pain cases go unsolved.

Quite the head trip, eh? Well, yes and no. Yes, if you try to wrap your head around the neurology of it. But it’s not so confusing if you just realize that Area B may or may not have its own problems, and the referred pain from area A may or may not actually be the main problem.


Beyond the tennis ball: commercial massage tools

Tennis balls are the most commonly used self-massage tool (mostly everyone has one, and they work pretty well), and I’ve already said that everyone should have a “bucket of balls” in their bag of tricks. Over the years, I have become convinced that such a nice selection of balls is, collectively, by far the best of all self-treatment tools for muscle pain, because it’s an easy collection to work on, cheap and endlessly useful, adaptable and portable.

Once upon a time, I wouldn’t have recommended a selection of balls as a big deal in particular. I was enamoured with (and experimenting with) many of the other massage tools described here, many of which I still like. But balls “win” — ultimately, you just can’t do better than a nice selection of balls! No one prone to muscle pain should be without their balls.

So, start your massage tool collection with a bucket of balls. Some particularly excellent balls, and balls with special purposes, will be described below.

But there are other tools in my bucket!

There are, of course, countless massage tools out there. I advocate working with the simplest and cheapest first, but there is also an incredible array of commercial self-massage tools on the market: sticks and widgets, rollers and thumpers and vibrators, wooden thumbs, and on and on. And many of these are useful. Some of them are useful for only a single thing, but that’s okay — sometimes that’s just the thing you need!

Here are some of my favourites:

The Jacknobber

A better example of a “knobbly hand tool” than the cute novelties like the Octipet.

Jacknobbers, Index Knobbers, Octipets (a popular octopus-shaped novelty tool) and other misc knobbly hand tools. There are countless tools on this theme: something you hold in your hand that has hard, knuckle-like projections. There are so many different variations on this theme that it’s impossible to recommend just one, or even ten of them — it comes down to personal taste. But the concept is, of course, simple and useful, and most of them are pretty cheap.

The Knobble

The Knobble II (second edition) is yet another knobbly tool, but it is the best of them and deserves a special mention. It has stood the test of time, and it is the tool I grab from my boxes more often than any other except a plain ball. By happy coincidence, I used mine to save myself from a nasty headache within 24 hours of its arrival in the mail (see Perfect Spot No. 1). Its grippy handle and radial symmetry makes it more versatile than other knobbly tools. More in my full review of tools made by Pressure Positive.

The Zubo, handmade by Allan Saltzman of This is another superior variant on knobbly tools: a short stick! Your first impression might be, “$20? For a piece of dowel?!” But I admire the simplicity of it, and my first impression was, “I need that.” The Zubo is (as you can see) a wooden dowel with rounded ends. That’s it. But you can do a lot of good self-massage with a wooden dowel with rounded ends. Sure, make one yourself — if you happen to have a wood file handy, and a half hour to kill. Or just say twenty bucks worth of “thanks” to the small businessman who thought of it first. Mr. Saltzman also sells some other handy tools that are not so easy to whip up yourself, such as his spinal rollers (see below).

Brain suckers — vibrating head massage tools. Remember that old kid’s joke? You “suck” on someone’s head with your fingers and say, “It’s a starving brain sucker!” Well, my friend, brain suckers are real. And they are relaxing. This is not quite exactly a “massage” tool in the sense of a tool that you apply pressure with, but it sure can feel nice! It’s a great way to relax yourself before treating trigger points with pressure.

The Backnobber

The best of the massage sticks. Best of all? It breaks down for easy storage.

Massage sticks. The TheraCane® is probably the best known of these tools, but The Backnobber is my favourite. Massage sticks are mainly about getting at hard to reach places, and they are indeed very good at reaching those spots — but less good at actually massaging them. They tend to be clumsy. When you want some kind of pressure, any kind of pressure, on a hard-to-reach spot, reach for the massage stick. But if you need precision and quality pressure, you’re either going to need a lot of practice and experimenting with the stick, or another tool altogether.

Foam rollers. It’s just a handy thing — soft tubes. There’s a million kinds of ‘em! Don’t spend too much, because there are plenty of cheaper ones. Note that pool noodles can also work, and are even cheaper. Foam rollers are especially handy for side of the hips, as pictured — balls are often too “pointy” for the sensitive trigger points in the gluteus medius and minimus muscles there. With a foam roller, it’s easy and more comfortable to just settle your weight onto the roller. Most are variations on such a strong and simple theme that there’s really nothing to distinguish them. However, there are a couple unusual ones, such as Allan Saltzman’s spinal rollers and the Tiger Tail (see next items).

The Tiger Tail Rolling Muscle Massager

The Tiger Tail Rolling Muscle Massager is sort of a foam roller with handles — or a specialized rolling pin, made for squishing muscle instead of dough. There is no question that I thought of (and tried) using an actual rolling pin on myself long before I heard of the Tiger Tail. But a rolling pin tends to be too hard, too broad, and too fragile (the handles tend not to be sturdy enough, unless you’ve got a really good quality rolling pin) for most massage purposes. The Tiger Tail solves these issues: it’s got a foam cover on a narrow cylinder, and it’s extremely sturdy. Its applications are fairly limited to “rollable” spots, primarily the legs and the forearms, but it does those spots very well, and it’s perfect case study in how the right tool can make all the difference: it’s easy to apply and control plenty of pressure.

But Caveat emptor! Commercially available massage tools are nearly always more expensive and not necessarily any more effective than improvised massage tools adapted from freely available objects and cheap devices not originally intended for massage (like dog toys), and so on. Coming soon below, I’ll discuss some commercial massage tools I don’t like.


Thumping trigger points with vibrating massage tools

The Thumper is a sturdy example of a vibrating massage tool, a class of massage tools that deserves a little more attention. There are many gadgets like the Thumper, but I am fond of the Thumper brand: a well-designed device built here in Canada. I’ve had my Thumper for about 15 years now, and it works as well today as it did the day I brought it home. I used it routinely in my clinic for many years (a favourite part of the treatment for many clients), and mainly as a self-massage tool ever since, but it’s also a nice easy way for my wife to give me a quite a bit of massage for minimal effort.249

The difference in the tone between a big one and a little one is substantial. The big one (the Maxi Pro) is heavy by design, so much so that it would be hard for some people to handle, especially trying to apply specific pressure in awkward areas, but their heft also delivers more satisfying thumps that make other vibrating massagers feel more like “tapping.” Physics is physics, and sheer mass counts for a lot here: insert obligatory “size matters” joke. Some people may even prefer the “Equine Pro,” designed for horse massage to offer “even more power and strength”! There are days when the Maxi Pro, as substantial as it is, doesn’t seem like it offers enough thump for me.

But if you can’t reach the spot you want to thump, obviously a lighter model with a handle is the best you can do on your own.

A Thumper is not cheap, so there ought to be a good reason to get one. Fortunately, it offers a lot of value regardless of therapeutic effect, just as massage does generally, but probably even more so: for those who enjoy them, vibrating massagers can deliver a lot of pleasant stimulation super conveniently for a long time. It may cost up front, but over the long haul it’s quite economical.

And then there’s the possibility that it helps trigger points, on top of that.

Why does vibration feel so good?

Vibration is inherently relaxing for most people, assuming it isn’t applied too suddenly or intensely or in an uncomfortable location. I think there are a couple reasons for this:

  1. Proprioceptive confusion. Proprioception is the sense of position or movement, our under-appreciated “sixth” sense. If you move or shake the body at random, the cerebellum gets a deluge of nonsensical proprioceptive data, sensory information about movements that the brain did not plan. Assuming a safe and healthy emotional context, the nervous system, overwhelmed by the flood of stimuli, willingly “gives up” and stops resisting the movement — an unusual state.

  2. Sensory novelty. Fresh and unusual sensations are the bedrock of massage therapy: when we get a good massage, we experience many sensations that are unique to that context, and that is half the appeal. But vibration delivers especially strong and distinctive sensory novelty: it feels like nothing else, and it feels like the opposite of feeling stuck and stagnant. Like splashing cool water on your face when you’re hot, vibration feels like a natural antidote to the sensation of stiffness.

The case for treating trigger points with vibration

Thumpers are not reputed to be good for trigger point pain specifically, and there’s no direct scientific evidence.250 I’m not aware of any strong biological rationale for why vibration in general would work for trigger points, let alone why any specific frequency or intensity or other specific approach would be optimal.

To the extent that vibration is relaxing and pleasing to the nervous system, it may also help with trigger points — as with any kind of pain. Vibration might have a bit of an edge given the potency of the sensations it can produce — very relaxing, and very pleasing for many people — but this is more about relieving symptoms than treating the problem.

There are some other intriguing possibilities, however. This is pure speculation now …

Vibration has a fascinating effect on flexibility. If you just add some vibration, even already flexible gymnasts can get a surprising boost in flexibility, even an “astonishing” increase according to Sands et al. This has been shown in three different experiments.251252253 Shaking appears to actually improve the range of people who already have great range! That is almost certainly a neurological effect on muscle behaviour, a rare “hack.” And since trigger points might be a misbehaving patch of muscle … well, hey, maybe something cool and good can happen that way. It’s not a strong reason to try it, but it’s not a bad reason either.

This effect may simply be deep muscle relaxation, suggesting that the relaxation induced by vibration might be more meaningful than just feeling still and quiet: it may reduce muscle tone to levels we cannot readily achieve by any other means.

For this reason, when you thump a trigger point, I recommend simultaneously elongating the muscle it is in, if practical. Stretch on its own is not a good treatment for trigger points (see the stretching summary), but stretch+vibration could be.

There is also the vague possibility that vibration has a mechanical effect on tissue fluids in trigger points, which are probably swampy with waste metabolites. A large number of pressure waves pulsing through the trigger point could conceivably facilitate cleaning it out and a return to homeostasis. And I also think this is a bit of a reach.


Commercial massage tools to avoid

The moment something is labelled a “massage tool,” its price magically doubles to about twice what you’d pay for an object like that if it had a more ordinary purpose.

Sticking to my relentless theme of do-it-yourself-as-cheaply-as-possible, I strongly recommend that you practice a healthy skepticism about all commercially available massage tools, especially if they are sold as part of a “system” or “package.” For example, the Acuball …

The Acuball debacle. Consider the chiropractor Michael Cohen’s invention, the “Acuball” (promoted at You can pay too much for the ball itself at $30, or you can pay twice that much and get it as part of a kit containing another smaller ball and some instructional materials. Cohen actually sent me a free sample of the whole kit, giving me the opportunity to discover that I’m glad I didn’t buy it. The DVD was produced on the cheap, the book was amateurishly written and published and contained too many pseudoscientific and unjustified claims to count. In particular, I was amazed to see a section claiming that stretching will cause weight loss. Wow! Really?254

But the real problem was that the ball itself just didn’t work well. It’s got this great concept: that you can heat it up before applying it, which sounds like a nice idea, but it takes a significant amount of boiling (5 minutes) to heat it up thoroughly, and then it’s too hot at first but then cools down fast, and the point of contact between you and the ball is pretty small so there’s not that much heat transfer anyway. In fact, the ball doesn’t even have a smooth surface, but is covered by tall knobblies, which will minimize skin contact and maximize heat dissipation (d’oh, simple physics). And then to add insult to injury, the knobblies also pinch mildly as you move the ball: as the surface of the ball compresses, the knobblies bend towards each other, grabbing skin and pulling a little uncomfortably as the ball moves. Not a horrible flaw, but why is it a flaw at all? It’s a nearly useless design, for 30 clams.

River rocks, by contrast, are free.

In the same vein, a Texas company called Trigger Point Technologies alleges that their massage tools are made of a “special” substance that is especially good for self-massage. (“Special substance” reminds me of the ancient Saturday Night Live sketch, Happy Fun Ball [YouTube, 1:35, a remake because the original isn’t available].)

I’m not really concerned with whether or not the claim is accurate. The problem is that it doesn’t matter! There are many cheap and easy ways to self-treat your own trigger points, so there’s really only so much need for a “special” and expensive tool for this job. The effectiveness of self-treatment for muscle knots is limited primarily by completely different factors, many of them uncontrollable … not by the quality of the substance your massage tools are made of.

I’m not opposed to the idea of spending money on a massage tool that is especially handy or effective, it’s just not that high a priority. By making the substance their massage tool is made of a focus of their marketing, Trigger Point Technologies fails to persuade me that they understand either massage therapy or trigger points.


Massage tools: 7 free (or very cheap) tools from objects not originally intended for massage

Here’s a list of my favourite clever, interesting massage tools that are cheap or entirely free, and charmingly adapted from objects that were not originally conceived as a massage tool.

Lacrosse balls are really firm — too firm for many people — but they have a great rubbery texture that makes them easy to work with, and less prone to slipping, especially when they are pinned between backs and walls. They are also a bit smaller than tennis balls, and therefore also a little more precise. For patients/muscles that tolerate the harder texture, they are just terrific. They’re very cheap, of course, and it’s well worth having one in your massage tool kit.

River rocks. Here’s a massage tool that “rocks,” har har — a therapist I know collects smooth river rocks, and gives them away to patients as self-massage tools. It’s a great idea! Although hard as rock (too hard for many patients and situations), they’re perfect for certain self-massage challenges. For instance, they might be ideal for firm “scraping” of the muscles of the forearm — a muscle group which can really take a beating in some people.

Squash balls. I love my squash ball. It’s ideal for self-massaging in the upper back, where trigger points are often too intense for harder tools. Its stickiness makes it highly “steer-able” when pinched against a wall. Its size makes it quite accurate. It just has nice properties for self-massage! They also come in a range of textures (indicated by the dots on the ball).

Dog KONG® (classic). (Note: not actually cheap.255) The more I learn about trigger point therapy, the more I believe that you can get some of your best massage tools at … your local pet store? Yep. A KONG dog toy is another great massage tool that a lot of people have handy, or that they can get easily. With its pyramidal shape and hardness that varies depending on how you use it, it’s even better than a tennis ball!

Dog KONG® (ball). The Classic KONG® with the funny shape is terrific in some ways, but not ideal for every situation. The simple ball version of the toy is a great companion tool: its softball size is ideal for certain locations where other balls get “lost” (i.e. the small of the back). It is as hard as you’d ever want a massage ball to be, yet still has a little rubbery give. Its rubber surface means it doesn’t slide around too much. And it’s perfect for “the bath trick.”

Sock ball. (This is different than the “sock trick” described below.) A sock ball — socks rolled into each other, as most of us have in our sock drawers — is a perfect massage tool for more sensitive trigger points. It’s the tool to switch to if you need to work your way up to stronger massage.

Rolling pin. Ah, sweet simplicity — there are hundreds of different “foam rollers” on the market for self-massage, and I actually like foam rollers. However, often a rolling pin is just as good, and already in the house. Of course, a rolling pin is hard — and while that’s just fine for some applications (the tibialis anterior muscle, shin splints), and the quadriceps, it’s obviously too hard for others. However, there’s nothing stopping you from wrapping something soft around it — either a temporary solution, or something more permanent if the rolling pin is going to be your best friend and permanently recruited for muscles instead of pie crusts.

Foam rubber balls. This kind of ball has a particularly nice texture, and can be anywhere from very soft to very hard. Finding them is a bit tricky, unfortunately. I used to have a great recommended supplier for this type of ball — simple, no branding or gimmicks or the price tag that always goes with that, just a range of sizes and degrees of hardness, and cheap — but, alas, they are gone now. On my last check in mid-2021, I couldn't find anything comparable, although there were many branded, gimmicky, and too-expensive alternatives.

Advanced tips and tricks continue relentlessly in the next two sections, with a pair of tool-using tricks I particularly like …


The sock trick

Whether you work with a tennis ball, a KONG® dog toy, or even a rock, most massage tools can be put into a long sock or stocking, allowing you to dangle it down your back into those hard-to-reach places. This can give you much finer control over the exact location of your tool.

Of course, if you don’t have unusually long socks — and not many of us do — there are other solutions along the same lines. KONGs can be tied to a rope or string. A tennis ball can be put in a long, soft sack … or in a short sack.

The truly enthusiastic self-massager — you know who you are — may wish to actually craft their very own custom “massage tool sock.” You can easily sew one yourself, or go to any seamstress and pay probably less then $10 to get them to make you a long, narrow sock of sturdy fabric. Amaze your friends!

What parts of the body is the sock trick especially good for? Use the sock trick to reach muscles from the upper back down to the lower back. It will save you considerable time as you work your way from top to bottom (or bottom to top), systematically applying pressure to the full length of the paraspinal muscles.


The bath trick

From the Department of Why Didn’t I Think Of This Before: the bath trick!

I discovered this long ago while working on my own muscle knots, trying to tame an episode of low back pain, which is a never-ending job — they are always under control, more or less, but also always threatening to come back.

This is what trigger points do, of course — they come back. It’s in their nature. It’s a creative challenge that never ends.

The Bath Trick

Run a hot bath & trap a ball between your body & the bottom or back of the tub to rub your back muscles — your buoyancy allows for excellent control over moderate pressures.

The bath trick is a “together at last” trick: it came from combining two other classic tactics for releasing your own trigger points: the heat of a bath, with the pressure of a ball. But the result is more than the sum of the parts, like chocolate and peanut butter, and it works better in some ways than anything else I’d come up with before. Suddenly I’m using the bath trick regularly myself, and recommending it to readers.

Absurdly simple instructions for trigger point release in the bath …

  1. Simply run a hot bath …
  2. climb in and get nice and warm and comfortable …
  3. and then bring in a ball! Trap the ball between your body and the bottom or the back of the tub, and cheerfully crush your trigger points with relieving pressure.

Why bother?

The bath trick works particularly well because the pressure is mostly quite easy to control, and easier still if your tub is equipped with hand-holds.

Often people find that the full weight of their body trapping a tennis ball against the floor is simply too much — the pressure is too intense, and they’re unable to achieve a relieving sensation. But in the bath, you are much lighter! You have much better control and a moderate intensity of pressure.

But pressure caution is still required! I think the heat of the bath can mask the intensity of the pressure. I have bruised myself even when I thought I was being careful. Bruising is not cool and not therapeutic. Please be careful not to overdo it, especially at first!

While the heat relaxes you, your buoyancy in the water allows finely tuned control over moderate pressure on your trigger points. Applying a little more or less pressure is as simple as rising up in the water a little, or submerging more of yourself. You can also raise or lower the water level for additional control over your buoyancy — many people will find that they are too bouyant and are basically floating over the ball rather than pressing down on it. Fix that by draining off a little of the water.

What sort of ball should you use? Some balls are better for the bath than others. Either a lacrosse ball or a KONG® brand rubber dog ball is perfect. (Not the pyramidal KONG with the hole through the centre, but preferably the ball, which is made with the same dense rubber.) These balls don’t get soaked, and they have a nice neutral buoyancy — they don’t sink or bob up to the surface — so it’s nice and easy to move them around underwater, trapping them right where you want between your body and the bottom of the tub.

Tennis balls, generally so useful for self-treatment, are not especially good for the bath trick. Wet ones are kind of a pain outside the bath, and they like to pop up to the surface.

What parts of the body is the bath trick especially good for? The muscles of the back and low back are the most obvious targets. However, one of the best things about the bath trick is that it’s one of the few tool-massage methods that’s quite effective for the neck and upper shoulders. Regular tennis ball work, with the ball pinched against the floor or wall, is quite awkward in this area. In the bath, the sloped back of the tub and your reduced weight make it much easier to apply strong, well-controlled pressures to this area. Great!

Another fantastic location to apply the bath trick is the sides of the hips. Simply turn on your side in the bath, and it’s possible to get quite relaxed onto the ball in a way that’s not easily achieved outside of a bath.


Introduction to non-massage self-treatments for trigger points

We have now covered self-massage methods in exhaustive detail. But self-massage is only the best treatment most people can apply to their trigger points, not the only one. There are three other major helpful methods, and some of them may be more effective than massage for some people — it depends on the case. There are many other therapies — but these three are the primary self treatments.

Stretching feels good and may help some trigger points some of the time, but it’s generally over-rated, and sometimes stretching can actually do harm. Yoga classes injure people often enough that it’s a fair question whether there’s even an overall benefit. Stretching is such a complex topic that it’s covered in great detail in its own chapter after the advanced treatment tips are wrapped up.

Mobilizing, or “massage with movement.” Mobilization — rhythmic contraction and elongation of tissues — is a concept of my own invention. Mobilizing is routinely more effective than stretching, and it can be particularly helpful eliminating trigger points associated with tissue stagnancy. Mobilization is summarized in more detail below, and discussed in great detail in the article Mobilize!

Heat therapy. Trigger points love heat: hot baths and showers, hot tubs and Jacuzzis with their jets, saunas and steam rooms, heating pads and hot water bottles and microwaveable bean bags and gel packs … you name it, if it’s hot, your trigger points will like it. Using heat on your trigger points gets its own section below, and there’s also a good general article on heat therapy elsewhere on


Stretching (executive summary)

This section is an executive summary of a much larger batch of sections below. Stretching is such a huge topic that I felt it interrupted “the flow” to have a big stretching discussion in this part of the tutorial. Read the basics here; later on, you can read much more in the main stretching section. Note: this summary deliberately lacks footnotes and substantiating detail.

The anecdotal evidence that stretching “works” for stiff and aching muscles is substantial. (Ominously, so is the anecdotal evidence that it can backfire.) There is also some scientific evidence suggesting that stretching is helpful for common musculoskeletal problems, such as neck and back pain (but it’s also a complicated, incomplete, underwhelming mess). Stretching doesn’t seem to come close to “curing” anyone, but darned if it doesn’t also “take the edge off” enough to make it worth trying. So people in pain stretch, and sometimes they feel a little better for a while.

Stretching as a treatment for trigger points has some expert endorsements. In the weighty text Muscle Pain, researchers Dr. David Simons and Dr. Siegfried Mense wrote that stretching “by almost any means is beneficial.” This depends on a chain of assumptions and theories about how trigger points work: the micro-cramp is metabolically exhausting, like an engine revving in the red, producing waste metabolites that pollute and irritate the surrounding tissues, causing pain and more contraction. In theory, a trigger point cannot burn fuel if it is fully elongated, which would give the energy crisis a chance to abate — a vicious cycle breaker.

If they are right, then stretching works about the same way that stretching out a calf cramp works: you win the tug-of-war with spasming muscle, just on a smaller scale. This sounds great on paper, but there are several major problems in both theory and practice. Simons and Mense also emphasize that it has “not been firmly established” that stretching trigger points is helpful, and that stretch works primarily for “newly activated, single-muscle” trigger points … leaving out a lot of trigger points that are serious problems. There are many circumstances in which you cannot realistically hope to win a tug-of-war with a strong one, because it would be too anatomically awkward and/or too painful.

How can we pull apart a powerful contraction knot — a tiny segment of muscle fibres in full spasm — with anything less than pliers, a vice, and a glass of bourbon? We almost certainly do not have the leverage or pain tolerance required, especially if the muscle fights back with a defensive contraction (which may account for the cases that backfire). That trigger point is like a knot in a bungie cord: all we’re going to do is stretch the hell out of the bungie cord on either side of the knot. If it works at all, it probably mostly only works on the milder cases that don’t matter much in the first place.

And then there’s the possibility that Simons and Mense were just wrong, and a trigger point is not like a tiny cramp at all. If there is no metabolic “revving,” no energy crisis to interrupt by pulling muscle proteins apart like kids fighting on a playground, then it’s back to the drawing board: either stretching doesn’t work at all, or we just have no idea how it works. Which is possible.

It’s not a very promising treatment method, but the hope is not going away either: it feels good even when it fails, and partial and temporary successes will keep most of us trying. Just beware of wasting your time! For most people, other treatment methods are probably more useful.

See below for the full discussion of stretching for trigger points, which gets into the nitty gritty details.


Mobilizations: massaging with movement and the Goldilocks zone

Doo doo doo doo, doo doo doo doo …

Can you exercise to help beat trigger points? Yes. But you have to enter …

The Goldilocks Zone.

To qualify as an advanced trigger point troubleshooter, you have to do better than simply avoid a few common things that piss trigger points off: you have to actively pursue the ideal alternatives. So, in various ways before now in the tutorial you’ve learned that both overexertion and tissue stagnancy (getting stuck) are irritating too.

So, what’s the alternative?

Regular, easy exercise. Exercise intensity that is “just right.” Just enough stimulation to keep muscles warm and happy … but not enough to irritate them.

Anyone struggling with trigger points must (must, must) embrace life in the Goldilocks Zone. You have got to constantly but gently stimulate your body. Weekend warriors need to let the ski slopes go for a while and take up a walking habit instead. Hardcore power yoga bunnies need to switch to a gentler class. Office workers have to learn to “microbreak.” Gym rats have to ease up on the “reps to failure.” And so on.

You can easily take the idea of the Goldilocks Zone and run with it. It’s not hard to understand in principle. But there are many details.

Chair warriors, for instance — office workers stuck in chairs all day every day — can learn a great deal about how to cope with their predicament, how to work “defensively” and prevent severe muscle tissue stagnation. For much more information, see The Trouble with Chairs. Strength training enthusiasts can read all about the relationship between strength training and trigger points in the next section, “Trigger points at the gym.” And yoga practitioners and stretching enthusiasts need to learn that stretching can also irritate trigger points. Stretching can be a pleasant Goldilocks Zone activity.

But the idea that absolutely everyone needs — the ideal embodiment of the Goldilocks Zone — is the idea of “mobilizations.”

“Mobilizations” are rhythmic, repeated movements that alternately stretch and contract musculature and other soft tissue — massaging your tissues with movement. I prescribe at least one or two key mobilizations to nearly every client, usually in preference to stretching. Mobilizations are more “neurologically interesting” than stretching and stimulate more metabolic activity in the tissue while remaining gentle. They are more practical and efficient than stretching in many ways, especially because they can affect more tissues more quickly, and because they constitute both a better warm up and a better warm down for more intense activity.

See Mobilize! for more information.

And they are ideally suited for efficiently, accurately stimulating — but not-overstimulating — muscles with trigger points. Don’t just think of mobilizations as an exercise that is compatible with trigger points. They are also a therapy for trigger points.256


Case study: mobilizations prove to be crucial factor in recovery from neck pain that started in the 1970s

Trevor Elliott is a self-made man: entrepreneurial and good at it, a gentleman farmer and commercial real estate investor, he could easily retire but doesn’t seem particularly interested in doing so. A gregarious Irishman with an enthusiastic handshake, he’s always getting into a project … and getting into trouble.

In 1971, the trouble was that he fell off a motorcycle in Ireland. He savagely wounded his neck, and never really recovered. Although bones and ligaments healed, Trevor was left with a severe and seemingly permanent “crick” in his neck. It was so severe that all who knew him knew his habit of wrenching his neck constantly, like a tic, always trying to wriggle free of the grip of his pain — for decades.

When I met him, Trevor had been intermittently trying every possible therapy for thirty-five years — especially chiropractic adjustments — but never in all that time had any significant, lasting results.

Interestingly, his anterior neck musculature had never been “worked” by any therapist in any way in all that time — “no one has ever rubbed me there!” It was one of my highest priorities, based on some of his symptoms, which were consistent with irritated scalene muscles.

Trevor had ten treatments with me between February 23 and May 31, 2006. In that time, he improved to the point where he began doing things he hadn’t been able to do for many years, friends and family commented on the change, and he felt substantial and lasting relief from the feeling of his neck being “out.” He wasn’t “cured,” but his symptoms were down a good 80% — far more than he had ever dared hope for. He had expected to go to his grave with this pain.

Trevor’s relief lasted. Although he occasionally saw me for a “tune up” — and for help with other minor issues — from years after that, he effectively managed occasional flare ups of neck pain with neck circles — a simple mobilization exercise, just stimulating the neck with thorough movement: rolling the head around in circles.

I never thought of Trevor as “cured.” I suspect that his neck was simply too injured to ever fully recover, like a sprained ankle that is just never the same again. But his neck problem was “controlled.” His revelation was that such a large percentage of his symptoms over the years had been produced by irritated muscles — which could be managed surprisingly easily with some long overdue massage, and some simple exercises. It may not have been a cure, but it was almost as good.

Another key to this case was treating the scalenes. 99% of neck massage is directed at the musculature on the back of the neck. There are good reasons to give more attention to the back, and to be cautious and conservative with the front, but the anterior musculature can get just as cranky as the back. In Trevor’s case, the “itch” that needed “scratching” was in the lateral and middle scalene muscles — which he was oblivious to until he felt it.


Trying to squirm your way out of trigger point pain? Don’t do it! Consider a little more method in your madness

Here’s a useful perspective, another way of thinking about mobilizations that may make a lot of sense to you. Imagine this scenario …

You’re sitting at your desk. As usual. You’re reading this, or something — you’re always reading something, typing something. Without even noticing, you tilt your head to the side, and then wrench your neck into rotation with a grimace. You quickly turn it the other way, and there’s a soft pop that gives you a little relief. Until the next time. It’s going to be five minutes, tops, before you’re at it again. Might be seconds.

Sound familiar? Almost everyone has this problem. This kind of reflexive effort to escape stiffness and pain with a brief, exasperated stretch and/or joint pop — squirming, basically — may happen dozens or even hundreds of times per day. It is most common in the neck, followed closely by the low back, but can occur in virtually any body part. Argh.

“The squirm” is a response to an instinctive desire to move — to mobilize! Answering the instinct is definitely the right idea. Stagnancy is definitely a problem, and movement is a solution. Unfortunately, done in this way it will never do any better than just “take the edge off.” As symptoms increase in severity, this twisting and squirming becomes more intense and frequent — and even less effective.

Imagine this scenario:

You’re sitting at your desk. As usual. You feel an impulse to squirm, but instead of squirming, you move more mindfully and properly. You take a 30 second break, stand up, and roll your head in a full circle just five times — easy, quick. Then swing your hips around a few times.

That’s better!

In other words, squirm more thoroughly! And in a more positive frame of mind. A microscopic yoga break. The movement involved will be a good order of magnitude greater than a brief, reflexive squirm. The difference in mental attitude is subtle, but incredibly important over time.


Strengthening: should you take your trigger points to the gym?

Executive summary. People with trigger points often feel weak, but we don’t know if they actually are. Strength training is very healthy in general — much more than most people give it credit for — but we have no idea if it’s good for trigger points, and it has the potential to both help and harm. Moderate intensity contractions pose minimal threat to muscles “sick” with trigger points, and the moderate stimulation and the increased circulation might be helpful.

If you like lifting weights, and you want to try to treat your trigger points that way, I encourage you to “go for it,” but please be more cautious than you normally would: baby steps, allow for extra recovery time, avoid maximal and eccentric loading, include more endurance training (higher reps, lower loads).

If weight-lifting is not your style, no worries: you have my blessing to carry right on not lifting weights. But please do consider it as a healthy activity that has some potential to also help your muscle pain.

The contents of this section can mostly be inferred from your guru-like knowledge of trigger points, which you’ve acquired from your reading so far. For instance, in the previous section we were discussing the importance of moderation, gentle exercise, and the Goldilocks Zone — so you’re not exactly going to fall over with surprise when I tell you that lifting heavy weights at the gym with your muscles full of trigger points may not be the best idea you’ve ever had.

Yet a lot of people want to do exactly that. Many independent, motivated people in pain will go to the gym hoping to “bury” their pain, only to discover that it isn’t quite that easy. A few enthusiastic people will succeed and become gym-therapy evangelists, which is a problem for the many people who either fail or actually get hurt. So there’s a need to tackle the subject head on. Mostly we’ll talk about the most manly gym activity, strength training, but we’ll also compare and contrast it with the main alternative, endurance and aerobic training.

Is strengthening even therapeutic? Strength training is weight training, bodybuilding, pumping iron. It means “high load, low reps” — lifting heavy weights just a few times. Its most obvious goals are to make muscles bigger and stronger, which works really well, but it has much more general health benefits than most people realize, and it’s safer and more efficient than people think too.

But there is also a common belief out there that strengthening is the way out of all kinds of injuries and painful problems. “Core strengthening” is especially overhyped: it’s probably the most popular pair of words in exercise therapy for the last couple decades. Strengthening is often prescribed as a therapeutic exercise to help people recover from all kinds of injury and pain problems. Many manual therapists see exercise and “active” therapy in general as being the future, and “passive” therapies — doing things to patients — as old school nonsense.

Strength training has some risks for people with chronic pain however. And is it even worthwhile? Can you actually treat anything by throwing weights at it?

In some cases, probably. But not for most people, most of the time. The evidence is overwhelming that strength training is underwhelming as a therapy for specific painful problems. For example, in 2006, Smeets et al concluded that it was “more promising” to study “the interplay between biological, social and psychological factors” in back pain than to bother with more studies of lumbar strengthening.257 A 2016 study showed that there was no difference between high load lifting and low load motor control exercises for back pain.258 Those are just a couple of representative examples. It’s a huge topic, which I am just glossing over here — I’m covering it just enough to emphasize that the benefits are not clear at all.

It’s not that strength training never works as therapy. It’s just considerably less impressive or consistent than you might think. Particularly given the risks, you might want to ratchet down your enthusiasm for curing yourself with weights.

And there are risks!

The physiological changes associated with strength training and “gettin’ huge” occur when you exhaust a muscle by lifting something heavy over and over again. Recent evidence has shown clearly that it doesn’t matter much how heavy the weights are or how many times you lift it, just as long as you are good and worn out at the end.259 If you’re not doing this, you’re doing some kind of exercise, but it’s not strength training, not really. “Exhaustion” has a meaning in strength training beyond simply being tired. Exhausting muscle tissue completely, or close to it, is called taking it “to failure,” is essential for building strength — but also potentially a problem for trigger points and pain. That intensity can mess with people with chronic widespread pain,260 especially in fibromyalgia patients. Maybe pissing off trigger points is one of the reasons that happens. No one knows.

But maybe you can get away with it? Hey, you never know. Taking your trigger points to the gym and exhausting them is definitely not necessarily going to be a disaster. It could go either way. It could even feel great! Rehabilitative strength training does aid rehabilitation in many cases. Two recent scientific papers have shown that both strength and endurance training were effective for treating neck pain,261262 which likely involve a lot of trigger points. This suggests that almost any activity, even strength training, could be better for trigger points than no activity.

Nevertheless, I hear a lot of stories from people whose strength training efforts at the gym came to tears, or simply failed to help the problem. Some people predictably experience significant aggravation of their symptoms every time they try to strength train. Many more simply experience mild symptom exacerbation and underwhelming results — their problem isn’t helped, and the strength training doesn’t work very well either.

And latent trigger points can really interfere at the gym — long before you are aware of any problem! Ironically and somewhat tragically, people with latent trigger points may still suffer rotten consequences at the gym, even if those trigger points never actually flare up into activity. Some people almost certainly misinterpret poor strength training results for years on end — strength training is supposed to be difficult and exhausting, and discomfort afterwards is normal, right? How can you tell the difference between the normal challenging sensations of strength training and the dysfunctionally excessive discomfort of strength training with a bunch of latent trigger points making you feel weaker, quicker to exhaust, and more sore afterwards?

Strength training should be hard, but it shouldn’t be that hard. Not everyone can get results at the gym, probably because of genetics … but perhaps also because so many people are walking around with a crop of latent trigger points that make strength training rather difficult.263

The more relevant trigger points are to your case, the more likely it is that the strength training will be uncomfortable and difficult, fail to build strength, and/or make no difference to your problem, or make things even worse than they were.

Endurance training to the rescue? Gentler, more repetitive usage of the muscle — lower loads, higher repetitions, less exhaustion — is the general solution to all of this. If you have active trigger points and are in acute discomfort, mobilizations are even gentler than endurance training, and often more appropriate. But endurance training is simply a terrific way for enthusiastic weight lifters not just to safely continue training, but to actually help to relieve the trigger points and get back to strength training all the sooner.

The low loads of endurance training simply minimize the risk of aggravating trigger points or tearing some muscle, while the high repetitions provide plenty of stimulation and metabolic activity. No tissue can thrive without some stimulation! A good endurance workout creates a significant metabolic demand, which increases circulation more than any massage ever could.264

Injury rehabilitation is all about taking “baby steps.” Understanding endurance training gives you another step — a way of using the gym without banging your head against a brick wall. Good luck!



Advice to “avoiding ice and chills” and “try heat” is about as far as I go when training beginners. But for advanced students … ah, we need to talk! You need to become a heat connoisseur — you need to experiment with actively and extensively using heat as a way to prepare for and support other trigger point therapies, and as a trigger point therapy in itself.

Muscles simply love heat. There is a strong and predictable reduction in muscle tone underlying heated skin — a fairly straightforward neurological effect, a reflex. And every reduction in muscle tone helps to relieve trigger points. And practically everyone with serious trigger points says something like, “Well, heat is one thing that does actually seem to help.”

I don’t know of any case, ever, that could be cured with heat alone — it’s a powerful aid, not a cure — but I do know of many cases where heat was a critical factor in recovery. Here are several tips and tricks for how to get the very most out of heating your trigger points.

Distinguish between systemic and local heating. They both have their uses. Systemic heating is full-body heating in baths, hot tubs, showers, saunas and steam rooms. The advantage of systemic heating is that it addresses a lot of tissues at once, and — done properly (i.e. avoiding headaches) — can add a powerful relaxation component to the treatment. Local heating is heating of specific regions of the body with heating pads, gel packs, bean bags, soaking in sinks or buckets, and so on. Local heating methods can be more intense in an area that needs it, and are often simply more convenient for repeated/frequent treatments, which is often quite important during a phase of intensive trigger point therapy. Use both systemic and local methods for different reasons at different times.

Take a better bath. Sadly, many people don’t care for a hot bath, but mostly because they’re doing it wrong. How can you do a bath “wrong”? Surprisingly easily! Many people make it too hot (which is more stimulating than you think, and can keep you awake at night), fail to keep their head cool (which can lead to headaches), and don’t drink enough water. (Dehydration can really sneak up on you in a bath. No, really! Watch out.) For complete details on how to bathe properly, see Hot Baths for Injury & Pain.

Get a Thermophore. For specific/local heating, I particularly recommend seeking out a large-sized (14 × 27) Thermophore. Vastly superior to drugstore heating pads, Thermophores are the Rolls Royce of heating pads: large, heavy, thick, and with “a special tightly-woven fleece blend cover which retains moisture from the air” — which really, really works. If you leave a Thermophore on a plastic surface, there will be beads of water under it five minutes later. The moisture captured from the air by the Thermophore conducts heat far more effectively than a dry heating pad. Luxurious! Both genuine Thermophores (roughly USD $50-100) and knock-offs (cheaper and probably nearly as good) can be ordered online from, and are also usually available in medical supply stores. Of course, Amazon has them, too, and probably cheaper.

Contrast! The main goal of heating for trigger points is relaxation of the muscles that contain trigger points. But another goal is to increase circulation, to aid in “washing” out the stagnant tissue fluids that may be the reason trigger points hurt, and to do so without subjecting the muscle to any exercise stress. In the limbs particularly, you can get a much more powerful effect on circulation by combining heat with cold. This is called “contrasting.” Contrasting is a free, safe, easy self-treatment for a wide variety of conditions that can benefit from an increase in circulation (i.e. practically anything except acute injuries). Contrasting involves alternating between soaking in hot water and soaking in cold. Always finish with cold. Use a double-sink, a pair of buckets, a detachable shower head ... or whatever arrangement you can dream up. Please see Contrast Hydrotherapy for more detailed information and instructions.


Breathing deeply is free, safe, and possibly good therapy for trigger points

Deep breathing while doing trigger point release is a bit of a no-brainer: it may be an extremely effective aid to trigger point release, and even if it doesn’t it is free, safe, and has some other clear benefits (similar to what you might get from meditation). This is probably the strangest advice I have for readers, but I have some confidence in it as a therapy. It has a sound rationale. You can read more about it in the article The Art of Bioenergetic Breathing.

Let’s start with an overview of what kind of breathing I’m talking about.

Since the early 1990s I have been practicing, teaching, and exploring an unusual form of therapeutic breathing called “bioenergetic” breathing (a.k.a. “round” breathing). It is a useful tool for the stimulation of healing and personal growth (not a claim I make lightly). When a therapist tells you to take a deep breath, there’s more to it than you think, and often more to it than they think. It’s the tip of an iceberg most people have never seen or heard of.

Bioenergetic breathing originated in the bodywork philosophies that emerged originally from Alexander Lowen’s interpretations of Reich and Jung.265 Some of it is undoubtedly obsolete nonsense, and it has been paired with many other strange ideas over the decades. I believe it remains useful regardless of its backstory.

Ah, deep breathing! So mystical! And possibly great for your blood acidity.

But what about the effect of breathing on trigger points?

Earlier in the tutorial you learned that recent scientific research has shown that there may be irritating metabolic wastes floating in the tissue fluids of trigger points: “ … not just 1 noxious stimulant but 11 of them.” Yuck. The same research showed that trigger points are also acidic. “The milieu [of the trigger point] is strongly acidic,” Simons writes. “The amount of these [acidic] substances was very significantly and consistently greater in active MTPs than latent ones.”

This discovery is satisfying for me because, several years ago, I guessed that it might be the case. I often told my patients that trigger points were “acidic,” because it seemed likely to be true and because … well, it just sounded good, I guess! In those days I was not as scientifically literate as I am today, and I hadn’t noticed that I was being intellectually dishonest, presenting a sketchy theory as though it were a meaningful fact. Naughty therapist! Fortunately, the scientific evidence now actually does support my opinion.

Trigger points really are strongly acidic. And breathing hard — outside of an exercise context — reduces blood acidity to the outer limits of the normal range, or a little beyond: minor, transient respiratory alkalosis. Respiration is the main way that we aggressively, quickly regulate blood acidity.266 Which means that it is plausible that deep breathing could be relevant to trigger point treatment. One of the likely goals of massage therapy is to “flush” trigger points by pushing stagnant tissue fluids out. Perhaps if blood arriving in the area is significantly less acidic, the trigger point will recover more easily? Perhaps?

It’s certainly possible!

But far from proven. And these days I know much better how much I don’t really know, so I’ll stop with just the suggestion. 😜

Meanwhile, there are other benefits to vigorous deep breathing. The most obvious is that it tends to be deeply relaxing via a kind of “blowing off steam” effect. This isn’t slow, meditative deep breathing we’re talking about here: it’s fast and strong, even hyperventilatory.267

How to breathe bioenergetically for trigger point therapy

Bioenergetic breathing is basically just fast, deep breathing. Specifically:

In a full bioenergetic breathing session, you might work up to a vigorous pace of breathing in the space of a minute or two, continue for five to ten minutes, and then wind down again. This much bioenergetic breathing is optional for trigger point therapy. You can also simply:

  1. Take just 10-20 deep, fast breaths before starting trigger point therapy.
  2. Continue to breathe deeply and steadily during therapy.
  3. And then optionally add another one, two or three short sessions of 10-20 breaths in the hour after treatment.

Once again, for people interested in trying this kind of breathing, I strongly recommend reading the full article about it: The Art of Bioenergetic Breathing.


Strain-counterstrain (AKA positional release): find a neutral, comfy position and rest there

  • Jun 5, 2021 — Improvements: More detail and polish, strain-counterstrain chapter

Resting peacefully in a position of comfort for a minute or two may ease chronic pain for much longer. There are a variety of techniques that exploit this idea in different ways, but “strain-counterstrain” therapy is the most common label for treating pain essentially just by positioning limbs for patients. Most massage therapists call it “positional release.” I’ll mostly use SCS here.

We have here yet another odd treatment approach of unknown and probably low value at best. And also free. And also particularly harmless, since the point of it is to do almost literally nothing, like a form of meditation. At worst, SCS is just a comfortable, peaceful waste of time.

SCS is almost comically simplistic, so basic that you might wonder why I would even bother. Well, I’m bothering because … I’ve seen it help people. Which doesn’t mean that it actually works — it’s easy to be wrong about this kind of thing, and I would never “swear by it” — but that is why I am writing about it.

SCS also has a surprisingly rich history: despite being quite obscure, it’s a full-blown member of the manual therapy family, the subject of books (but precious little research, of course). So I can give it a chapter, if for no other reason than it’s something people ask about.

I’ll be focusing on a do-it-yourself version, because you don’t really need to pay someone to position your limbs for you.268

I will also put a modern “science of pain” spin on this. But first, here’s the backstory for this therapeutic oddity…

The origins of strain-counterstrain and positional release therapy

SCS has a long and muddled history going back to the middle of the 20th Century, at a time when really the only requirement for creating a new therapy was to have a plausible-sounding idea and then promote it — reputation-based medicine. A 2012 paper in Manual Therapy advertises itself as a “master class” in this topic, a cringe-inducing hyperbole that says a lot about how SCS is the product of a professional culture that still takes its “gurus” and experts way too seriously.269

The SCS idea came from an American Doctor of Osteopathy, Lawrence Jones, who believed that his patients were getting disproportionate pain relief from finding a joint position that minimized discomfort and just hanging out there for a little while. People have been doing it, explaining it, and riffing on it ever since… and just assuming that its efficacious. But there is almost no science here, just a hodgepodge of speculation and experimentation, with theories ranging from plausible neurological models to vitalistic claptrap — it’s clearing a path for your “energy,” like qi gong or yoga.

I originally was taught positional release as a student massage therapist, specifically as a way to treat trigger points. That was in the late 90s, and the idea was already 40 years old at that point. It was a “massage” technique that could stand alone or, more likely, something that would be integrated with other techniques. You’d never do a whole session of it, any more than you’d want your massage therapist to spend your hour doing a single Swedish massage technique.

So SCS is definitely more of a “technique” than a “therapy,” and you can see the influence of it on a variety of other techniques. But SCS is the canonical method of treating pain by joint positioning. In the context of neck and back pain, positional release is actually a flavour of spinal manipulative therapy — because “positioning” spinal joints is almost the same as wiggling, stretching, and popping them.

Does comfortable positioning actually relieve any kind of pain?

Who knows? Literally no one. There are just a bunch of manual therapists out there who think that they have seen it work… including me.

“Comfortable positioning relieves pain” is a clear, specific, and scientifically testable claim which has — shocker — never actually been tested. There are just a handful of SCS papers in the usual-suspect manual therapy journals, mostly too junky to even cite. Here’s the only evidence I think is worth citing (barely)…

In 2011, Lewis et al tried SCS on 44 adult women with acute back pain, four sessions in two weeks, and compared the results to another few dozen patients who got “standardized exercises.” They used a disability score as the primary outcome measure, and there was no difference at all, “no advantage in providing SCS treatment.” A nakedly negative result, but also from quite a limited study.270

The bottom line is that evidence is just absent for any kind of pain, let alone trigger point pain specifically.

A practical example of using strain-counterstrain

One of the diagnostic characteristics of a trigger point is pain on stretch and contraction. Some muscle positions and states are more comfortable than others, and we seek out those positions naturally, to escape the pain, but we can do so more carefully and systematically as a form of therapy. In the same way that dynamic joint mobility drills (AKA mobilizations) are quite a different experience than “squirming,” deliberate neutral positioning is a different experience than impulsive, erratic avoidance of painful positions.

Let’s pretend to be a fly on the wall, observing a patient with neck pain aggravated by postural stress at a desk. This patient may feel quite a bit better with a simple forward tilt of the head, and can be seen to do this many times per day, seeking relief. However, the position of greater comfort is never sustained — no matter how long we watch, all we see is reflexive, distracted, disorganized pain avoidance behaviour (“squiriming”).

What if that person were to take a ten minute break and rested, head supported, relaxing in a position where the pain is the mildest, or even absent? What if she was mentally calm and focused on that experience? Is it possible that they might emerge from that more deliberate rest feeling far better? You can bet your boots it is — hardly guaranteed of course, but certainly possible. As natural as it may be to seek out a position of greater comfort, it’s unlikely that we will ever do it as thoroughly or as well as we can with a little conscious effort.

That’s it. Unproven but basic and plausible.

If strain-counterstrain works, how can we explain it? A modern take

If the SCS effect is real, I suspect that it exploits the idea that sore spots may be more of a sensory phenomenon than a “thing” in the muscle. I doubt it would work if trigger points are “micro cramps” (though still conceivable).

Pain is always a threat alarm, and sometimes a false one. It is more likely to work with muscle pain than with, say, a broken arm, because persistent trigger points — like many chronic pains — may often involve more alarm than fire. Repositioning may persuade your nervous system that the threat is reduced. A true injury will quickly resume hurting when the comfortable position is abandoned and damaged tissue is disturbed. A trigger point may not resume hurting again — or not so fast — because there may be less wrong in the tissue to disturb.

Note that SCS is a curious mirror image of mobilizations: stillness instead of gentle movement, but both with the goal of gently reassuring the nervous system and “practicing” being pain free. Neutral positioning overlaps with stretch a bit, because sometimes the most comfortable position is a stretch. To the extent that stretch occasionally seems to help treat pain, this could be why.

What does it mean if it doesn’t work?

Failure doesn’t mean much. Although success is probably an indication that sensitization is a factor, with failure the interpretation could go either way:

  1. There’s still something wrong with your tissues.
  2. The false/excessive alarm is still false/excessive.

There’s no reason to think that significant ongoing tissue distress will be helped much by positional release. This technique is not going to treat a tumour growing into a nerve root.

Level up: resting at the edge of the comfort zone

Another way to do SCS is to find the edge of a comfortable position and hang out there. Hanging out in the middle of your comfort zone is saying to your nervous system, “Hey, see? We’re just fine!” But we can move to the edge of the zone and add this: “We’re fine even over here where the alarm starts to pipe up!”

Just spend time there not having much of a problem.

Positional release as “exercise”

Rehab exercise can be divided into a hierarchy of intensity: pain-free range of motion, mobilizations, endurance, and strength training. Although neutral positioning barely registers as an “exercise,” it fits in nicely at the easy end of that spectrum.

Positional release can be considered the first stage in a rehab journey back to normal activity levels: just comfortable stillness instead of gentle painless movement, but both with the goal of gently reassuring the nervous system and “practicing” being pain free. Even as you progress with more challenging activity and exercise, you can also periodically interject a little positional release, to continue reassuring your central nervous system.


An introduction to medicating muscle pain (hint: not a great option)

The next few sections expand on ideas already presented in the basic medications section, and also discuss medications that aren’t available without a prescription (such as Oxycontin).

“No non-narcotic medication is known that is specific for the pain generated by central myofascial trigger points. The new understanding of the pathophysiology of trigger points opens the door to identifying drugs that specifically inactivate the trigger point mechanism.”

Janet Travell, David Simons, and Lois Simons, Myofascial Pain and Dysfunction: The Trigger Point Manual, 1999, p147

Alas, although the door has been opened, no such drug has yet been identified. There is no “muscle knot medicine.” For now, the options are limited to the usual pain-killer suspects — anti-inflammatories, opioids, and muscle relaxants. None of those are particularly likely to impress you with their effectiveness, and some are surprisingly ineffective (I’m looking at you, muscle relaxants — their comeuppance and references lie below).

If you experiment with medications, bear in mind that it’s possible for them to actually backfire: not only to fail to treat your problem, but to make it worse. Because trigger point physiology is complex and mysterious, it’s hard to deny the possibility that certain medications might interact unpleasantly with it. More straightforwardly, there is a phenomenon called “analgesic rebound” which is a common cause of pain: basically, you become more pain sensitive when you stop or reduce pain-killing drugs.


Anti-inflammatories and Tylenol

Anti-inflammatories like ibuprofen (aka “Vitamin I” or Advil and Motrin) and aspirin can be wonderful for controlling the pain of inflammation in the aftermath of a trauma. Unfortunately, as discussed above, trigger points are not particularly an “inflammatory” condition, so anti-inflammatories don’t seem to have a strong effect on them. The biochemistry of inflammation is probably only partially similar to the biochemistry of trigger points. Therefore, there is only so much that medications like aspirin and ibuprofen can do. It’s somewhat analogous to trying to treat painful acne lesions with ibuprofen: it might take the edge off by masking the pain a little bit, but basically it’s just not that relevant to the problem.271

Voltaren gel, basically ibuprofen in an ointment form, deserves its very own section (see the next section).

I’m including this diagram for the second time, to emphasize that the biochemistry of trigger points is different than the biochemistry of inflammation.

Nevertheless, since biochemistry is insanely complex, it’s also unpredictable, and some people seem to luck out and find that anti-inflammatory medications actually do work somewhat well for trigger point pain — which makes them worth experimenting with. And treating myofascial pain syndrome is all about experimenting until you find the thing that works.

Another fairly obvious way that anti-inflammatory meds can be effective is if they successfully reduce the inflammation of some irritated structure that is driving trigger point formation: if the pills can reduce the irritation significantly over the course of a few days or weeks, the trigger points might ease up!

And yet, in practice, only a small fraction of patients get lucky with this approach — maybe 10% — and these drugs can also be pretty hard on your guts (ibuprofen is a gastrointestinal irritant). Between their low overall effectiveness and the people who find the side effects intolerable, there’s hardly anyone out there successfully self-treating their myofascial pain syndrome with vitamin I.

Acetaminophen (Tylenol and Anacin in the US, Efferalgan and Doliprane in Europe, Panadol in many other places) seems to have little effect on trigger point pain … and they are now also infamous for being hard on your liver. It’s become clear over the last few years that it’s a little more dangerous than most people realize.272 Except for a brief test of moderate dosages, I don’t recommend trying to treat muscle pain with this drug — and definitely check with your doctor or pharmacist about dosage and correct usage. (Note that acetaminophen is often combined in a pill with codeine273, which is a whole different deal.)

Here’s comedian Louis CK satirizing a doctor talking about the pain-killer dilemma: “Oh, it’ll do some intestinal damage after a while. But you’ve just got to weigh that against how much you like your ankle not hurting!” And that’s assuming the drugs help! If they don’t, it’s not much of a dilemma. The (hilarious) excerpt from Louis CK’s show, Chewed Up:


Voltaren® Gel, an intriguing new option

Voltaren® Gel is neat stuff: an anti-inflammatory ointment that can be applied only where it’s needed, delivering a dose of NSAID medication to exactly the right spot, and only there — minimal, targeted dosing is the key to safety. It’s an intriguing treatment option for trigger points — probably not much more likely to work miracles than any other medication, but intriguing because it might work and it’s safe and cheap to try. Available for years in Europe, but only approved by the FDA in 2007 for treating arthritic joints, I think this is one of the best bang-for-buck treatment options for muscle pain.

In general, Voltaren® Gel will probably fail to amaze and delight you for the same reason that other anti-inflammatory medications do: because trigger points are not an inflammatory problem. On the other hand, it could also succeed for the same reason that ibuprofen occasionally does: either your trigger points are more inflamed than other people’s trigger points, or you successfully treat some inflamed and irritated tissue that is the real root of the problem.

The medicine gets into the trigger point by soaking in through the skin and tissues. This is both an advantage and a disadvantage. On the one hand, the accuracy of delivery is one of the things that makes it safe: you don’t have to soak your entire system in medication in order to get an effect. That makes it far safer than taking the same medication orally.274 You might even be able to deliver a fairly large dose of medication to the target tissue with multiple applications. Conceivably, this concentrated and focused delivery — almost like injecting the stuff275 — could even have a therapeutic effect that a pill cannot, while still remaining quite safe and not exposing your entire system to a high dose of medication.

On the other hand, deeper tissues are much less likely to be affected. Some trigger points in the gluteal and low back musculature, for instance, may be a full inch or two under the skin — I am not at all confident that an adequate dose of the medication would get there at all. But the very common trigger points on the back of the forearm muscle (Massage Therapy for Tennis Elbow and Wrist Pain) are just under the skin, and so they are an ideal place to experiment with Voltaren.

Although the effect of Voltaren on trigger points has not been studied — and probably never will be — and it is not officially approved by anyone for this purpose — I think it’s worth trying, and an interesting and potentially effective addition to your options. It’s not that I think Voltaren® Gel is all that likely to be effective for muscle knots. But the cost-benefit analysis comes out pretty clearly positive. Muscle knots are so common and so frustrating that every safe, cheap option that has the slightest chance of helping is worth a shot.


The nuclear option: the opioids

An opium poppy seed head with very blurry vegetation in the background.

Ripening seed head of an opium poppy.

The notorious opioids, derived from the milk of the poppy flower,276 are mainstream drugs like codeine, and the infamous heroin derivatives and imitators like Oxycontin, Percocet, and Vicodin. Most patients assume that opioids are “powerful” pain killers, and we joke about “the good stuff” like it’s a given that it will do the job if anything will, despite the well-known horrors of addiction and overdose. But opioids are curiously impotent for many kinds of pain and people.

(Opioids do not include the infamous benzodiazepines, like Valium, discussed in the muscle relaxants section.)

Opioids mostly induce deep relaxation and euphoria that may make you not care about pain, as opposed to “killing” pain. But not caring is not a cure, and their efficacy is surprisingly poor for musculoskeletal pain, especially chronic pain (non-cancer).277 Some people are even genetically immune to them.278 They can also backfire and cause pain.279 And, of course, life-altering opioid addictions and life-ending overdoses are shockingly common. The CDC declared in early 2016 that opioids should not be an option for chronic musculoskeletal pain: there’s just too much danger, and too little evidence of benefit.280

Demonizing an entire class of drugs is usually a bad idea. Not everyone gets addicted and some people get real relief, so there’s plenty of grey area here despite the risks. With proper medical supervision, opioids might provide some much needed relief from a particularly debilitating and extreme chronic pain problem.

But, I suspect, probably not for most trigger points.

Opioids and myofascial pain syndrome specifically

The risks of opioids are probably greater for people with “mere” myofascial pain syndrome. Myofascial pain syndrome does not rank high in the world of chronic pain. There are much more savagely painful conditions, like pancreatic cancer, rheumatoid arthritis, or complex regional pain syndrome. Although myofascial pain syndrome can be serious, very few cases, if any, are in the same league as the really painful diseases. You should definitely be cautious about thinking that you might need opioids to manage MPS: it rarely warrants the risks, and maybe never.

That said, opioids might help muscle pain in two ways:

  1. they lower muscle tone overall, which may actually have a direct therapeutic effect on trigger points
  2. they tend to make you feel good about life, the universe, and everything … which could have a therapeutic effect by reducing some of the stress that is an aggravating factor for so many trigger points

The potential benefits are just speculation. Anecdotally, people report to me that opioids are somewhat helpful. Scientifically, no one has any idea.

What about really severe myofascial pain syndrome?

Really severe myofascial pain syndrome is basically indistinguishable from fibromyalgia. As discussed in the introduction, they may or may not actually be different. But if they are the same … fibromyalgia is notoriously unresponsive to opioids. If your particular case of “myofascial pain syndrome” involves other classic symptoms of fibromyalgia, especially serious fatigue and mental fog … probably best to stay away from opioids. (For more detailed information about fibromyalgia symptoms, see A Rational Guide to Fibromyalgia: The science of the mysterious disease of pain, exhaustion, and mental fog.)

If you don’t obviously have other fibromyalgia-ish symptoms, then they might be worth the risks. If you still want to consider trying opioids for your pain, find a doctor who respects opioids as a powerful tool to be used with extreme caution, if at all. Consider refusing a prescription from any doctor who does not raise the serious concerns.

This section is a simplified version of a more detailed article about opioids:


The surprising futility of muscle relaxants such as Robax-whatever, Valium and other benzodiazepines

“Muscle relaxant” is an odd category of drug. There are several psychoactive drugs, including alcohol, that are relaxing and may reduce muscle tone and can be considered “pseudo muscle relaxants.” But they aren’t actually interfering with muscle contraction itself. A true muscle relaxant is essentially a poison that messes directly with a muscle’s ability to contract.

If you think about that for just a moment, you’ll realize that you really don’t want too much muscle relaxant. Amazonians used a muscle relaxant … on their poison arrows. Curare poison relaxes you to death. European explorers encountered the stuff early in their visits to North America, and it led to some of the earliest scientific studies in pharmacology.

The most famous muscle relaxant is diazepam — aka Valium, a benzodiazepine — along with several other well-known drugs like Klonopin, Ativan, and Xanax. Like the opioids, the benzos are another “nuclear option” — they interfere with muscle contraction,281 but they also interfere with a great deal else: like consciousness! And, like the opioids, they are also highly addictive due to the intense feeling of well-being they cause. Like the opioids, the benzodiazepines are complex drugs with many effects, both known therapeutic effects and unwanted side effects.

There are also muscle relaxants that aim to reduce muscle contraction without doping you up. Such muscle relaxants are only widely available without a prescription in the form of methocarbamol, best known in Robaxin/Robaxacet and their sister drugs, all of which are mixtures of methocarbamol with some other pain-reliever, such as acetaminophen or ibuprofen. The point of methocarbamol is muscle relaxation without drowsiness.

There are also some prescription muscle relaxants, none of which are all that familiar to consumers: carisoprodol (Soma), cyclobenzaprine (Flexeril), metaxalone (Skelaxin), and methocarbamol. Some of these are marketed specifically as remedies for muscle pain.282 For instance, King Pharmaceuticals claims that Skelaxin produces “fast relief for muscle spasms and back pain.”

And then there’s Botox — the infamous face-paralyzing drug of the stars! Botox is a special case, quite different from the other muscle relaxants. Like curare on poison arrows, Botox is outrageously toxic and doesn’t “relax” muscles but outright paralyzes them, even in small doses. I discuss Botox in its own section.

The relevance of a muscle relaxant to trigger points seems obvious: a trigger point is a zone of intensely contracted muscle, ergo muscle relaxation should help it. Right? Wrong! Alas, apparently it’s not that simple. (Is it ever?) Drs. Travell and Simons comment rather emphatically on this, sternly concluding “we see no rationale for muscle relaxants in the treatment of myofascial pain caused by trigger points.”283 Clinical evidence is damning as well as expert opinion. Robaxin284 and Skelaxin do not produce “fast relief for muscle spasms and back pain” to any meaningful degree. Botox does not appear to either, despite its good reputation for exactly that purpose. There is “strong evidence” that muscle relaxants do some good … but only a little tiny bit.

Some are probably a bit better than nothing (better than a placebo) — which is certainly worth knowing — but not by a lot, and certainly not all of them, and that’s the take-home message. For instance, although on the one hand there is some good research showing that muscle relaxants provide a modest benefit in conditions where muscle pain is probably often a significant factor (i.e. neck and back pain), it’s a really minor benefit, shown by other good research that muscle relaxants aren’t even as effective as ibuprofen, or no more effective.285 A medication that can’t outperform ibuprofen is basically a waste of time, because obviously ibuprofen is no cure for any of the common chronic pain problems.

A 2008 physician tutorial in American Family Physician286 sums up the blah state of the evidence:

Skeletal muscle relaxants are widely used in treating musculoskeletal conditions. However, evidence of their effectiveness consists mainly of studies with poor methodologic design. In addition, these drugs have not been proven to be superior to acetaminophen or nonsteroidal anti-inflammatory drugs for low back pain.

And “skeletal muscle relaxants should not be the primary drug class of choice for musculoskeletal conditions.”

But the case against muscle relaxants gets even stronger and even stranger: how much does the effect of a medication depend on what you are told about it? Quite a bit, apparently! A strange and fascinating 1999 study in Psychosomatic Medicine showed that a muscle relaxant actually increases tension when the patient is told (lied to) that it is actually a stimulant — the information actually results in the opposite of the intended effect of the drug. But the reverse was not true: subjects did not actually enjoy any notable benefit from the muscle relaxant, even when they were told that it was relaxing. They relaxed, but no more than people who had taken a placebo, and in some cases the placebo was more relaxing.287 All of this strongly emphasizes that your central nervous system is the boss of your muscle tone, almost no matter what is circulating in your blood stream. Even deep anasesthesia can’t over-rule your brain on muscle tone — it is a (fascinating) myth that muscles are actually paralyzed by anaesthesia.288

(That study contained many other gems of lovely weirdness, such as the bizarre fact that quite a lot more muscle relaxant was found in the blood of people who had been told that the muscle relaxant was a muscle relaxant. It appears that they literally soaked up more of the stuff from the GI tract when they believed that it was a relaxant! Cool! And yet it still didn’t actually relax them much.)

If muscle relaxants help pain problems that involve trigger points, it should be dead easy to prove it. The lack of such evidence is damning. It’s also damning that there doesn’t seem to be much difference between muscle relaxants: “Comparison studies have not shown one skeletal muscle relaxant to be superior to another.” So we have a class of drugs that shows little sign of effect, no matter which flavour you use. Whoop-de-do!

Some speculation about why muscle relaxants don’t seem to work all that well on trigger points:

To the small extent that muscle relaxants help common painful conditions, it’s probably due to miscellaneous effects that have nothing to do with trigger points.

For instance, they may relieve some painful muscle spasm associated with trigger points. Or the euphoria caused by a benzo like Valium may relieve stress and reduce pain perception.

But then there’s the side effects: “Adverse effects, particularly dizziness and drowsiness, are consistently reported with all skeletal muscle relaxants.” My emphasis.

Oh, and they are all potentially addictive, too. Especially the benzos!

The bottom line? As with most of the pharmaceutical options discussed in this section: it might be worth a careful try with physician supervision, but keep your expectations low for the muscle relaxants.


Lidocaine patches

Lidocaine patches allow lidocaine to seep through the skin, rather than being injected. Unfortunately, they have not been proven effective for anything, let alone trigger points.289 They are mainly used to treat post-herpetic neuralgia, but do not clearly seem to work even for that.

In theory, lidocaine works by suppressing electrical activity in nerves — sodium channel blockade — and this might be relevant to trigger points, which may show abnormal electrical characteristics. It’s a reasonable reason to try it, but, as always with medicine, you simply have to test it …

As of 2016, there are only three half decent trials — which is practically nothing, really — of lidocaine for myofascial pain syndrome.290291292 They are all technically positive, but not remotely decisive: Linde concluded that “probably superior to the placebo patch,” but I’m not sure why, based on their data; Firmani et al think their results “support” lidocaine patches, but again they seem surprisingly optimistic; and Affaitati et al declared them “effective,” but based on modest improvements that were statistically but not clinically significant.

So, “meh.” This is how it almost always goes with treatments that researchers study in a wishful-thinking way.

But lidocaine patches are fairly safe and reasonably cheap, so I see little harm in experimenting with them, if you can talk a doctor into prescribing them for this purpose.


Combination treatments: why and how to throw everything at it but the kitchen sink

Applying pressure to trigger points is the only self-treatment method that we’ve discussed so far that actually has a respectable potential to single-handedly release trigger points. All of the others will fail on their own, most of the time. So, enter the combo treatment. The ol’ one two. The ol’ one, two, three, four, five …

Serious trigger point therapists must combine partially effective strategies for a total effect that is more potent. Here are three quick examples of combination therapies:

It’s easy to imagine how those combinations could be more effective than any isolated treatment, isn’t it?

Some combinations are so powerful that they should probably not be considered “combinations” so much as simply good technique. In the same sense that boxing without combinations is not really boxing, self-treating trigger points without at least some combinations is not really self-treating. For instance, consider breathing: you should probably always breathe deeply when you’re releasing trigger points, as opposed to optionally throwing it in.

Test individual components of effective therapy individually, and over time rate their effectiveness. If you seem to get quite good bang for buck from stretching, but mobilizations never seem to do much for you, then include stretching in your combos but not mobilizations — or vice versa if you have the opposite results.

This simple concept of combining treatments is what nearly every patient who’s “tried everything” has not yet tried. Most people, even experienced patients, haven’t even tried half the things recommended in this tutorial. Almost none of them have gotten into combinations seriously — maybe just a little, almost a coincidental effort, as in the case of people who have a hot shower in the morning and then feel naturally inspired to mobilize. That’s a combo treatment, and they probably see the benefit of the combination, but don’t think of the combination as a strategy that they can elaborate on.

Almost every time I have ever coached someone on how to self-treat their trigger points, it turns into “let’s review the key self-treatments … and now you need to combine them.”

“Oh!” they say. It’s always a little bit of a surprise for some reason! “Okay. I guess that makes a lot of sense.”

Now, go combine.


Troubleshooting referred pain: the referred pain field guide

As established already in several ways, referred pain can fool both you and the best help you can find. “Advanced troubleshooting” for trigger point therapy means nothing if I don’t equip you with some knowledge and tools for beating it. For a great referred pain story, see the extra section after this one.

It’s routine, even for trigger point therapists, to waste energy and your money barking up the wrong tree, massaging where it hurts instead of where the pain is actually coming from.

To be a self-treatment expert, you have to have some idea of how to find the real source of pain. There are two basic methods, and you should use both:

  1. Look it up.
  2. Make an educated guess. (Guidelines below.)

That’s what I’d do. Indeed, this is what every trigger point therapist uses. No one tries to memorize referral patterns.

There are many medical charts on the market that show common referred pain patterns in detail. And Clair and Amber Davies’ popular book, The Trigger Point Therapy Workbook, is a muscle-by-muscle, region-by-region reference — that’s its primary advantage over this tutorial. But, remember, I’ve deliberately left reference material out of this tutorial.

And you should also just “guess.” Referred pain can seem very strange, but it tends to follow some patterns. Here are some guidelines and principles (which is what this tutorial is all about):

Trigger points are usually inside the pain pattern. The trigger point is usually located somewhere inside the area that actually hurts. This is very helpful to know. It means that you can usually count on a trigger point being located somewhere in the area that hurts, probably about 9 times out of 10. It may fool you by not being at the epicentre of the problem — it may be way out on the edge as in the “heart attack” story previously discussed — but it will usually be somewhere in that zone.

Trigger points are usually on the same side as the pain pattern. Referred pain does cross the midline of the body. However, it’s unusual. At least 90% of the time, you’ll find both the trigger point and your symptoms on the same side of the body.

Trigger points are usually medial to the pain pattern. That is, they are more likely to be closer to the centre of the body than the pain. If they are inside the pattern, they are much more likely to be in the inside half rather than the outside half.

Trigger points are usually proximal to the pain pattern. “Proximal” means “closer to the trunk” than something else. Your elbow is “proximal” to your hand. Your hip is “proximal” to your knee. The opposite term is “distal” — your toes are the most distal parts of your body. Referred pain is almost always distal to a more proximal trigger point. Here’s three quick examples:

  1. Trigger points in the forearm refer pain down the forearm and into the hand and fingers.
  2. Trigger points in the low back and hips refer pain down into the legs.
  3. And a trickier one: trigger points in the neck often refer up — distally, away from the trunk — into the head. However, it does get confusing in that area. Some neck trigger points always refer downwards.

These guidelines can be pretty powerful! You can save a lot of time if you know that, in a case of knee pain, it’s virtually pointless to look for trigger points below the knee — there are no trigger points that refer up the leg. With these guidelines, you can avoid wasting time looking for a trigger point in the biceps as a possible cause of your head pain — that would be extraordinary.

Nothing seems to be impossible with referred pain. Over many years, I’ve observed what seemed to be some “freaky” referred pain patterns that break all the rules — a left foot trigger point that refers pain into the right shoulder (seriously, I saw that). However, nearly all the time, referred pain sticks to fairly predictable patterns — either surrounding the source or close to it, usually spreading out and down on the same side.


Case study: referred pain causes a “heart attack” and completely fools dozens of professionals

James was a client of mine in the 2000s, a jolly registered nurse in his forties with a massive, bear-like physique. He was so sturdy that it was all I could do to apply enough pressure to his muscles so that he could tell I was doing anything. I could basically beat on him with all my strength, and he’d still say things like, “Could I get any more pressure on that spot? If you can.” He’s tough.

But one morning James woke with sickening, vicious pain in his upper, lateral chest and spreading down his left arm — classic heart attack pain. He called an ambulance and spent forty-eight hours in a hospital, ministered to by his baffled colleagues. He was not having a heart attack. His doctor finally sent him home, saying, “We don’t know what’s wrong with you, but, whatever it is, it’s not going to kill you today.”

Except it was “killing” him — the pain hadn’t let up one bit. It was still like the pain of a heart attack, just without the heart attack! By coincidence, he had an appointment with me the next day, which he came to, looking pale and exhausted. He told his story, without the slightest expectation that I would have any professional input.

I did have professional input.

“Sounds like it could be a trigger point, James,” I said. “Of course I could be wrong, but it’s worth a check. Mind if I have a look?”

I soon had my finger on a tiny, exquisitely sensitive nodule along the length of a taut band in his medial pectoralis major muscle. The muscle twitched violently when I hit it, and James jumped like I’d given his heart a shock.

“Holy %$#@*!” he cried out. “That’s it!” There’s the subjective recognition that’s critical for diagnostic confidence: the sensitivity of that spot felt “like” his “heart attack” pain.

With only gentle pressure applied, strong pain with a sickening quality spread out from the trigger point like a toxic waste spill. The epicentre of the pain was several centimetres lateral to the trigger point (a good example of referred pain spreading “out” from the centre). The trigger point itself was sensitive when pressed, but there was no pain in that location — just the most medial fringes of his symptoms reached the actual location of the trigger point. 99% of the pain generated from that spot was elsewhere — the side of the chest, the shoulder, the arm. Very widespread referral… resembling heart pain referral.

The trigger point eased quickly. In twenty minutes of simple rubbing, we reduced the “heart attack” pain by 80%. The next day it was gone, and two years later it had still not come back.

What would have happened to James if I hadn’t known to look where I looked? As a regular in my office, with mid-back trigger points that I can’t get rid of in twenty minutes, he was no stranger to trigger points… but he failed to recognize the pain as a trigger point problem, let alone which trigger point. In three days of agony, his instincts had not led him to try pressing on his medial pectoralis major muscle. Would he have tried in another three days?

Maybe. Maybe not.


Troubleshooting negative reactions to treatment

Unfortunately, negative reactions are a common problem with treating more cantankerous trigger points. Just as trigger points have the potential to respond positively to virtually any stimulus, they also have the potential to get worse in response to nearly anything. One of the most common concerns I hear from my patients and readers goes like this:

I’ve tried to self-treat my trigger points, but every time I do it I end up feeling like I’ve been beaten up.

lots of people

Intense massage therapy can do some harm.293 But do not panic! Most negative reactions are probably not so bad after all, and may even be a counter-intuitively good sign. It is still possible to make progress in trigger point therapy even if you are getting nasty reactions. The trick is to know when to ease up or give up, and when to press on. And for that you have to have a reasonably good understanding of what’s going on, and some decent thumb rules.

Some kinds of bad reactions to massage are quite typical. These should not be overly discouraging:

Most of those symptoms can be generally explained by a slightly toxic state known as rhabdomyolysis, or just “rhabdo” — the mild cousin of a much more serious medical condition. Sometimes we feel cruddy after a massage, like it was a big workout. Post-massage soreness and malaise (PMSM) is embraced as a minor side effect and hand-waved away by almost everyone as some kind of no-pain-no-gain thing. But it needs explaining. Massage is not “detoxifying” in any way (that’s pseudoscientific nonsense). Ironically, it may be the opposite: some PMSM is probably caused by mild rhabdomyolysis, a type of poisoning that can occur even with heavy exercise (a medical reality), and possibly strong massage (a plausible hypothesis). If so, it’s a big deal, a serious side effect. There are also some non-rhabdo explanations for milder PMSM.

The rhabdo problem is on pretty firm scientific ground, and the case study I referred to is particularly persuasive — an 88-year old man who got an unusually extreme massage, and ended up with a dangerous case of rhabdo.294 If extreme massage can do that, it’s a sure bet that all strong massage is wreaking at least a little of the same kind of havoc. See Poisoned by Massage for much more detail on this topic.

More speculatively — but reasonably — the rhabdo might be worse when you’ve got a lot of trigger points.

Trigger points, rhabdo and healing crisis

The tissue of trigger points may be in a poor state, with waste metabolites already present in force before anyone starts massaging, and probably more vulnerable. There’s even some evidence that the tissue of a trigger point is physically fragile, and treatment may really traumatize cells — which would certainly liberate a nastier “rhabdo cocktail” of molecules into the bloodstream when squeezed, like a popped zit squirting pus. Even if the trigger point is neutralized at this point — even if it stops “revving” metabolically and producing more waste product — it will take some time to clear out the sewage from the area.

(The number and severity of trigger points might even be one of the key variables that makes some people more vulnerable to PMSM than others. More trigger points, more PMSM? There’s a good question for a researcher to work on.)

It also means that the tissue might have more actual post-massage healing to do. Hopefully, when the tissue repairs itself, the trigger point does not return, or does not return quickly. But if cells are actually broken, obviously the spot will feel irritable as it heals. So this is certainly a “healing crisis” — treatment may actually work by “nuking” the trigger point with trauma that temporarily makes it feel worse, temporarily disguising the fact that the situation has improved.

A lot of ifs and maybes in there. But that’s the best we can do.

Advertising the idea of a normal “healing crisis” as part of trigger point therapy worries me, even though it is defensible. It’s an abused cliché in alternative medicine, and often a harmful one295 — most healing processes do not involve feeling worse before you feel better. However, trigger point massage may actually be one of the exceptions that proves the rule. Many patients do indeed seem to feel improvement after a day or two of significant discomfort.

How bad a negative reaction should you tolerate?

There are certainly limits to how painful a trigger point should be in the hours and days following treatment. If you have a negative reaction involving a lot of pain, say, anything more than 50% of your pre-treatment symptoms, what you’re experiencing is probably actual aggravation of the trigger point — and an aggravated (intensified) trigger point can hurt a lot. By contrast, a puddle of caustic trigger point remains is simply not going to hurt as much as an active, pissed-off trigger point!

Here are three ways that you might be able to tell the difference between a “true” negative reaction, and healing crisis:

  1. The quality and intensity of the negative reaction contain valuable clues. The pain of a truly activated/irritated trigger point will be very similar to your normal symptoms, just worse! By contrast the pain of a trigger point that has actually been deactivated, but the tissue in the area is still irritated, will tend to feel more like inflammation and/or bruising.
  2. Another distinguishing feature is the duration. A proper healing crisis should resolve quickly and steadily, showing clear improvement within two days. A negative reaction that tends to persist beyond two days, or which only fades back to the intensity of your original symptoms — no net improvement — almost certainly indicates that it is actually a negative reaction to a failed treatment.
  3. The appearance of similar symptoms, but in new locations, is a particularly interesting case of a negative reaction that probably isn’t really a negative reaction. As long as they aren’t too severe and/or persistent, new symptoms may be the best possible reaction to treatment short of simply being cured. Why? Because it usually means that your highest priority trigger points are responding positively to therapy, and your brain has decided to move on to other concerns: i.e. the next worst muscle pains you have. This is sensory triage, and your nervous system is very good at it. It’s usually a strong sign of progress! However, it can be confusing, especially if the new pain is particularly close to the old pain.296

Other kinds of bad reactions

So far I’ve just discussed excessively painful reactions. But other kinds of negative reactions can be bad news, too. More serious versions of the normal negative reactions top the list: dizziness, headaches, and nausea are particularly of concern.

These symptoms, if they are mild and resolve quickly, are probably just particularly bad PMSM — more rhabdomyolysis than usual, but mostly just a sign that treatment intensity should probably be dialed back a notch or two. However, if dizziness, headaches, and/or nausea happen at all, they should be mild or temporary. If they are severe or do not steadily fade over 1-2 days, you should be concerned.

If you vomit or feel extremely disoriented or dizzy after an appointment, you should consider it a potential medical emergency. I never had a vomiting client myself in ten years of seeing patients. But it does happen, and rarely in a good way. Sometimes people are just prone to more dramatically woozy reactions to an intense treatment (vasovagal syncope),297 but even then it’s usually a milder reaction, more like a nasty swoon. But if you feel really terrible and it doesn’t steadily ease up, then you should get to a doctor immediately.

If your symptoms are significantly aggravated for more than a few hours, if you feel extremely tender, or if you have major bruising, that’s not a good sign either.

Most genuinely negative, no-benefit-involved reactions to treatment can usually be resolved simply by refining your treatment methods.298 I had many successful experiences with clients who initially claimed that it was “impossible” to massage a certain area of their body without a negative reaction. In was usually just a matter of experimenting gently and building trust. Before they knew it, trigger points that had always seemed to “freak out” before were suddenly easing for the first time.

In self-treatment, you’re usually less anxious — after all, you’re in charge. You know you’re only going to be so rough with yourself. However, if you’ve experienced nothing but negative reactions, and you don’t know how to prevent it, you can pretty quickly get into a head space where results seem impossible … which, interestingly enough, tends to make it quite hard to get results.

Avoiding basic treatment mistakes and having generally good technique is critical, of course, to preventing negative reactions. There’s every possibility that negative reactions can be eliminated not with specific reaction-eliminating strategies, but simply by getting more skilled with self-massage. So, to avoid negative reactions, study this tutorial carefully and learn everything there is to know about effective self-treatment!

However, the promise of this tutorial is also to help you troubleshoot every possible problem. So, here are three specific tips for avoiding negative reactions:

Above all, less treatment. Less pressure, shorter sessions, fewer sessions … whatever it takes. Trust me, there is some level of treatment that will not cause a negative reaction. Whatever you can do that doesn’t provoke a negative reaction, then that’s what you do. If you have to back off so much that it seems like you aren’t even doing anything: everything about your biology is designed to adapt to stimulation and stresses. If you gradually add intensity to treatment, your trigger points will adapt. It may start slowly, but it’ll happen!

Or don’t “treat” at all — not with self-massage. In the sections below you will find many non-massage treatment methods, such as hot baths and mobilizations. A great way to avoid negative reactions is to stay away from “poky,” self-massaging treatment entirely, for a while. A few days of other, gentler approaches, and you will probably find that you are much more tolerant of pressure.

Greater diligence with combo treatments. People with cranky, reactive trigger points need to place greater emphasis on treatment that isn’t just 5 minutes of digging in, but is a well-designed session combining a number of positive elements: i.e. 2 minutes of meditation and deep breathing and heating, followed by 2 minutes of mobilizing, followed by 2 minutes of gentle massage, followed by a hot shower, and then another 2 minutes of treatment. This kind of approach is covered pretty thoroughly in the combination treatments section.


Part 6

Perpetuating Factors

What makes trigger points stubborn?

Many stubborn trigger points are not so tough once you understand and eliminate the perpetuating factors — the (evil!) forces in your life that cause trigger points to form in the first place, and then keep them going. Typical perpetuators are nutritional and hormone deficiencies, other sources of pain (such as a slow healing injury), muscle fatigue or stagnation or alternating between them (weekend warriorism), awkward working postures and positions, sleep deprivation, and so on.

Unfortunately, there is a bottomless pit of possibilities in trying to understand, identify and purge such factors from your life. Most advanced trigger point troubleshooting is all about trying to identify and eliminate these perpetuating factors. They are divided into two broad categories — the medical and non-medical. The medical factors are usually the most important but also most difficult to diagnose, and they are discussed below. Don’t be fooled into thinking they are less important just because they aren’t described first — they are actually the most important factors for people with serious cases of chronic pain. But I will kick things off with the next several chapters about the more obvious perpetuators of pain — the most important factors for the average person with average muscle pain. To begin this journey, please chant with me:

Usually. Sooner or later.

Based on past experience, I think about 20% of people with a straightforward case of trigger point pain are the “lucky ones” who get quick and lasting relief. Of those, perhaps one third will never feel that pain again, or they will self-treat it so effectively that it is never much more than an annoyance. The remainder will get the pain again, probably within a year or two … because of perpetuating factors.

Perpetuating factors are numerous and often require special knowledge to recognize their importance to trigger points. They are commonly overlooked and neglected. In patients with chronic myofascial pain syndrome, attention to perpetuating factors often spells the difference between successful and failed therapy.

Travell & Simons, Myofascial Pain and Dysfunction, p178

Here are three typical examples to help illustrate how this works:

Renee is a receptionist with headaches caused by trigger points in her neck muscles. One hour of therapy once per week for a month “resolves” her headaches in the short term, but there’s nothing she can do about her bad chair at work.299 So, three months later she’s right back where she started. This is the most typical scenario — trigger point therapy “works,” but not for long. For Renee, a maintenance treatment every six to eight weeks would probably be enough to keep her free of headaches for years. Is this “effective” therapy?

George is a workaholic executive with headaches just like Renee’s, except that severe emotional stress, terrible working posture (he’s got a computer monitor that forces him to look up), and weekend warrior-ism make treatment relatively futile. For a while he comes for therapy weekly, and feels terrific for two or three days after every appointment … but then he hits the slopes after a week of slouching in front of a computer, and every trigger point comes screaming back. He actually loses ground, but he keeps making appointments for “damage control.” Is this effective therapy?

Claire is another executive, but she does a good job of balancing work and play. A low-velocity car accident gives her a bit of whiplash, however, and she heals too slowly. Treatment resolves the problem completely in three appointments, because she isn’t doing anything that aggravates her neck.

The next few sections will troubleshoot the most common and obvious perpetuating factors. But first, an overview of all perpetuating factors. Check off the ones that you have. Any more than 2 or 3 is significant!

Troubleshooting “stuck” trigger points — adhesions and contracture

A client in his thirties once asked for my opinion of his massage therapist’s diagnosis: “Apparently my muscles are contractured,” he said. “He says my back muscles are really hard and ropy and the only thing we can do is try to break it up. What do you think?”

I think back muscles are routinely hard and ropy without contracture. I think it’s almost impossible for a fairly young man to have anything we would call “contracture.” I think that practically everyone over the age of 16 has “hard and ropy” back muscles. Healthy back muscles are just naturally like that, especially in certain body types. And if you’ve got trigger points? Even more likely. Although trigger points cannot be reliably detected by feel, a rigid muscle texture is more likely, and a taut strap is considered a classic diagnostic sign — all without anything remotely like “contracture” occurring.

So a therapist should never feel a tight strap and say, “You’re contractured.” Trigger points do not generally involve a true whole-muscle contracture, let alone scar tissue (as often claimed by therapists). There has to be other evidence of adhesions or contracture. Here’s a checklist for identifying “sticky” trigger points.

Adhered trigger points tend to be old trigger points. For adhesion to be a factor, a severe trigger point would probably have to exist in the tissues more or less continuously for at least a few years, and a milder trigger point would have to be fairly constant for at least a decade.300

Adhered trigger points tend to occur in older people. Age is definitely a factor as well. Clinically significant adhesions become much more likely with advancing age. A senior will develop adhesions much more quickly than a middle-aged patient. People in their teens and twenties are unlikely to develop any significant adhesions at all, even with nasty trigger points.

Adhered trigger points don’t release well. Of course, there’s a lot of other reasons why trigger points might not release: to the extent that you feel you’ve eliminated other concerns, a trigger point that still won’t release may be adhered.

Adhered trigger points usually feel harder and more fibrous. This is a loose guideline. Non-adhered trigger points can still be plenty hard. And not every adhered trigger point feels like a rock. But generally speaking there is a greater hardness in the adhered trigger point.

Crunchy, crinkly texture. When adhesions break, you can feel a kind of “giving way,” a crunchy, crinkly, crackly sensation as fibres pull apart, as skin tears away from the tissue below it. It can be subtle or dramatic. Full-blown adhesions are harder to break, so you’re actually less likely to notice this phenomenon in the worst cases, and more likely to notice it as it’s developing. Also, it may occur in the area around the trigger point.

None of these is a “dead giveaway.” It is almost impossible to confidently diagnose adhered trigger points. You can only be sort of sure. So, if you’re sort of sure, what do you do about it? The technique is simple, but difficult to apply yourself in many locations.

  1. Strum with focused, poky, fingertip or thumb pressure back and forth across the fibres of the muscle knot, and in the taut band of muscle tissue that it causes. It’s got to be hard pressure, because nothing less will actually break the adhesions. Do at least five minutes of pressure that is almost too strong to tolerate.
  2. Massage it with an ice cube briefly, perhaps a minute. Yes, ice! Ice it in spite of the warnings not to ice in other places in this tutorial — this is an exception. You have to risk irritating the trigger point with ice in this case: the pros usually outweigh the cons.
  3. Do not re-treat for at least 48 hours. When breaking adhesions and using such strong pressures, it’s essential to give the tissue a chance to recover.

At least 3–6 such sessions will probably be necessary to break up adhesions, depending on their severity.


Troubleshooting stress (without meditation or yoga, unless you like that sort of thing)

Trigger points are a genuine physical problem, but — like an ulcer — they are sensitive to your emotional state. In other words, stress is a trigger point trigger. I have many memories of clients who invariably felt better when they were on holiday, so you really should take the beach vacation option seriously. Stress-reduction is an obvious goal in advanced trigger point management — with many other benefits as well, of course.

But there is rarely a one-to-one relationship between stressful incidents and flare-ups of trigger point pain. As discussed in the “out of nowhere” section, there are many other factors affecting trigger point pain — so simply having a bad day at the office is rarely going to be the direct, obvious, primary cause of a trigger point incident. That doesn’t stop people from trying to make that connection, mind you! The temptation is immense. But do not succumb: it’s just not that simple an equation.

What stressful incidents do is create a physiological context of generally increased vulnerability to trigger point aggravation. A bad day at the office won’t usually lead directly to pain, but it will lead to a .5% increase in muscle tone (tension), adrenalin fatigue, a sleepless night, et cetera … and those things, in turn, will ramp up the odds of having a trigger point problem over the next few days, weeks, months …

So stress reduction is a great idea. 😃

But how to do it? The stress reduction thing is a bit of a stumper. When it comes to cures for stress that don’t involve a beach, the imagination seems to stop at “meditation or yoga.” Even people who don’t need to be convinced that they “need to relax more” or “reduce stress” don’t know how to do it. They don’t know what stress reduction looks like, what actual practical steps or actions they have to take to achieve it.

Meditation and yoga are appealing for some people, and certainly effective for nearly anyone who chooses to pursue them diligently. For those who have had previous experience with yoga and meditating, extending that practice may be an excellent and practical self-treatment strategy for trigger points.

Yet the reputation of yoga and meditation is immense, almost oppressive, eclipsing other options. People feel that they “should” try them, and often feel guilty for not trying them or for not liking them.

As popular as yoga and meditation are in North America, they are still not mainstream.301 Most of my clients have only dabbled in them at best, and have never experienced any success more significant than “taking the edge off” their stress. Many of my clients are also productive, energetic people who find it difficult — almost alien — to invest in subtle or indirect self-improvement, and find meditation particularly exasperating. They have a kind of personality conflict with it. It’s not that they can’t or shouldn’t try to learn these skills, but it’s really not for everyone, it’s a steep learning curve, and trying to climb that curve quickly while also coping with pain may just not be a practical solution.

Relaxing? Or scary?

Yoga classes are allegedly relaxing — in reality, they can be emotional pressure cookers, inflicting intense performance anxiety & self-consciousness about fat & fitness on the participants. And, worse still, stretching can aggravate trigger points, especially in those conditions.

There’s another large group of people who might like to reduce their stress, but just aren’t suited to yoga and meditation: the ones who never liked the idea to begin with! You know who you are, and you’re not alone. Plenty of you think that all “that flaky stuff” is a cure that’s worse than the disease, and you are more likely to want to reduce stress by “blowing off steam” with exercise … which would be a great idea, if only your pain allowed it. It often doesn’t, and so you may despair at the loss of the only stress-management strategy you take seriously.

Many of my clients have identified this exasperating Catch-22: they know stress aggravates trigger point pain, yet they have to reduce the pain before they can reduce the stress! Frustrating. Stressful, even!

Please consider the option of studying yoga and/or meditation. They really are worthwhile pursuits, and they definitely have the potential to reduce stress and trigger point pain — especially in regions that are “emotionally charged,” like the low back — and offer you a host of other benefits. But rest assured that they are not the only options, nor even necessarily the best options.

Better, more practical, more understandable stress-reduction options for most people are as follows:

My favorite way to blow off steam is to sing obnoxiously loud in the shower.

Chris Pratt, actor

Troubleshooting insomnia

Based on personal experience and clinical observation, I have long believed that myofascial trigger points are probably aggravated by insomnia or even by mild but chronic sleep deprivation. There is no direct scientific evidence to support this idea, but there is plenty of indirect evidence.

At the very least, insomnia results in increased pain perception by “messing with your head” (changes to your central nervous system) and/or increased sensitization of nerve endings. But that is the tip of the iceberg. Kundermann et al write, “Although it is well documented that subjects with different pain syndromes suffer from sleep disturbances, the direction of cause and effect in this relationship is still a matter of debate.” In fact, insomnia almost certainly causes painful changes in your tissues.302

Many studies over the years have shown how sleep disturbances of different types result in all kinds of pain. Sleep-deprived people with fibromyalgia hurt more,303 people with insomnia get a lot more migraines,304 and low back pain increases,305 along with virtually any other musculoskeletal complaint.306

And what insomnia taketh away, sleep giveth back … and then some. One fascinating study showed that letting sleep-deprived people with pain catch up on their sleep had a strong pain-relieving effect … greater than the pain-causing effect of the sleep disturbance … and even greater than standard pain medications. Catching up on your sleep will help more than losing sleep will hurt, and it will also help more than Tylenol. Cool!307

Another important point is that Dr. Stanley Coren’s excellent book about sleep science308 generally comes to the conclusion that everyone needs to take sleep deprivation much more seriously than we generally do: essentially, that there is no such thing as “mild” sleep deprivation.

If you’d like to know more about this subject, read my article which specifically looks at more of the scientific evidence that insomnia aggravates trigger points — pretty much required reading for insomniacs with body pain! See Insomnia Until it Hurts

Okay, so insomnia and even just chronic low-grade sleep deprivation are probably factors in stubborn myofascial pain syndrome. Now what?

Talk about “easier said than done”!

Of course it’s a no-brainer that stress is a cause of insomnia of any severity. In fact, so pervasive and strong is the idea that stress is the cause of insomnia that many people feel quite helpless to fix insomnia. If you can’t fix the stress, how can you fix the insomnia?

But both stress (see previous section) and insomnia itself are easier to treat than you probably realized.

Insomnia is much more of a behavioural condition — a bad habit — than most of us realize (or want to admit). I can say this with great authority, because I am personally one of the all-time worst offenders in this category: I have suffered from extremely severe insomnia in my life, refused to believe for years that it was a “bad habit,” and then eventually got smart with the help of a good doctor at a sleep disorders clinic. So this is one of those cases in health care where a professional can say, “Listen up — I know about this, personally.”

There are good, logical ways to tackle most insomnia, including insomnia that you think is “invincible,” including cases in which you think you’ve “tried everything” — no offense, but you almost certainly haven’t tried everything. I believed that for a long time, only to discover that I still had a great deal yet to try, and it was the stuff I hadn’t learned about yet that finally did the trick for me.

That said, I’m going to refer you to other articles now, because this is too big a subject to cover properly even in this large tutorial. For more detailed information about the relationship between insomnia and pain, and specifically how insomnia might affect trigger points, see Insomnia Until it Hurts. See also my primer on treating insomnia — something I have a lot of experience with.


Troubleshooting posture, ergonomics, and muscle imbalance

This is a major category of confusing but important perpetuating factors.

It stands to reason — or seems to — that poor posture, an awkward computer keyboard position, or being obviously crooked (as in scoliosis) is going to predispose people towards trigger point formation. However, it very much depends. Yes and no. Sort of. It’s complex.

Posture is a difficult subject. It’s one of those things that seems straightforward, and yet becomes slippery and complicated when you try to get a firm grip on it. The basic problem with posture is that it’s actually surprisingly hard to define, no one is quite sure whether or not “bad posture” is even harmful, and it’s very difficult to change it in any case. If the postural question interests you, you can find much more detailed information in this article: Does Posture Matter?.

Everyone is just a little too keen on the appealingly simple idea that crookedness is bad for you (and I’ve already brought this idea up a couple of times above — overemphasizing “structure”). In fact, scientific evidence constantly shows that “mechanical” problems are routinely not the cause of pain, and many “common sense” ideas about crookedness and pain have been disproved over the years.

For instance, way back in 1984, a paper in the British medical journal Lancet showed that leg length differences — a very common diagnosis — are unrelated to back pain, period.309 Not that minor differences can even be reliably diagnosed in the first place.310 And just last year, Grob et al published findings in the European Spine Journal that abnormal neck curvatures do not have any connection with neck pain.311 There are many other examples.

On the other hand, it seems clear that some kinds of “crookedness” absolutely do cause problems.

For instance, I just spoke to a gentleman who lost his leg at the age of four — talk about a leg length difference! — and he regaled me with detailed stories of his extremely painful and stiff shoulders, and of the way minor changes to the length of his crutches had major effects on the trigger points in his upper body.

Over the years, I have seen numerous cases in which poor computer workstation ergonomics seemed to be the cause of trigger point pain. And people with certain kinds of congenital deformities like torticollis (wry neck) or scoliosis clearly suffer from severe, chronic trigger point pain — such trigger points are often nearly invincible, and it seems clear that they are directly related to the crookedness of the body.

I myself have a very minor deformity called “fixed forefoot varus” — a slight twisting of the foot that causes me to walk with my right leg turned fairly far out, because it’s easier to get my big toe down on the ground to push off with that way. My parents first realized I had a problem when I was about four years old, and couldn’t keep my right ski in its track while cross country skiing! That deformity, slight as it is, has resulted in a more or less permanent collection of trigger points in my right foot and hip that I cannot ever get rid of, despite all my knowledge and experience with treating trigger points. The problem is mild, and yet apparently invincible. (I tell the story of my funky foot in more detail in my plantar fasciitis tutorial.)

Where is the line between an unambiguous muscle imbalance that is causing problems, or at least contributing, and a subtle postural defect that may not have any real importance? The short answer is: no one knows.

Ergonomic improvements are an important option to pursue because ergonomic problems are simply more fixable than other kinds of postural problems or muscle imbalances. A scoliotic spine cannot be straightened. If it can, I have never seen it myself, or seen persuasive evidence of it happening. But computer keyboards can be moved. It is easy to make ergonomic changes that might make a difference, and simply find out if they are important. For troubleshooting ergonomics and a life spent in chairs, see The Trouble with Chairs.


Troubleshooting mysterious perpetuating factors

Harold Smage of Elkhorn, Wisconsin, wrote to me:

As I search for therapists and peruse reading material I often come on the statement that just erasing trigger points will result in a return of the problem — that the underlying cause and/or perpetuating factors must be addressed.

Okay. But, to date, I have not been able to find what these might be.

Often, significant perpetuating factors are missed due to lack of knowledge, experience and self-awareness. But, sometimes, they are missed because they are mysterious and difficult to identify. Just like some trigger points are not actually physically accessible to any kind of therapy, some perpetuating factors can never be definitively diagnosed. They may be hard to identify because they are subtle, trivial, odd, or they may be strange and also terrible: an ominous biological vulnerability that you will probably never be able to identify, or do anything about even if you could. More about the terrible possibilities in the next section.

The defense against the problem of mysterious perpetuating factors is to start by understanding your body and known perpetuating factors as well as possible. If you do this diligently and never can identify any significant perpetuating factors, then eventually you can more or less safely conclude that your perpetuating factors are likely to remain mysterious. Just don’t try to tell me that your perpetuating factors are a mystery before that! First you have to put in the time.

Another long-term strategy for troubleshooting mysterious perpetuating factors is to “tinker” with the major forces in your life: where you live, what you do for a living, your hobbies, your hang-ups. Here’s a couple of examples:

A bad marriage might be the “mysterious” perpetuating factor in your pain. While it might seem like sitting all day at work is the main aggravating factor, you might find that no amount of microbreaking or mobilizing or even a career change makes any difference, because you are still suffering from constant low-grade unhappiness and countless minor and major irritations at home. Until you actually get the divorce over with, no amount of squirming around with other perpetuating factors is ever going to do any good.

Or, suppose you live on the coast, and you’ve never lived anywhere else, and you don’t want to live anywhere else — but, unbeknownst to you, humid air is actually a problem for you. You’ve noticed on vacations that you really prefer dry air, but you haven’t yet made the opposite observation, which is that you actually feel a bit lousy when you breathe coastal air. You have more colds, more allergies, a general logeyness, you don’t sleep as well, and so on, all of which adds up to a “mysterious” and major aggravating factor — a physiological context of vulnerability. Until you decide to up and move inland, you will probably fail to identify your aggravating factors.

So, shaking up the big picture can shake loose some pretty big revelations! This is related to the idea of treating difficult health problems by personal growth.

On the other hand, if you “change everything” in your life and still have unrelenting trigger point pain, then trigger points may be your “biological destiny” — perpetuated by forces that will never be clear and may not ever change. The next section addresses the idea that some people are “just triggery.”


The relationship between trigger points and other physiological disorders and diseases, especially fibromyalgia

What if your perpetuating factor is just your biological destiny?

Some diseases are obviously likely to cause and aggravate trigger points. Some straightforward examples include any of the inflammatory arthritides, such as rheumatoid arthritis or ankylosing spondylitis, or diseases that directly affect muscle tissue, such as Parkinson’s disease or amyotrophic lateral sclerosis (Lou Gehrig’s disease).

Put yourself in the shoes of someone with Parkinson’s.

If you have Parkinson’s, the disease may well predispose you strongly to trigger point formation. You are more likely than someone without Parkinson’s to get more trigger points and worse trigger points. Indeed, trigger points are probably one of the main ways that Parkinson’s becomes painful. Parkinson’s may also cause similar kinds of pain by other means, and there is no way to be sure how much of a Parkinson’s patient’s muscle pain is “pure Parkinson’s” versus “Parkinson’s causing trigger points.” However, it is a reasonable theory that trigger points could be a major mechanism by which Parkinson’s causes pain.

As with other diseases that aggravate trigger points, treating trigger points in a Parkinson’s patient is both (a) a valuable method of controlling muscle pain symptoms, and (b) probably doomed to be not especially effective. In other words, when a disease process is driving myofascial pain syndrome, trigger point therapy is both vital and somewhat futile.

This might seem a bit discouraging, but there is a legitimate glass-is-half-full perspective here — despite the ineffectiveness of therapy in terms of actually vanquishing trigger points, trigger point therapy for a patient in this situation can be a godsend. Even if it can’t get rid of trigger points, it may still help a lot, and that ain’t nothing — patients with invincible, disease-powered trigger points may actually get more subjective value from therapy than someone with more defeatable trigger points!

Some people seem to be awfully triggery in the absence of any other obvious problems that cause trigger points. Something about their personal chemistry seems to predispose them to trigger points: more of them, more painful, more stubborn. This often seems to occur in people who have other syndromes with no obvious effect on muscle tissue, such as a pain-system dysfunction like fibromyalgia, poorly understood autoimmune disorders like lupus or irritable bowel syndrome, or not-really-understood-at-all conditions like chronic fatigue syndrome.

Something about the neurology and biochemistry of these patients “obviously” — obvious to me, anyway, from clinical experience — makes trigger points worse. But I cannot overstate how mysterious this all is. As much as trigger point science has advanced, we are still nowhere close to understanding exactly why some people get trigger points and some people don’t, or why one person has relatively little difficulty getting rid of them while another person seems to be stuck with them forever.

Fibromyalgia is a particularly important topic for this section, because it is so common, and because the relationship between fibromyalgia and trigger points causes so much confusion. The major diagnostic difference between having trigger points and having fibromyalgia is widespread sensitivity to pressure. Things that shouldn’t hurt at all hurt quite a bit. Things that used to just hurt a little hurt a lot. This includes all kinds of stimuli that would not cause any problem for someone who only has trigger points — i.e. a toe stub. Due to their system-wide sensitivity, a fibromyalgia patient will just about go through the roof with a minor toe stub that would cause no particular problem whatsoever to the “pure” trigger point sufferer.

Fibromyalgia patients will suffer greater sensitivity than anyone else in several key locations around the body — these are the “tender points” of fibromyalgia, often confused with trigger points.

Tender points vs. trigger points

Tender points are not trigger points, and do not seem to respond like trigger points. Trigger points routinely change in response to stimulation. Tender points remain stubbornly tender. Massage therapy does not seem to be of much help to fibromyalgia patients, not even temporarily (see Li et al). The data are inconclusive, but the absence of any good news is bad news: it may well be helpful for some FM patients (probably the ones who also have trigger points), but not many and not much. To be fair, this may be the case for trigger point massage as well, strictly speaking — as far as we can tell from the limited evidence. But the anecdotal difference between seems huge.

Distinguishing between a case of fibromyalgia and a case of serious widespread trigger points may be almost impossible, because fibromyalgia patients almost always have the symptoms of both conditions, and because serious myofascial pain syndrome is so painful and it causes such a wide variety of symptoms.

What makes fibromyalgia an important thing to discuss in this tutorial is that differences between the conditions can be so hazy that serious questions must be raised about their relationship.

Are they opposite sides of the same coin?

Is fibromyalgia an extreme form or a different “flavour” of myofascial pain syndrome? Quite possibly.

I have seen numerous cases in my career of “tender points” that acted suspiciously like trigger points, and vice versa. Some patients defy diagnosis: they are like hybrids, not entirely fibromyalgic and yet obviously not “just” suffering from trigger points.

More or less exactly the same relationship exists between myofascial pain syndrome and an extremely painful and all-too-common neurological disease called either “reflex sympathetic dystrophy” (old name) or “complex regional pain syndrome” (the new name, CRPS).

CRPS is a really nasty condition that causes the worst imaginable pain — it is a disease in which virtually all sensory signals are maximally over-interpreted as threats by the nervous system, and for which there is not yet a single proven treatment and the research is “something of a mess.”313 Suicide rates among people with this disease are high, as you might imagine. They often develop open sores and have to have amputations and are treated with drastic methods like induced comas. They do strange things like walk around with their hands wrapped in wet towels for years because “the air hurts,” a terrible phenomenon known as allodynia — a painful response to a harmless stimulus. So this is a truly serious disease — and what could it possibly have to do with trigger points?

Maybe nothing.

But I once had a patient I got to know very well who had “mild” CRPS (meaning that it is not as severe as other cases of CRPS, but still incredibly nasty). We discussed this ad infinitum, and we developed a pet theory, completely unsubstantiated by science but rational. Our hypothesis is that there is overlap between the physiology of trigger points and the kind of neurological Armageddon that occurs in extreme diseases like CRPS. Diseases of pain system dysfunction are at one end of a spectrum. Whatever goes wrong in CRPS may be going wrong — obviously to a much lesser degree — in people with nasty trigger points, and to an even lesser degree in people with mild trigger points.

CRPS only gets diagnosed when the process degenerates beyond trigger points and into severe neurological problems. If this is true, if this is how it actually works, it would account for a major category of “triggery” people who have shockingly serious myofascial pain syndrome, yet fall short of a diagnosis of fibromyalgia, CRPS, or one of the painful autoimmune diseases (i.e. polymyalgia rheumatica would be a good example, a disease my father had).

For now, though, this is an area of real scientific mystery, and nothing can yet be done about the uncertainties.


Way beyond stubborn: troubleshooting extreme cases

There are tragic cases of trigger point pain that seem to exceed all reasonable limits. See the earlier section, What’s the worst case scenario for trigger points? for more information about just how truly bad it can get. Although rare, the worst cases really are awful. Generally speaking, they can transcend mere myofascial pain syndrome and become something else: probably a general breakdown of the neurological systems that regulate pain perception. In such cases, trigger points are probably no longer the main cause of pain, but simply the original trigger, or only one trigger, for generally broken pain perception.

What do you do when the problem seems extreme? What do you do when “stubborn” doesn’t even come close to describing the persistence of your trigger points? What if they seem to respond to nothing? Either no response at all, or relief so temporary it might as well not have even happened.

Of course, there are not going to be any easy answers for you. But I do have considerable experience working with people in the same boat. While I was editing this section a few minutes ago, I received a call from a 50-year-old woman with severe low back pain who said, “I’m too young to have this much pain.” No one should have that kind of pain, at any age! Yet I have often worked with 25-year-olds who were in equally bad shape. You are not alone, even if it seems that way.

Here are some strategies to consider:

First of all, make sure you’ve actually tried everything yourself. Most people haven’t — even desperate folks who’ve been working at it for years have typically spent 75% of that time chasing red herrings and exploring dead ends. It’s not uncommon for me to hear from people with severe cases who have literally never experimented with a single massage tool other than a tennis ball. That sounds strange, but it’s true — it takes a long time, and a certain outlook, before most people get truly creative with their self-treatment. So go through all the ideas in this tutorial one by one, and then start experimenting with combining them. Chances are good that you haven’t already been that thorough. And it’s possible that, before you’re done, you will have found something that helps more than anything else you’ve ever tried.

Shop around. Never give up looking for the right therapist or doctor. Expect to eliminate many practitioners. Never continue to pay anyone for therapy that isn’t showing promise relatively soon. And never buy into anyone’s sales pitch. The very same woman I just referred to also told me that her last attempt at therapy was with a chiropractor who insisted that she had to try at least 45 appointments before giving up. Forty-five is excessive. Although it may be possible for therapeutic benefits to take that long to develop, it’s unlikely, and irresponsible for a therapist to claim to have reasonable confidence in such a long term outcome.

Take it slow. The nicest thing about self-treatment is that it’s cheap, so you have the luxury to give it more time to work than if you were paying by the hour. Take the self-treatments that seem to work a little, or that seem like they could work — just something you have a good feeling about, if that’s what it takes — and apply it slowly and gently and carefully and consistently for a long time — weeks. Tedious? Maybe. But desperate times call for desperate measures.

Work on personal growth. As science advances and mind-body perspectives on health and healing become more sophisticated and practical, we understand that pain problems are powerfully mediated by stress, self-limiting behaviours, and “emotional constipation.” I have seen many examples of how people’s quirks and habits are interacting with their recovery, either helping it along or slowing it down, and maybe even stopping it outright. Particularly for clients struggling with a difficult and slow healing process, I recommend that they “get personal” with their problem. Sometimes it’s a matter of just learning new coping skills for a problem that is never going to go away. And sometimes people need to come to terms with the fact that years of self-sacrificial workaholism, for example, are actually the root cause of severe chronic pain. Usually the truth is in the middle: healing requires a complex mix of coping skills and personal responsibility. Through this kind of learning, people often find long term relief.

Of course, there are nearly infinite ways of approaching this challenge, and I’ve written about it in several ways. I discuss the theory in detail Why Do We Get Sick?, and I get more practical in Pain Relief from Personal Growth.

Hit the breathing particularly hard. If you don’t get into the personal growth approach, at least try to get into the breathing exercises. Even in the advanced troubleshooting sections above, I don’t really go overboard recommending bioenergetic breathing to my readers. But for really nasty cases of trigger points, deep and fast breathing is my favourite secret weapon. Do I know if it works? Is it evidence-based? No and no. But I have a lot of reasons to believe it’s well worth trying. It certainly won’t do any harm, it will be an interesting experiment no matter what, and it has the potential to make a big difference. So, if you haven’t already gone looking at it, read The Art of Bioenergetic Breathing.


Reality checks: some self-treatments that don’t work at all (or not nearly as well as you would hope)

Stretching. It’s already been mentioned several times, but it can’t be mentioned enough: stretching is a less effective method of treating trigger points than most people think it is or “should” be. It’s not completely ineffective, but it is certainly much less effective than we would all like. A massive stretching section is coming up right after this one.

Epsom salts. Many people look to Epsom salt baths to relieve muscular aches and pains in general, and assume that it’s probably good for trigger points in particular. While a hot bath is certainly a good idea for other reasons, as we’ve already discussed, I’m afraid that it’s unlikely that salting your bath will help much with trigger points. Recent scientific evidence has shown that Epsom salts do indeed soak through the skin when you bathe in them314 — which is a bit surprising, and had never been proven before!

Unfortunately, there is just no scientific evidence about what happens after Epsom salts soak through the skin. Do they have any therapeutic effect? On anything? On trigger points in particular?! No one knows. It’s possible, but not particularly likely. One thing is certain: Epsom salts definitely don’t work miracles. Even stretching, which is obviously ineffective for many patients, has more obvious benefits. For a very detailed discussion of the whole Epsom salt issue, see Does Epsom Salt Work? The science and mythology of Epsom salt bathing for recovery from muscle pain, soreness, or injury.

Drinking water. It’s common for massage therapists to tell patients to drink some extra water following massage therapy. The only rationale ever given for this is “detoxification,” which makes no sense.315 While it certainly won’t hurt you to drink a little extra — nothing could be cheaper or safer — I have never seen any good reason to believe that it’s a factor in recovery from trigger point therapy, let alone treatment or prevention of muscle pain. Meanwhile, there are good reasons to be skeptical. For instance, we now know that dehydration does not cause cramping in athletes — no, seriously!316 And paranoia about dehydration clearly comes mainly from one disreputable source, Dr. Batmanghelidj, whose books and writings on the subject are simply awful … and yet they sell well, because Joe Public loves a simple solution to all his problems! For the sordid history, see Water Fever and the Fear of Chronic Dehydration: Do we really need eight glasses of water per day?

T-Relief (“Traumeel” for many years). Homeopathic (diluted) herbal ointments featuring Arnica are claimed to be good medicine for muscle pain, joint pain, sports injuries and bruises, but their effectiveness is questionable. Known to most customers as an “herbal” arnica cream, most actually contain only trace amounts — too little to be a chemically active ingredient. Homeopathy involves extreme dilution of ingredients, to the point of literally removing them. Some other herbal ingredients may be less diluted and more useful. However, neither homeopathic or pure herbal creams of this type have produced results better than placebo in good quality modern tests, for any condition.

Despite the broad manufacturer claim of effectiveness for “muscular pain,” both herbal and homeopathic arnica products are marketed primarily as anti-inflammatory creams for acute superficial injuries like bruises and sprains… and trigger points are not primarily an inflammatory problem (if at all), and often much too deep in the tissue to be easily affected by any topical ointment even if they were. And so it is quite doubtful that they are relevant to most myofascial pain syndrome (regardless of whatever else you might think of homeopathy or unproven herbal medicine). But homeopathic remedies are over-priced and ineffective in general, and homeopathy as a profession is rotten with dangerously irresponsible ideas, as shown in the BBC’s 2006 exposé of homeopaths in London recommending completely ineffective remedies to travellers in place of genuine anti-malarial medication.317 Wikipedia has quite a good complete review of homeopathy.318 For more information about tubes of cream with arnica in them (maybe), see my article, Does Arnica Gel Work for Pain?.

Popular muscle relaxant drugs based on methocarbamol. The trade names of these drugs are Robaxin, Robaxacet, Robax Platinum, Robaxisal. Methocarbamol may be combined with other drugs, such as Aspirin or codeine, which may well do more good. Here’s some good information I can’t give a reference for, just a credible source you’ll have to take my word for: a pharmacologist I know explained to me in detail that methocarbamol is simply ineffective at recommended dosages. Higher dosages will indeed reduce muscle tone, but with unpleasant side effects. Somehow the drug got approved even though the low recommended dosages are virtually useless. Any benefit you seem to get from these drugs at normal dosages is a placebo and/or the result of other active ingredients, especially codeine, which is much more effective at relaxing anyone.

Acupuncture for muscle pain in general, and for low back pain in particular. Acupuncture’s failure to treat low back pain in well-designed scientific trials earns its inclusion here in this list of particularly underwhelming treatments. The evidence is discussed more below.


Part 7

Medical Factors That Perpetuate Pain

The effect of statin drugs, nutritional and hormonal deficiencies, infections, and inflammatory diseases

  • Oct 9, 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.

This book has already introduced the concept of “perpetuating factors,” such as insomnia or postural stresses. Although those things may be important, the trickiest of all perpetuating factors are medical, things like: drug side effects, a shortage of vitamin D, or a the lingering effects of an infection you didn't even know you had in the first place.

Here be dragons. It is all too easy to blame our problems on vague threats. Trigger points themselves are an unclear scapegoat, worrisomely adaptable to almost anything we want to explain with them. This is going another layer deeper: scapegoats for the scapegoat!

Without knowing the true nature of trigger points in the first place, we really cannot possibly have confidence about what medical factors makes them worse. We must hold our opinions about this lightly. Never succumb to foolish certainty that you “know” what’s really going on.

It can make perfect sense for people with stubborn body pain to cautiously explore underlying medical causes, and at least try to eliminate some of them — as long as it doesn’t cost too much, as long it’s not a greater threat than the pain itself, and as long as it doesn’t involve spending the rest of your life evangelizing your pet theory (not just overconfident of your own story, but convinced that what you think worked for you must also apply to everyone else — a surprisingly common behaviour). If you find yourself blaming everything on one sketchy hypothesis, you’ve lost your way. Come back to us! Dial down the overconfidence!

Uncertainty is the only rational position. Biology is way too complex for anything else.

If you are unusually biologically vulnerable to trigger points, which is a plausible thing, then the most heroic efforts to treat your trigger points are probably doomed, like pissing on a bonfire. Fortunately, some relatively straightforward medical factors do seem to be linked to myofascial pain syndrome, and are relatively cheap, easy, and safe to try to diagnose and treat. You can do it by yourself, using this chapter as a guide — although, of course, it is always preferable to have expert help. One way or another, every patient with a tough, chronic case of myofascial pain syndrome must consider and investigate these factors.

First things first: get tested and treated for deficiencies

Disclaimers aside, many people can probably manage your own diagnosis using this book as a guide. Find a cooperative doctor. Download this PDF file: Laboratory Tests for Medical Perpetuating Factors of Pain [PDF]. Print it out, and take it to your doctor’s office and request a lab order form for these tests. More specifically, take it to the nurse, get the form, and then just ask the doctor to sign it.

Fortunately, the big drug and insurance companies have blazed the trail for you: As a result of massive direct-to-consumer drug advertising, doctors are accustomed to patients asking for specific medicines and tests. Insurance companies pay doctors per number of patient visits, not time per visit. The insurance-paid doctor needs to finish your visit quickly to get the most visits in per day. Many doctors sign any lab form the nurse presents. Many doctors will prescribe whatever medicine you ask for rather than take time for discussion of the subject.

After your doctor gets the lab results, get a copy. Compare your results for each item to the desired range for pain relief, spelled out in the sections below. Make a list of any deficiencies indicated by the testing.

Make another appointment with your doctor to ask for the prescriptions you need. You may encounter some resistance: your doctor may not want to encourage/enable indulgence in the hype around a supplementation option that he doesn’t believe is necessary. That’s a reasonable concern. Never push — just discuss. (Any doctor you have to “push” isn’t worth working with anyhow.) If reasonable discussion can’t get the job done, find another doctor, or let it go.

🚩 It’s possible that all direct treatment of trigger points will be futile until correctable deficiencies are corrected, which can take several weeks. During that month, learn self treatment of your own trigger points by studying this tutorial and beginning to experiment. But don’t be surprised if results are weak while there are still outstanding medical concerns.


Pain-causing drug side effects

Statin drugs to lower blood cholesterol may also cause pain. Statins are important and widely used drugs, and their deleterious effect on muscle is seemingly common that is widely considered a diagnosable condition: statin myalgia, or statin-associated muscle symptoms (SAMS).320 A few patients, about 1 in 10,000, get a more obvious, serious case of muscle poisoning, rhabdomyolysis,321 and an even rarer and more serious condition afflicts 1 in 100,000: statin-associated autoimmune myopathy.322323

And yet there is also confusion and controversy about the prevalence of statin myalgia.324 There’s even clear evidence that it could be some kind of illusion or misunderstanding: in one head-scratcher of a study, taking statins only increased pain when patients knew they were taking statins.325 So that’s weird! The truth is probably “all of the above” and “it’s complicated” — it seems likely that some patients are genuinely intolerant of statins, while others are suffering from fear of statins and/or some other cause of musculoskeletal pain (of which there are many). There might also be some tricky X-factors, like vitamin D deficiency, which seems to be linked to statin myalgia.326

There is good news, though! Ridding yourself of these side effects, even the worst, is usually as easy as lowering the dose or switching to another statin. Important: The risks of stopping statins include stroke, heart attack and peripheral vascular disease, unless your doctor prescribes another treatment for your hypercholesterolemia.

Example: My family member developed a sudden case of frozen shoulder a few days after his statin dose was increased. I found active, painful, motion-limiting trigger points in every muscle of his right shoulder region. On my advice, he stopped his statin. He improved within a few days. I then treated his trigger points with dry needling once. He was cured! Then he followed my instruction to go to his doctor to get another type of medicine for his high cholesterol. She then prescribed him a different statin and we went through the whole process again. Finally, he went back to her with a letter from me describing statin myopathy and how statins affected him, and requesting a non-statin drug.

And bisphosphonates too

The statin (cholesterol-reducing) drugs are probably the biggest culprit for drugs that cause pain, but another popular class of drugs that may do so are the bisphosphonate (Wikipedia), for osteoporosis and Paget’s disease. On January 7, 2008, the U.S. Food and Drug Administration alerted health professionals and consumers to their unusually severe side effects.327 They can cause “severe and sometimes incapacitating bone, joint, and/or muscle pain” which “may occur within days, months, or years” after first taking the medication. This probably explains a lot of otherwise undiagnosable pain in a lot of people.

Alendronate and risedronate are the two most popular bisphosphonates, and they are usually prescribed for osteoporosis or for a bone-deforming condition called Paget’s disease. If you are 40+ and grappling with a mysterious pain problem, check your medicine cabinet for bisphosphonates in particular, but of course any other medication that could cause pain as a side effect.


Nutritional and hormone deficiencies

Proper blood tests can reveal the problems listed below. The healthiest blood amount of each of these chemicals is usually different from the laboratory report “normal” or “reference range.” Why? Because the laboratory companies have not updated their long-standing “normal” or “reference ranges” to reflect current medical knowledge. Also, the “healthy” people sampled to determine the “normal” range are often college students, army recruits or other groups who may not be thoroughly examined to determine their health. Their blood laboratory results may not reflect what we need to keep our muscles healthy in middle age and beyond.

You may have a hard time finding a doctor in your region who will prescribe medication to help you achieve the healthiest blood amount if the laboratory report says “normal” or “within reference range.”


Vitamin D deficiency

Vitamin D deficiency is surprisingly common in general,328 and causes many problems329 probably including muscle pain330331332333334 and dysfunction335336.

There are a few ways that Vitamin D might help people with chronic pain. For instance, chronic pain is well-known to have a strong psychological component — it is sensitive to mood. Vitamin D may have effects on these factors by helping with conditions like seasonal affective disorder (SAD), depression, and anxiety. That would be a curvy road to take to get to improved regulation of pain, but it might just work that way. Hat tip to New Zealand pain science writer Bronnie Thompson for this observation.

Our goal is a patient serum 25 (OH) vitamin D level between 50 nanograms per milliliter (abbreviated as 50ng/ml) and 100ng/ml. That’s more than what was considered adequate historically. According to outdated sources, 15ng/ml is enough — but this is almost certainly wrong. According to Holick et al, 30ng/ml is the lower level of what his research indicates is healthy, and you may need even more to eliminate chronic pain.

A huge range of vitamin D dosages have been used in various studies. For patients below 50ng/ml, I prescribe a fairly high dosage of vitamin D. My current protocol is based on the recent new development of many drugstores stocking over-the-counter vitamin D3 in 5000 IU capsules. I recommend one 5000-IU tablet with each meal for one month, then one per day as a maintenance dose for another month, and then it’s time to check the serum vitamin D again.

Obviously there could be safety concerns with high dosages. However, there is firm scientific evidence that high dosages are safe,337338339340 According to Heaney, “There is, in fact, a comfortable margin of safety between the intakes required for optimization of vitamin D status and those associated with toxicity.”341

Still, it’s very important to know that taking more vitamin D than you need can kill you, starting with the destruction of your kidneys.342 Please do not assume that “more is better”! If you are not deficient, anything more than minor supplementation could be dangerous. If you are deficient, too much supplementation could be dangerous. Despite the wide margin of safety, please stick to the dosages recommended here!

Note from Paul: in late 2010, the Institute of Medicine published new guidelines for dosages of Vitamin D, prompting a thorough review of this topic. Keen readers can get a full dose of information about it here: Vitamin D for Pain: Is it safe and reasonable for chronic pain patients to take higher doses of Vitamin D? And just how high is safe?


Thyroid hormone deficiency

Hypothyroidism is the medical term for thyroid hormone deficiency. It might cause problems even when the deficiency is subtle (in the low-end of the normal range). The simplest lab blood test for this is serum thyroid stimulating hormone (TSH).

TSH inversely relates to thyroid hormone like this: Your brain measures how much thyroid hormone is in your blood. If you do not have enough thyroid hormone, your brain releases more TSH. So the higher your TSH, the less thyroid hormone is in your blood. Ideally the TSH should be between 0.3 and 2.25 uIU/ml (a narrower range than the official “normal” or “reference range” of 0.5 to 5.5 uIU/ml.) Thyroid hormone dosage must be carefully monitored to avoid overshooting the goal and ending up with the opposite problem.


Iron deficiency (and excess)

Low muscle iron supply is another common deficiency that is linked to pain patients.343344 Most doctors only look at your red blood cell iron. Your red blood cells may have plenty of iron, and the red blood cell lab tests may be fine, while your hurting muscles are starving for iron. Muscle gets iron from serum ferritin. Target serum ferritin of 50 to 100 nanograms per milliliter (50-100 ng/ml) — again, more than the bottom of the laboratory report “normal range” or “reference range.”

This chart from the eMedicine article on iron deficiency shows the relationship between several measures of iron in the body. There are two points of interest here. First, note that several of the measurements (inside the large blue circle) do not change even as when the serum ferritin (top row) is showing significant deficiency. Put another way, it shows that iron deficiency (including inadequate ferritin to transport iron to muscle), happens before the usual red blood cell tests show a problem.

The second point of interest is that the chart also shows a normal serum ferritin to be 60 micrograms/liter of blood serum. Most laboratory report forms are based on outdated information which states ferritin as low as 20 is “normal.”

As you can see, science is not always exact.

So if you’re deficient, what can you do about it? Unfortunately, our bodies keep only a fraction of the iron we eat in food and little of what we take in pill supplements. You might never get enough iron from food or oral supplements. The best food sources are chicken liver and very lean red meat such as venison. If you can get a source of good, clean blood to drink or cook with, go for it!

Not only are iron pills a relatively ineffective way of supplementing, they also commonly cause ulcers. Indeed, “oral iron supplements are highly corrosive to the entire gastrointestinal tract.”345 Iron shots may be preferable. But, unsurprisingly, you may have a hard time finding a doctor who knows enough about iron metabolism to recognize that you need iron shots. You will probably have to limp along with red meat and iron pills.

Not too much either

Ironically, excessive iron can also cause pain, especially joint pain. High iron is a much less common problem than low iron, but it is another medical factor that you should be aware of. There is a genetic disease, hemochromatosis, which causes the body to retain too much iron. (Which is treated by, no joke, bloodletting.) So if you see too high an iron measurement on your blood test, it’s definitely a concern. This is a great example of how more is definitely not always better — indeed, the symptoms of too much iron can easily be confused with the symptoms of too little.

Treatment for excessive iron is wonderfully simple, though: you can treat it quite effectively just by donating blood frequently!


Vitamin C deficiency

  • Dec 22, 2021 — Upgrade: More and better information, especially a science-based revised of vitamin C dosing advice.

Vitamin C deficiency is not a proven cause of myofascial pain syndrome, or indeed in any disease other than scurvy. The recommendation to supplement vitamin C, if you are deficient, is mainly based on the clinical experience of Drs. Gerwin346 and Travell, which may never have been correct and is of increasingly doubtful value as many years tick by with no hint of more rigorous validation.

If a blood test confirms that you are C deficient, myofascial pain syndrome may be the least of your worries, and you should certainly be having a conversation with your doctor about just exactly why that’s happening.

It’s nearly impossible for a healthy person to be C deficient, even with the crappiest typical modern diet. If you fear deficiency, get tested, and make a point of eating citrus, bell peppers, tomatoes, potatoes, broccoli, and cauliflower — not exactly a hardship, although I suppose the last two are a reach for some folks.

Even if you are deficient, supplementation (pills) simply shouldn’t be necessary. If you do supplement, err on the side of a conservative dose of 500mg/day, ideally even less… if you can even find that. 500 and 1000 mg tablets dominate the market, even though the recommended daily amount is 75/90 mg daily for women/men, and up to 120 during pregnancy/lactation.347

But potatoes are tastier.

Higher doses up to about 2000 mg/day are unlikely to do any harm, but are also increasingly pointless and wasteful, and gut irritation gets likelier as you pass 1000/day. Even 500 is almost certainly more than anyone needs, and even more than your body can absorb — at that level, you have started paying to literally piss some of that vitamin C away.348 However, they can be hard on the gut, and so “extended release” tablets are preferable, especially if you have other gut issues.


Vitamin B12 deficiency

You can be B12 deficient without knowing it: even significant deficiency may be mostly asymptomatic, and symptoms are vague when they do occur. Common early symptoms are tiredness, poor concentration and memory, irritability and depression — all of which can be caused by other problems as well. However, if your serum vitamin B12 is below 350 pg/ml (350 picograms per milliliter), then this could keep you in pain.349 This level is higher than the bottom of the usual laboratory report “normal” or reference range.

Many people have a stomach problem, called intrinsic factor deficiency, which prevents them from absorbing B12 from food or supplements. Vegans have few sources of B12 in their diet.

The best way to treat B12 deficiency is with a monthly injection.


Vitamin B1, B2, and folate deficiencies

This chapter is being revised and will back soonish.


Magnesium deficiency

  • Dec 22, 2021 — Major upgrade: Dramatically improved quantity and quality of information about magnesium deficiency and using it as a treatment for pain or cramping.

Magnesium deficiency has a strong reputation as a factor in pain — especially neuropathic pain, which makes it less relevant to trigger points. But also cramping, which swings the relevance back our way quite strongly — insofar as trigger points might be a kind of cramp.

Deficiency has been widely anecdotally reported as a perpetuating factor for myofascial pain and other miscellaneous body pain, and that increased magnesium intake is helpful. But hey, what hasn’t been so reported? Every supplement has its fan club.

Acute magnesium deficiency, aka hypomagnesemia, looks nothing like typical myofascial pain syndrome: the primary symptoms are weakness, muscle cramping, or rapid heartbeats, among many other possible symptoms.350 This doesn’t mean that muscle pain couldn’t be a symptom of subtler deficiency but not of more acute deficiency, but that would be a bit weird.

But it’s complicated, and the magnesium-pain hypothesis does contain some seeds of truth at least. For starters, deficiency is actually somewhat common, even though this element is easy to eat (nuts, spinach, potatoes, brocoli). It could be a side effect of acid reflux drugs.351 And deficiency may also “hide” from routine blood tests.352

And magnesium is clearly a staple molecule in neurology especially, and all kinds of other biology that might be related to pain. For instance, intriguingly, deficiency and low-grade inflammation appear to be “interactive risk factors” — that is, they tend to go together.353

Popular beliefs can easily persist without a shred of truth to them, of course, but I concede that it’s possible that the magnesium factor is real (and may explain why so many people think Epsom salts baths help with aches and pains).

Unsurprisingly, the role of magnesium in pain has never been tested properly.354355 To date, I am aware of just one promising test of magnesium supplementation for any somewhat common kind of pain, and it’s still a bit of a miss for our purposes here, focused on back pain with a clear neuropathic component.356 Even if magnesium actually is efficacious for neuropathy, it’s rather unlikely that it is also helpful for whatever causes sore spots and muscle aching.

I’m aware of only one science experiment that is, to some extent, specifically about the effect of magnesium on muscle pain. Muscle pain is one of the side effects of suxamethonium chloride, an anaesthetic drug used to cause short-term paralysis. Injecting magnesium sulphate had no effect on this kind of muscle pain, compared to doing nothing, and was “followed by unpleasant side effects.357 The applicability of this data to myofascial pain syndrome is probably poor, but it’s not exactly encouraging either.

The magnesium-cramping connection

These are the conventional-wisdom premises that might connect magnesium to trigger points:

  1. Trigger points are basically small cramps.
  2. Cramping is caused by magnesium deficiency (either acutely due to dehydration as a cause of exercise-induced cramps, or chronically due to deficiency).

As this book has already explained ad nauseum, we don’t really know if the first point is true. Even if it is true, it is like that it doesn’t work the same as other kinds of cramps.

And other kinds of cramps are, in any case, either not clearly helped by magnesium, or we simply have no idea (absence of evidence).358 But we do also know that exertional cramps are not caused by dehydration or low magnesium,359 which means it’s unlikely that adding magnesium will prevent them.

The possibility of a role for magnesium in myofascial pain syndrome cannot be ruled out, but there’s nothing clearly pointing to it either.

It’s easy to eat magnesium. You just have to be willing to eat salad. Or potatoes!

Worth a shot anyway? Unknown. It might be possible to absorb magnesium through the skin in an Epsom salts bath, but it’s a long shot, not an adequate or predictable source of supplementation. People with magnesium deficiency should just stick to dietary sources. Basically, eat more salad, with nuts and seeds, especially pumpkin seeds, and potatoes are a decent source too (see dietary sources of magnesium). There’s no reason not to do this, and it might just help.

I discuss this in some more detail in my supplements review, and the Epsom salts article really digs into it (because Epsom salts baths are basically magnesium baths — and yet not that good at getting magnesium through the skin, as it turns out).


Testosterone deficiency

A downward spiral: Chronic pain and pain medicines can cause low blood serum testosterone, and low testosterone can in turn aggravate pain.360 Men or women in pain with serum testosterone below “normal” should get testosterone injections. You cannot get more testosterone into your blood by taking testosterone or supplements by mouth, despite what supplement sellers say. Testosterone deficiency must be treated by testosterone injections. The injections may be once per week, once every two weeks, or once per month, depending on the patient’s situation.

Androgel and testosterone patches are good alternatives, but more expensive than injections and not always covered by insurance. Topical testosterone must be applied daily, versus a weekly or every-other-week injection. Note that some people are allergic to the adhesive of the testosterone patches.

Testosterone is often prescribed simply as a tonic to men who may or may not actually be deficient, and have no real problem to treat — this should be avoided! Too much testosterone can kill you in a lot of different ways.


Estrogen deficiency

Estrogen deficiency can occur at any age in women and is a part of menopause. Below-normal serum estrogen contributes to pain.361 Prescription estrogen pills or birth control pills easily correct the deficiency.

Estrogen supplementation is a complex and controversial subject. For instance, the aggressive marketing of bioidentical hormone therapy is hype, not medicine, and you should ignore Suzanne Somers. And it is not clear that menopausal levels of estrogen are actually a “problem” that needs to be “fixed,” and attempting to do so may well be risky. By far the most sensible medical writer on this subject is right here in my backyard in Vancouver, at the University of British Columbia. Dr. Jerilynn Prior, MD, publishes a great website for The Centre for Menstrual Cycle and Ovulation Research.

However, if you are suffering from chronic pain, that gives you an additional reason to consider estrogen supplementation in spite of the risks. Estrogen supplementation to attempt to treat a medical problem is much more justifiable and less controversial than hormone replacement therapy “just ‘cuz.”



Many viral infections such as the common cold, flu and others can cause muscle aches, but all you can do is wait for them to go away.

Hepatitis C virus, on the other hand, is often mostly asymptomatic — you can have it without knowing it — but it can be found by a blood test, and it can be treated.

Lyme disease may cause malaise and pain, especially joint pain, long after the initial infection. The lyme disease organism poisons victims with a toxin that remains even after the immune system (and antibiotics) have killed the bacteria.362 Some people do not know they had Lyme disease. Blood serum Lyme antibody tests show if you had the disease.363 Treatment can be difficult, and it’s controversial.

Dr. Mark Crislip writes, “I do not think that the data supports the concept of chronic Lyme disease, and being a Tool of the Medical Industrial Complex (TMIC®), that is just what you would expect me to say.” But, for more, see the footnote.364

Vaginal candida infections may contribute to pain. If they persist or recur after the usual topical medication, then investigate for causes.



Inflammatory diseases such as rheumatoid arthritis, systemic lupus erythematosis and others can perpetuate pain. Their diagnosis includes blood serum antibody tests. Both diagnosis and treatment can be challenging.

Other pain-associated infections and inflammation can be detected by blood serum laboratory tests for C-reactive protein, antinuclear antibodies (ANA) and others.



Smoking was established long ago as a strong predictor of failure of pain treatment,365366 and the data continues to show that smokers are about 2-3 times more likely to be in pain.367 It probably also increases the risk that pain will become chronic in the first place.368

Smokers are so difficult to treat for chronic pain that some physicians won’t even work with them until they quit. Back surgeons — who glibly hack at peoples’ spines despite the lack of proven efficacy of back surgery — often refuse to operate on smokers for the same reason. What’s the point in a risky procedure with a patient who is virtually doomed to on-going pain regardless?

In my opinion, quitting is a vital pre-requisite for treatment of any chronic pain problem. Unfortunately, “hard” doesn’t even begin to describe the challenge of breaking this addiction: the reported long-term (greater than one year) smoking cessation rate for most quitting products and programs is from 10 to 20%, with many findings of worse success rates probably “buried” by the medical industry sponsors.

See Smoking and Chronic Pain.


Overall treatment strategy

Attack on all fronts!

Treat as many potential pain-perpetuating factors at the same time as possible, and not just the medical factors covered in this chapter.

Some patients may be tempted to take the path of least resistance and just take a multivitamin — a generic “insurance policy” approach to nutritional deficiency. Travell and Simons endorsed this approach as better than nothing. However, they also made it clear that they wished for better scientific understanding and better medical assessment, and some of that superior understanding now exists. Patients can get better medical assessment by using this guide and with the assistance of the right physician.

I have seen no proof of benefit or harm for chronic pain patients taking that “insurance policy” multivitamin. Unfortunately, in the race to the bottom for production cost, many supplements and drugs do not contain what their label states, have active ingredients with poor bioavailability, and/or have dangerous contaminants or adulterants, so taking them has unknown risks as well as unknown benefits, so it is not an approach that I can endorse. It’s better to find out what your deficiencies actually are, and address them specifically.


Part 8


Stretching is generally over-rated … but it might be good for trigger points

Stretching feels good. But does it fix anything?

Stretching is the number one thing that people want to try — or just do reflexively, instinctively — to help their own muscle pain, and the number one thing that I get asked about. Surprisingly, given the popularity, it’s not a very effective treatment for treating trigger points (or much of anything else). However, because it is so popular, and because it does seem to help some people a little, it deserves detailed discussion in this tutorial.

The next several sections address the topic extremely thoroughly. (I have read entire books about both stretching and trigger points that barely mention the relationship between them, let alone examine it this carefully!) If you don’t want all the gory details, you can definitely just stick with the executive summary in the advanced treatment sections. And it can all be boiled down even further, to just this:

It might help, a little, but probably much less than you might think, and please don’t overdo it (because it can backfire).

Stretching has been a popular form of exercise in North America for a few decades now, but no one can figure out why.

Scientific research has yet to produce any convincing evidence that one method of stretching is better than any other for anything, and in the last decade or so one medical journal after another has published papers showing that stretching is basically not good for much, particularly popular goals like “warming up” and “preventing injury.” Some have even concluded that stretching is actually risky, that people tend to injure themselves: bad technique, too much intensity, vague goals and poor judgement often combine to make stretching a little bit dangerous.

The simple truth is most people (and even professionals) simply don’t know why they are stretching, and the explanations they come up with when quizzed about it don’t hold up under close scrutiny. Inevitably, when confronted with the facts and the evidence, people retreat to safe territory, to a reason that no one can shoot down, or needs to: they tell me that they stretch because it feels good.

And you know what? Stretching does feel good! Really, really good.

And that is probably why people keep stretching … even though it doesn’t necessarily mean that there is anything therapeutic about it. Is food therapeutic because it tastes good? Is music therapeutic because it sounds good? Pleasant sensations and experiences may have therapeutic qualities, but that doesn’t make them effective therapy.

Why does stretching feel good? And does that good feeling correspond to any medical benefit? Can stretching-as-a-treatment be vindicated? Can it be justified by anything other than feeling scrumptious?

There could be reasons why stretching is good for pain that we don’t understand, or are only just barely starting to understand. A 2016 study dug up some evidence that stretching reduces inflammation in connective tissues,369 and there is also evidence that inflamed connective tissue is involved in back pain.370 The evidence is too scanty to trust yet, but it’s suggestive. If stretching relieves pain this way, it could explain why so many people think it works for trigger points.

Or maybe it just works for trigger points. Stretching may “scratch” trigger points like an “itch,” and it may even truly banish them sometimes. But there’s even less evidence for that than there is the inflammation theory. I will now explain why stretching is at best a pretty hit and miss self-treatment method for trigger points, with many problems in both theory and practice.

The anecdotal evidence for stretching (is just huge)

The anecdotal evidence that stretching “works” for trigger points is substantial. Massive really. An avalanche of faith. People with aches and pains believe that it works. They tell me that it works. They insist that it works. It’s practically religion. It’s one of the most common of all self-treating behaviours.

This alone should not impress you, of course. Large numbers of people have been completely wrong about many things. There are countless examples of this in medical history alone, let alone history in general. Millions of people can be wrong, and millions of people almost certainly are wrong about all kinds of benefits of stretching which do not actually happen.

And yet there is a persistent observation that cannot be ignored: many people in pain stretch, and then they claim to feel better, for a little while at least. I’ve experienced it myself many times. Stretching doesn’t usually seem to “cure” anything, but darned if it doesn’t seem to “take the edge off” certain kinds of muscular pain and stiffness, and enough to make it worth doing.

These sensations demand some kind of explanation. (And this is the purpose that anecdotal evidence serves: it cannot answer questions, but it can tell us what questions to ask.)

For 22 years now, it has been my job — one way or another — to try to help people whose bodies are hurting. When I hear that stretching helps, it’s almost always in association with the idea of muscle pain. People don’t tell me that it feels good to stretch their arthritic knees or their dislocated shoulders. They don’t talk about how much they like to stretch their lesioned cervical nerve plexuses or their torn hamstrings. Hell no! Those things don’t feel good! Stretch obviously isn’t a treatment for traumatized tissue.

But they do talk about good-feeling stretches when they have pain that seems to fill their muscles.

Of course, it is equally obvious that these people have not found any lasting relief from stretching. When I ask them, “What helps your problem?” they will often tell me about stretching … but they still have the problem. This is important. In my experience, only the mildest cases, and perhaps a small minority of moderately serious cases, actually get any lasting relief from stretching. The anecdotal evidence may be enthusiastic, but it also seems to clearly show that stretching helps only a little and only for a little while — roughly as worthwhile as a hot bath.

So we must not only try to understand why stretching seems to be good for trigger points, we must also try to understand why it isn’t better.

Speaking of anecdotes, there’s another kind of story that people tell: stories of stretching gone wrong. In fact, I have my own …


Case study: A cautionary tale of stretching: that time I almost ripped my own head off

I am my own laboratory. And sometimes things in labs blow up. I’d like to tell you about the time I almost ripped my own head off. This is certainly my worst self-treatment disaster.

And this section is the short version of a story that I tell at greater length in another article. If you’re particularly interested in how stretching can go terribly wrong when treating neck pain, I recommend reading the long version.

I’d had a crick in the neck for about a day, and it was getting worse. I was on Bowen Island, just offshore from Vancouver, staying in a suite with a great clawfoot tub. I’d just finished a nice hot soak that hadn’t really put a dent in the neck discomfort, so I decided to do some intense stretching as well. I had three reasons:

  1. It had worked before. Back in 2007, I’d had a particularly good result from a hard stretch of a very similar neck crick. That was a success story, and a good one. This crick felt the same. Perhaps the same treatment would work again! Hope springs eternal. (So does stupidity.)
  2. I was really relaxed and toasty warm from the bath.
  3. I like to experiment.

So I started stretching! Not only did it feel good, but the sensitivity eased steadily as I held the stretch at a moderate intensity, so I upped the ante and started to stretch really hard. This was a truly strong stretch.

It was that “scratching the itch” feeling that kept me going. It felt like good massage. It felt satisfying. Something bad was happening but it felt good. I stretched hard and long, and then sank back into the bath to recover, sighing deeply.

Victory seemed certain. I felt great in the minutes after the stretch. My range of motion was full and free and painless. I could no longer detect that distinctive cricky sensation in my spine.

But within another half hour, the crick was back. I shrugged it off as a mere failure to treat — disappointing — but it kept getting worse. And worse. And worse …

Over the next three hours, my annoying little neck crick turned into a full-blown three-alarm fire. It grew to be so much more intense that it defied quantification. Six times worse? Nine? Does it matter?

It was baaad.

I had either injured myself, aggravated the problem, or both. For the next three days — long days of computer time — I suffered the equivalent of a pounding headache in my neck, a hot grinding ache that had me squirming and grabbing at it constantly. Fat lot of good it did me. Even with all the tricks I know, I was not able to put a dent in the pain.

The first signs of relief finally came on day four, after a good sleep in my own bed. It slowly calmed down over the next five days until I had one of those “hey, I haven’t noticed that pain in a while” moments.

I feel lucky that it calmed down as quickly as it did.

Was it worth the risk? No. I will never take a chance with a hard stretch like that again. I would far prefer to sacrifice the chance of a quick cure rather than risk ever giving myself another week like that.

Bear this story in mind as you read on. Don’t assume that stretching must be good for you just because it feels good. In fact, you can’t even assume that it’s safe.


Winning a tug-of-war: how stretching might help trigger points in principle

In the weighty text Muscle Pain (2000), expert authors and researchers Dr. David Simons and Dr. Siegfried Mense are enthusiastic about stretching as a treatment for trigger points. They propose that “essentially any technique that elongates the muscle out to its full stretch length” constitutes effective treatment for trigger points therein.371 “A newly activated, single-muscle myofascial trigger point is usually remarkably responsive to simple stretch therapy,” they write. Stretching “by almost any means is beneficial … At least five ways can be used to augment simple muscle stretch.”372

They make stretching for trigger points sound good.

Probably too good to be all true. A few pages later, they also write that it has “not been firmly established” that stretching trigger points is helpful, emphasizing that they are making educated guesses. No kidding.373

If stretching ever actually works, it probably works about the same way that stretching out a calf cramp works: you win the tug-of-war with spasming muscle. It just happens on a smaller scale. This is superficially plausible. Certainly stretching is the only defense against big cramps.

To understand the how of it, you should bring back to mind some key features of the “exhausted contraction knot” theory about what a trigger point is: a sick, poisoned patch of spasming muscle experiencing a metabolic bad day. It is consuming lots of fuel and excreting lots of junk molecules at exactly the same time that it is choking off its own blood supply. Waste accumulates and irritates nerve endings (causes nociception), and everything goes downhill. The main idea is that it’s a vicious cycle (“energy crisis”). Therefore …

If the muscle fibres in a trigger point could be fully elongated by stretching the muscle, they cannot burn fuel. Muscle fibres can burn fuel only when the working molecules inside the muscle fibre are mostly overlapping. When stretched out and disengaged, they cannot work, like a hamster without a wheel to run in. According to Simons and Mense, the stretch-state disengages muscle fibres, interrupts contraction, and presumably allows the energy crisis to abate, the vicious cycle derailed a little more with each passing moment of stretch.

The proteins in a muscle overlap like the tines of two forks as the muscle contracts. If they are pulled apart, they can’t burn fuel.

This is state-of-the-art trigger point science, such as it is. It is one of the most educated guesses available, from credible authors on the topic. This is about as close as we’re going to get to a good rationale for why stretching might help trigger points.

Alas, there are major concerns.


The bad news about stretching for trigger points

Even if all of the above is correct — which is granting quite a bit — there are still many problems. There are so many problems that I’ll be exploring them for the next four sections.

We are in an evidence-free zone, by the way. The efficacy of stretching for this kind of pain has never been studied well enough to guide us to a conclusion.

There are practical circumstances in which you cannot realistically hope to win a tug-of-war with your trigger points, even if it works in principle. But there are also reasons to doubt that it even works in principle, even in ideal circumstances. If it does, stretching probably mostly only works on the milder cases that don’t matter very much in the first place.

Simons and Mense importantly concede that stretching works primarily for “newly activated, single-muscle” trigger points, presumably because they think that you can more easily win a tug-of-war with a milder contraction knot than a meaner one. Newer trigger points are probably milder, on average, and milder trigger points probably aren’t contracting as powerfully. The less extreme physiological circumstances (less painful!) mean that a “defensive contraction” is relatively unlikely, and that the trigger point is not so tough that it can’t be pulled apart. That is, it will “fight back” less.

But what about the fiercer trigger points? Exactly how are you supposed to pull apart a powerful contraction knot — muscle fibres in full spasm — with anything less than pliers and a vice and a glass of bourbon? We probably don’t have the leverage or pain tolerance required to actually elongate the bigger, stronger contraction knots. If Simons and Mense are correct about how this works, a wee pull is not going to do the job — you have to elongate them enough to substantially disengage the overlapping proteins that are burning fuel. Simons and Mense emphasize that a trigger point must be “fully” elongated in order — theoretically — to have any effect on a severe energy crisis.

Many factors make “fully” elongating a trigger point unlikely.

The first is pain. After emphasizing that you must “fully elongate” trigger points to treat them, Simons and Mense also wisely caution that the stretch must be applied “slowly and only to the onset of discomfort.” I agree. Unfortunately, there is no hope of doing this to any seriously hurting muscle by applying stretch “only to the onset of discomfort.” By their own theory, discomfort will start when you’ve only begun to tug on a contracted trigger point! If you stop there, you’ve done nothing — either in theory or in practice. Such a gentle stretch could probably only be useful in the case of the most minor trigger points. Stretching for such minor symptoms might feel good to some, but it has no therapeutic importance to anyone troubleshooting serious pain.

People often have such acute muscle pain that they can’t bend over to tie up their shoes. They can’t fully elongate a Slinky without an onset of discomfort, let alone their trigger-point-riddled muscles.

The second big problem is the biomechanics. In many muscles, a strong stretch is biomechanically awkward at best, or just impossible.

Some muscles literally cannot be meaningfully stretched at all, no matter how you pretzel yourself. Most of the quadriceps, for instance, simply cannot be elongated significantly before the hamstrings meet the calf.374 Similar biomechanical limitations occur in several places in the body. The paraspinal muscles in the upper back and lower back are another great example, because they often harbour some of the worst stiffness and pain in the body, and they are also difficult to stretch — not impossible, but difficult — simply because the spine does not bend enough or in the right way to apply a firm stretch. There are many other examples of muscles we’d all really like to stretch, but it isn’t ever going to happen outside of a circus, or without dislocations and fractures. For more information about this important concept, see:

That’s a macroscopic biomechnical problem with arranging limbs and pulling on entire muscles. There’s also a microscopic biomechanical problem in principle: trying to stretch out a trigger point is like trying to stretch out a knot in a bungie cord.


Like a knot in a bungie cord

Terms like “tight” and “stiff” describe only a sensation, not a tissue state or functional limitation. It might be tempting to assume that “stiffness” refers to poor flexibility, at least in part … but people can and frequently do feel stiff without any apparent limitation in their range of motion. Since trigger points are so closely associated with the sensations of stiffness and tightness, there are some strong common assumptions and guesses about how they create that sensation.

For instance, if we accept the contraction knot theory, it has an obvious implication: all other things being equal, muscles containing trigger points probably can’t elongate as much as muscles without trigger points. A trigger point theoretically reduces the extensibility of a muscle, because a patch of shortened sarcomeres in a muscle is like a knot in a bungie cord.

Killer analogy, right? If I stopped there, I’d have quite a compelling story/image that artfully connects the dominant idea of how trigger points work with an incredibly familiar human symptom. It “explains” how trigger points restrict range of motion … which in turn strongly implies the need to stretch them out. Such stories are the bread and butter of many professionals who want to put a little science sauce on their work. But if it sounds too good to be true, it probably is. It is a lovely analogy in several ways, but it only goes so far, because …

A knotted bungie cord actually still works well. (And they are a lot simpler than muscles.)

I’ve tried a blindfolded test of pulling on two medium-length bungie cords, one knotted and the other not, and I cannot tell the difference by feel alone. Try it. You can’t feel it because a bungie knot affects only a small segment of the full length of the cord. Only at the extremes of stretch are you going to see any difference in the maximum length, and that much is probably true of knots in both muscles and bungie cords.

And good luck stretching the knot itself! The stretchiest parts yield first, and a lot. In fact, you will probably take up all of the slack in the elastic components of a muscle and its tendons before even starting to apply tension to any trigger point it contains. It will just sit there, a rigid section of an otherwise elastic structure. You’ll have a few contracted sarcomeres surrounded by stretched (or even over-stretched) sarcomeres.

Another difference between bungie and muscle is significant: while a knot in a bungie cord affects the entire cross-section of the cord, a trigger point afflicts only a small part of the total cross-sectional area of a muscle. So a trigger point in a muscle is more like a knot in one bungie cord that is part of a whole bundle of bungie cords, most of which are not knotted. One knot in a single cord in the bundle is not going to have a significant effect on extensibility of the whole bundle, and stretching the bundle will not have a significant effect — none really — on a knot in one of the cords.

This matches what we see in the real world: although trigger points are very common, significant restriction of range of motion with no other clear cause is not common. In general, muscles seem to elongate as well with trigger points as they do without. What seems like an obvious problem in principle when playing with cool analogies is probably completely trivial in biological practice.

But it is nevertheless possible that many severe trigger points could limit flexibility enough to be obvious. The effect could also completely depend on what kind of muscle we’re talking about. It might be much more of a problem in shorter muscles, for instance. And it’s possible that there is an effect on muscle extensibility that has nothing to do with the mechanics of contraction and everything to do with the discomfort — neurology, not mechanics. We feel the knot, even if we can’t actually detect any limitation in ROM.


The spray-and-stretch method, if it works, implies that stretch alone may not work

I’ve reviewed several practical and theoretical challenges for stretching trigger points so far. Here’s a logical problem with stretching trigger points that’s a bit glaring.

Travell and Simons — considered the world’s original experts on myofascial trigger points — were very keen on an augmented stretching method called “spray and stretch,” which must be applied by a skilled therapist. This method features prominently in The Big Red Books, with high quality illustrations demonstrating how the method should be applied for most muscle groups in the body. Basically, the stretch is supposedly enhanced with a spray that cools the skin. Many therapists believe that Travell and Simons’ method means that stretching must be unequivocally good for trigger points … forgetting the reason for the spray.

The spray is important, according to Travell and Simons! They actually caution against stretching without it — supposedly the coolant provides an important sensory “distraction” from the pain of stretching a dysfunctional muscle (jargon: the spray acts as a diffuse noxious inhibitory control). Without the distraction, the nervous system might otherwise react “defensively.”

This rationale for the spray and stretch technique is obviously based on the assumption that muscles may resist painful stretch without the help of the cooling spray. And I think they do: that matches my clinical experience, and extensive personal experience with my own muscle pain. And so apparently, according to Travell and Simons, sprayless stretch is actually a poor treatment method, especially for the worst trigger points. But if stretch-without-spray is fine and effective, then Travell and Simons were just wrong on a critical point.

We can’t have it both ways, and either way is a bit discouraging.


Other practical limitations of stretching for trigger points

After all the complex theoretical, practical, and logical problems with stretching, here’s a refreshingly simple one: self-stretching is just imprecise and inefficient! Even if it “works,” it’s just too blunt an instrument. Trigger points are small and finicky, and stretches are “big.”

Trying to get at ... relatively small trigger points by stretching whole groups of recalcitrant muscles seemed unnecessarily indirected and inefficient.

The Trigger Point Therapy Workbook, by Clair Davies, p. 8

Most people have only a little anatomy knowledge. It’s obvious how to stretch many muscles, but there are a number of important ones that aren’t so obvious. No patient has the faintest idea how to stretch the infraspinatus muscle until they’ve been trained. The infrawhatus? It’s anatomically obscure, and yet clinically important.

Even if stretching worked perfectly on every trigger point, trigger points are usually quite numerous … and stretches are slow. It could take literally hours to thoroughly stretch every muscle containing trigger points relevant to a particular pain problem … assuming that you even know which muscles to stretch, and how to stretch them.

And referred pain, of course, probably fools people into stretching the wrong muscles.

These are all practical problems with stretching even if it actually works. They are a factor regardless of the biology. They go a long way to explaining why stretching doesn’t seem to be saving many people from trigger point pain.


What about neurology? Stretch tolerance

Just to emphasize the depth of the theoretical uncertainty about stretching, now I’m going to give an example of a completely different theory of how stretching might be helpful!

The grumpy elephant in the corner here — for this whole book, really — is that the exhausted-tiny-cramp idea could just be wrong, in which case good luck “interrupting” it with stretch. It may be the best-educated guess available today, but it could still be wrong, in which case stretch simply can’t help trigger points.

What if trigger points are merely a symptom or an illusion of a neurological cause of pain? Stretch might still help, but it would have to do so by a completely different mechanism, with its own pros and cons. Stretching might still help even “pure pain” in muscle — even if there isn’t a contraction knot. This could actually be a more plausible explanation for why stretching sorta kinda helps.

Muscle & connective tissues are very difficult to physically change with stretch. It is probably just sensory tolerance for stretch that increases with practice.

We know (pretty well) that a diligent stretching habit increases flexibility, but probably not by actually changing muscle and connective tissue (or not with any ordinary stretching effort, anyway). Fascinatingly, it is probably just our tolerance for stretch that increases with practice.375 Muscle elongation is normally strictly limited by the brain and spinal cord, and only with repeated exposure to strong stretch can we “get used to” the discomfort and gradually push the limit back.

Trigger points might be a symptom or side effect of the nervous system imposing excessive limits on muscle extensibility. If so, they might — sometimes, when the planets align — fade away as we train ourselves with stretching to tolerate greater muscle extensibility.

It might also explain why stretch seems to backfire fairly often: because stretch is challenging a neurological edict. The wisdom of the body does not impose limits without some reason … and it may fight back. It is usually neither easy nor safe to “argue” with your spinal cord’s opinion of how flexible you should be.


What about stretching the antagonist muscle?

An “antagonist” muscle is a muscle that pulls a joint in the opposite direction. The triceps and biceps are antagonists to each other: the biceps flex the elbow, the triceps extend it. Agonist, antagonist. Could it be helpful to focus stretching on the antagonist to the muscle with a suspected trigger point? This is an idea that crops up now and then.

That’s just unknown, and not likely to be all that effective, but it is a little bit plausible and worth experimenting with. If it works, the effect would likely be entirely neurological. Certainly the nervous system treats a joint as a system, and sensory input received from any part of the system may change how the system is behaving. Stretching the antagonist might be a good way of stimulating the system without directly challenging the trigger point. Work on both sides of the functional equation of the joint, as opposed to just yarding on one side of it.

The main down side is that there’s no particular reason to think that this particular stimulation will have much effect. It’s indirectness is a both a highly speculative advantage and it’s obvious disadvantage: it may just not be relevant.

Another discouraging consideration is that there are many common locations for trigger points where the antagonist is either unclear, or seems — I can only cite my intuition here — especially relevant. For instance, trigger points in the low back and buttocks are common, but stretching the hip flexors and abdominals seems rather futile. The sensation of stretching the trunk and hip flexors doesn’t feel like it has anything to do with stiff and aching butt and back.

Other antagonists do feel more relevant. The best example I can think of is the forearm: whenever the forearm extensors are rotten with trigger points (as they often seem to be), the forearm flexors seem to be quite pleasing to stretch as well (pulling the hand and fingers backwards).


Stretching “conclusions”

Stretching for trigger points is an inefficient and imprecise crapshoot, afflicted with countless theoretical and practical problems — and yet that does not mean it’s useless. Almost everything therapeutic is “inefficient and imprecise.” Life is messy, and lots of solutions are imperfect: that doesn’t mean they should be ignored.

Although people may routinely be misled by referred pain to try to stretch the wrong muscles, I also trust that many people have sufficient body awareness that, sooner or later, they will find more relevant stretches by trial and error — especially with the aid of the systematic stretching and wide variety of postures and movements experienced in yoga or Pilates classes.

Stretching probably does have at least a small therapeutic effect on milder trigger points some of the time. This probably explains why it often feels so good, and partially, temporarily relieves pain and stiffness.

But please bear in mind that conventional stretching, as we know it — sustained, static elongation of muscle tissue — is almost certainly not the best method. For instance, there are some excellent reasons to believe that rhythmic, repetitive movements — dynamic stretches or mobilizations — might have a better chance, probably because they are more neurologically and metabolically “interesting” than stretch.

Yet there is no research validation for using any method of self-stretching to release trigger points. As long as this remains true, feel free to do your own research. Just be cautious with strong stretches of more severe trigger points in the shorter muscles, because it can backfire.

And beware of wasting your time, not so much because the benefits of stretching trigger points are unknown and controversial at best — which they assuredly are! — but because there are other treatment methods that are almost certainly more useful. This is the worst problem with stretching for this or virtually any other reason: just that it’s too inefficient and too uncertain, life is full, and there are probably better things you could be doing with your time. You should only try to stretch your trigger points if you seem to get results. If it isn’t working for you, experimenting thoroughly is a long shot: better to just move on.


Part 9

Getting Help

How do you find good therapy for your trigger points?

Getting good professional help for your trigger points can be difficult. Remember, the evidence is clear that most professionals can’t reliably confirm the location of trigger points. Although there is a lively community of health care professionals who understand this topic quite well, it is a small community — they are spread thin and are often difficult for patients to find. How is a patient to know the difference between a therapist who really has substantial expertise in trigger point therapy and one who only knows the basics yet claims to do trigger point therapy? In the sections ahead, we’ll try to help you solve this puzzle.

Generally speaking, massage in its many forms is the best flavour of therapy for trigger points. It offers the best bang for your buck. It is the type of physical therapy most likely to provide relief. Massage therapists work directly with muscle tissue, by feel, all day, every day. Therefore, even the most poorly trained massage therapists often have at least some concept of what a trigger point is, and some idea of how to help.

I often tell people to“ choose the therapist, not the therapy,” because the competence and dedication of an individual health care professional is almost always the most important factor in the quality of care they provide — not the particular profession they got into. In other words, a competent professional of any kind is almost always better than an incompetent professional in any other profession.

Trigger point therapy may be an exception to this rule of thumb.

Whereas massage therapists are inevitably, directly exposed to trigger points, most other kinds of therapists and doctors really have to “go out of their way” to learn about trigger points — they are extremely unlikely to learn much about them “naturally” as a part of their work. Although a few do make a point of studying trigger point therapy, most do not. Those who do could be valuable resources for you. Those who do not are usually worse than useless, extremely likely to misdiagnose — to “see a nail” because “all they have is a hammer.”

The challenge for the patient is to know enough about trigger points themselves to quickly detect the difference between health care professionals who do and do not know much about trigger points. It may be simpler just to err on the side of massage therapy, because the odds of finding a massage therapist who understands trigger points well are generally so much higher.

Nevertheless, here’s a bird’s eye view of your options for professional therapy. All of the types of therapies mentioned here will be discussed in detail below.

Types of therapists and doctors and their relationship to trigger point therapy

“Trigger point therapy” is a broadly defined modality, or treatment method, which can be practiced by almost any kind of healthcare professional in almost any kind of way. It’s not commercialized/branded for the most part — which is a double-edged sword. (There are a few trademarked trigger point treatment modalities, which I will discuss below, but they are mostly obscure and a really mixed bag.)

The lack of standards is unfortunate, but not really surprising or even wrong in the absence of any compelling evidence to base them on. So I’m going to spin not being an Official Therapy Method as mostly a good thing. 😜 It means that most "trigger point therapists" are free to experiment without being at odds with any teachings/doctrine. And it means that patients are less likely to encounter trigger point therapy specialists who have major when-all-you-have-is-a-hammer issues. I think it’s better to work with professionals who consider trigger point therapy to be just one of many tools for treating pain.

So what kind of healthcare professional should patients seek out for trigger point therapy? What are the “not a trigger point therapy per se” options?

Physiatry, or physical medicine and rehabilitation (PM&R), is the medical speciality devoted to rehabilitation and many musculoskeletal problems not addressed by other doctors. Think of them as “super physiotherapists.” Their job is to restore optimal function to people with injuries to the muscles, bones, tissues, and nervous system (such as stroke patients). This field has a broad scope, and many physiatrists may only be interested in and knowledgeable about more serious injuries and diseases (i.e. not muscle pain, even severe and chronic muscle pain). For instance, when my wife suffered a serious spinal fracture in a car accident, a physiatrist managed her rehabilitation in collaboration with surgeons and other specialists. Despite the importance of their expertise to seriously injured patients, however, of all medical doctors, they are the most likely to be well-educated about muscle pain (yay!) and may be able to accurately diagnose, locate and treat trigger points. The right physiatrist might be hard to find, but is also the professional most likely to be the best for a difficult muscle pain job.

Rheumatologists deal mainly with clinical problems involving joints, soft tissues and the allied conditions of connective tissues. This might seem to be an ideal fit for myofascial pain syndrome, but it’s not. Few rheumatologists are interested in “garden variety” muscle pain — their expertise is almost entirely devoted to autoimmune disease and some other serious medical problems. In my career, I can only remember a couple of cases of rheumatologists who showed the least bit of interest in muscle pain. Most just screen for autoimmune disease, and that’s the end of it. And yet many muscle pain patients are sent to rheumatologists by family doctors because muscle pain is not suspected.

Massage therapists are generally the most likely source of trigger point therapy, but the quality varies widely. Massage therapists will almost exclusively use massage therapy, but a few might use stretch and spray, which is a good option.

Physiotherapists work hands-on quite a lot, and are probably the next most likely kind of professional to have any kind of trigger point expertise. However, they are probably a somewhat distant second in North America, because the profession on this continent is dominated by a business model that depends heavily on short appointments and numerous technological treatments of dubious value. Physiotherapists who do study trigger point therapy usually treat it with massage, high-intensity ultrasound, or dry-needling (IMS). Physiotherapists abroad are more likely to spend longer with their patients per session, and generally have a more physical approach to their work. Maybe I’ve just gotten lucky, but the Aussie and New Zealish (sic) physiotherapists I’ve met have been unusually good.

Chiropractors also rapidly accumulate hands-on experience, and the best of them may do massage as well as joint adjustment, and they are capable of being excellent trigger point therapists when they study the subject. However, only a tiny fraction of chiropractors do so. Joint adjustment alone is probably of limited value to trigger point therapy, and the few chiropractors who do any kind of muscle manipulation tend to do so without much knowledge of trigger points, practicing primarily ART® or Graston Technique instead, both of which are also probably of limited value for trigger point treatment. And, like North American physiotherapists, the chiropractic business model is dominated by short appointments, which are never adequate for trigger point therapy.

Medical doctors are an unlikely source of trigger point therapy, and the extreme minority of those who have knowledge of trigger points usually use injection therapies almost exclusively (which is not necessarily a bad thing, but it is often premature — conservative therapies should be tried first). Once in a while you’ll find one who works with dry-needling (IMS), high-intensity ultrasound or TENS, and perhaps stretch and spray.

Any kind of medical specialist working in a pain clinic — there are usually a couple pain clinics in every major city — are by far the most likely to know anything about trigger points. The specialists most likely to know something about trigger points are sports medicine doctors, orthopaedic surgeons, rheumatologists and neurologists. However, in all cases, their knowledge is usually limited to simply knowing that trigger points exist, and it’s only a rare one that actually knows what to do about them. However, a doctor who will diagnose myofascial pain syndrome can at least be useful for insurance purposes, even if they can’t treat it!

Naturopathic physicians are perhaps slightly more likely than mainstream physicians to offer trigger point therapy, but practitioners of that profession hold such a wide range of beliefs about health care that I don’t generally recommend “going there” — there’s a high risk of being charged for expensive diagnostic procedures like Vega testing, or therapies like homeopathy, both of which have failed every scientific test they’ve ever been given.

Acupuncturists are unlikely to help your trigger points. Their only method of treatment is acupuncture, of course, and it is mostly debunked as a trigger point therapy below.

So, once again, you can see how massage therapy is probably your best bet for trigger point therapy. So, our next challenge is to address the quality control problem in massage therapy …


Quality control and safety issues (“But I’ve already tried massage therapy … ”)

Massage therapy may be the therapy most likely to succeed, but a great many patients have already tried massage therapy … and given up.

Unfortunately, there are many significant challenges in trying to find effective trigger point therapy. I routinely hear from people around the world who live in small towns and remote areas and cannot find a massage therapist who seems particularly qualified to treat trigger points, assuming they can find any kind of massage therapist at all. Even people who live in or near cities often struggle to find the right therapist. Consider this typical report from a reader (and also a professional himself, a chiropractor, with a clear sense of what he’s trying to find):

I’ve been to just about every massage therapist around — I love massage — and no one does trigger point therapy, even when I direct them exactly how I would like it done.

Why is it so hard to find effective trigger point therapy? There are a lot of reasons. First, there’s several problems with quality control in massage therapy generally:

And then there’s several more problems with trigger point therapy specifically:

A normal person should be tempted to dismiss that final example as exotic, and perhaps even irresponsible of me to bring it up. But that sort of thing is shockingly common in the world of trigger point therapy, and that’s my point. I have heard many alarming stories like that over the years. This particular example was likely based on two things:

  1. There’s an actual trigger point therapy treatment method called “dry needling” (big chapter about it coming up) that is just one short conceptual hop away.
  2. The surprisingly popular fetishization of the psoas muscle, which is largely due to one strange book that the industry has embraced (see Psoas, So What?).

But trigger points in general are often fetishized in their own right, the belief in their importance so inflated and uncritical that therapists often get, er, rather “creative” in their pursuit of a “release.” It’s a weird inversion of the old “when all you have is a hammer” thing: when all you see is nails, you start looking for new ways to bash them.

Trigger points are frequently worth exploring as a target for experimental therapy, but such nuanced restraint is often nowhere to be found. Instead, I see a lot of evidence of a single-minded, kill-it-with-fire approach to putative trigger points, which may or may not even be the actual problem. That is just dangerous amateurism… and disturbingly common.

And so, thanks to many factors, myths and bogus treatment concepts have always been rampant in the world of trigger point therapy, to the point of being dangerous. It’s just a mess, frankly.

Trigger point therapy does not come standard in massage therapy offices — it is a specialization without standards or regulation. It is not reasonable to expect all massage therapists to understand how to treat serious trigger points properly. Most massage therapists are unprepared to treat anything worse than mild-to-moderate cases of isolated trigger point pain.

And this is why readers from around the world so often tell me that they have “already tried massage therapy,” but got no relief. It’s pretty clear that they didn’t get good massage therapy. Specifically, they probably didn’t get good trigger point therapy, and they may not have even gotten safe therapy.

If you’ve already tried something branded as trigger point therapy, and failed to get good results, do not give up yet!

That all said, when in doubt, it is much better to just have a great massage than bad trigger point therapy. There is plenty of overlap between decent trigger point therapy and an ordinary pleasant massage.


Two case studies: highly-trained therapists failing miserably

This section presents two stories of well-trained massage therapists failing to understanding basic things about trigger points. Both problems were also success stories in the end, easily and completely treated without difficulty: a persistent headache, and a chronic shoulder pain, both relieved indefinitely in a single appointment.

Case study #1
“No one has ever pressed on that spot before”? Really?!

A young woman with a long history of completely unreasonable chronic headaches sought treatment from three of my colleagues at the time — three unusually well-trained Registered Massage Therapists.382 These people were my colleagues: what would usually be called “medical” massage therapists most other places, and, in theory, the créme de la créme of massage therapy. Any BC-RMT could walk into virtually any jurisdiction in America and be — by far — the best-trained massage therapist available to that population.

My client had seen three of these elite therapists before coming to visit me, but had not gotten any relief whatsoever. She enjoyed the massages, but unfortunately did not find them therapeutically useful.

I soon found out why.

Not long after I started her first treatment, I checked for unusual sensitivity in her suboccipital muscle group (a “trigger point,” a common sore spot linked to tension headaches). This is an assessement procedure I consider to be as automatic as breathing for a client with her symptoms — I can’t imagine not doing it. And I immediately found what I was looking for: a highly relevant trigger point, which is exactly what you’d expect to find in about 60% of cases.

What happened next is what makes it a good story. My client said in amazement (emphasis definitely hers):

That’s it! That’s where my headache is coming from! You’ve got it! And no one has ever pressed on that spot before.

Really? Could this possibly be? I asked her to confirm this in detail, because I found it so strange. Looking for and treating suboccipital trigger points is one of the most elementary things I can imagine a massage therapist doing for a client with chronic tension headaches. Not only is it a classic spot for massage therapy for headaches specifically, it’s one of the most useful and pleasant targets for good massage anywhere in the body — “Perfect Spot #1”! And yet three other fancy RMTs had not only missed it, but apparently had not even looked for it — an inexplicable oversight.

Actually, failing to massage suboccipitally in a headache patient is worse than an “inexplicable oversight”: it seems almost impossible to believe that well-trained massage therapists could make this mistake. But, unfortunately, such failures may be typical of the state of trigger point therapy in the world today — even from “elite” therapists.

A little massage of her trigger points relieved her symptoms for several months at least.

Case study #2
Missing the point: failed trigger point therapy for a simple shoulder case

In another common and disappointing scenario, massage therapy is focused … but focused on the wrong tissue. This story is about a determined and experienced patient, a middle-aged woman with severe, chronic shoulder pain on the “end” of her shoulder — where an officer’s epaulets would be — and radiating downwards on the side of her arm and through her biceps almost to the elbow. It was a nagging, sickening pain, like a toothache in her deltoid muscle.

She had been diagnosed with a whole bunch of common shoulder conditions, basically all of them — which is typical when someone has a nasty trigger point. Such people tend to get diagnosed with every possible thing except the trigger point.

What made her case a bit unusual was that she really had given physical therapy and massage therapy a good chance to work. She had seen a massage therapist and a physiotherapist concurrently and frequently for 12 weeks. But she had gotten exactly no relief. And, if two therapists working with a cooperative, diligent client continuously for many weeks hadn’t helped her … what chance did I stand of making a difference?

I cautiously quizzed her about exactly what kind of therapy she had received. “Oh, trigger point therapy,” she said. “She did detailed trigger point therapy on my shoulder muscles.” That sounded good. She almost certainly had shoulder trigger points! But why hadn’t she gotten relief?

“Did your massage therapist ever work here, on the back of your shoulder blade, several centimetres away from the location of your symptoms?”

“Oh, no,” she replied. “No, she only worked here,” she said, pointing clearly at her deltoid and biceps — the exact location of the symptoms.

Uh oh. Well, there’s your problem, I thought.

“Twelve weeks of that?” I asked. “Only there?

She nodded. “Why? Is that bad?”

Yes, that is bad.

Her therapists had never checked a likely cause of this particular pattern of symptoms — which happens to be the infraspinatus muscle on the back of the shoulder blade, several centimetres away from the symptoms. Infraspinatus trigger points have a highly predictable pattern of referred pain — knots in that muscle cause pain on the end of the shoulder, and the side and front of the upper arm, exactly like this patient’s symptoms.

Every massage therapist should know this. A massage therapist who doesn’t know it is flying blind, doing massage that is about as therapeutic as a manicure.

So what happened? Her shoulder problem, after almost a year of misery and misdiagnosis, was 100% relieved by a single dose of infraspinatus treatment. Just one properly directed massage. She sure was happy!

It doesn’t always go quite that smoothly, of course. A therapist may have to spend a fair bit of time looking for sensory relationships like this, and it can be tricky even if just one trigger point really is the only problem. But the point is that any good therapist will be trying to do that. Without knowledgeable exploration, it can’t be good trigger point therapy. And there should be pleasant, satisfying massage along the way — that’s the valuable consolation prize, if hunting for and prodding trigger points should fail to produce therapeutic results, which is of course all too possible.


Worst practices in massage therapy

Massage therapy is like pizza: even when it’s bad, it’s pretty good. But when you’re in pain and you really need competent help, your standards go up, and you start to notice that a lot of so-called therapeutic massage is a bit sketchy.

From 2001 to 2010, I systematically asked patients why they left previous massage therapists. The experiment continues in correspondence with readers today. I have heard it all. Excessive pressure is the most common problem, and massage that is only “skin deep” and unsatisfying is a close second. (See The Pressure Question for more about that.)

But I have also heard a litany of basic problems with customer service. You’ve heard of “best practices” — a bit of a buzzword for the last few years. Well, these are some worst practices in massage therapy. For example:

Such reports were routine during my career as an Registered Massage Therapist in the 2000s, and nothing much has changed since. And these were Registered Massage Therapists in Vancouver, Canada, with our unusually high standards (which have gone down since, not up).

What’s a patient to do in a sleepy midwestern town in the US, in a state where “medical” massage is simply an unheard of specialization? Where the only massage to be had comes from an old hippy bodyworker who speaks passionately about reflexology and wants to know what colour the pressure makes you think of?

Oh, dear.

One day I got a somewhat cranky email from a representative of an association of trigger point therapists, criticizing me for giving the impression to the public that patients can’t find good help for their trigger points. And yet her own organization’s so-called “directory” of therapists offers barely more than a few dozen therapists listed for the entire United States … and 90% of them were in the big cities. As much as I agree that there are many dedicated and talented trigger point therapists out there trying to help, there simply aren’t enough of them.

My own worst massage ever

I knew I was in trouble the moment I walked into her office: the place reeked of essential oils, enough to give me a headache, her shelves were festooned with crystals, and her walls were covered with Scientology posters. If I’d been just a bit older and wiser at the time, I would have walked out immediately. Unfortunately, I stayed — perhaps out of morbid curiosity.

Cheesy, loud new age music, of course. Violently strong pressures, and total disregard for my requests to ease up. Rapid, erratic changes in technique, intensity and location — one moment she was wrenching my neck, the next slapping my back, and a few seconds later she was driving her elbow into my kidneys. And so on and on. It felt more like an assault than a massage. She actually shoved the heel of her hand into my eye socket, apparently by accident — I wonder what she actually intended to do? For what purpose, exactly, would you shove so hard and suddenly on any part of a person’s face that you might accidentally miss?!

At the very end, she drenched her hands in some floral scent that made me want to throw up, covered my nose and mouth, and commanded, “Breathe! Deeper! Deeper!”

At the end, great insult was added to injury: not only was it the worst massage I’d ever received, it was also the most expensive at $110/hour.


How to find good trigger point therapy

I constantly hear from readers who have been dissatisfied with therapeutic massage, and the most common question I get (by far) is:

Can you recommend a therapist in [insert any place on Earth]?

I have been asked a thousand times if I can recommend a therapist in Europe, Asia, India, Africa, Australia … whole continents where I know only a few people, and only thanks to email and Facebook and Twitter. And so, unfortunately, the question is mostly impossible to answer. I really need to know a therapist well before I’m prepared to recommend his or her services … and I don’t know them if I haven’t been on their table a few times. Even right here in Vancouver I barely know any therapists that well. And even if I did, they’d soon be too busy to take new patients (or they move, or they retire).

Here are some tips for locating a therapist who will be able to help you with trigger points.

The high-maintenance test

When you start with a new therapist, ask for what you want, and watch what happens. Be politely demanding. Dare to be “high-maintenance.” In particular, be picky about pressure. Ask for more or less as needed throughout the treatment. Be nice about it, but say things like, “That’s a bit too strong for me right there, could I get a little less?” If you get a no-pain-no-gain response, counter with this: “Sure, okay, but I’d still like a little break from the intensity for a couple minutes — I need to catch my breath and relax a bit.” Or, if it’s too fluffy a treatment for your tastes, ask for more pressure.

If your therapist doesn’t respond well to your clearly expressed preferences, just never go back. This is the most efficient, painless way of eliminating a therapist who isn’t worth paying.

The letters-behind-the-name test.

Find out what the certification standards are in your state or province. Do some Googling. Does your government regulate massage therapy? How much? What does it take for the massage therapists in your region to become massage therapists? Now that you know what the standards are, use them, and favour the therapists who are well-trained and certified.

Credentials really do not guarantee anything, but they are better than nothing. Look for someone with letters behind their name, preferably a “BSc” (although that’s a long shot in most places), but at least “LMT” or “RMT” (licensed or registered massage therapist). I am not saying that unlicensed bodyworkers can’t be good therapists — some of them are truly excellent — but just that your odds are better with someone credentialed.

“Medical massage” on the sign is usually a good sign

There’s not really any such thing as “medical massage,” and the claim can be a symptom of serious overconfidence. Favour therapists who advertise “medical” massage therapy, especially in jurisdictions with low certification standards. It may be a false front, but it usually indicates a therapist who has promising aspirations to professionalism. For instance, it strongly suggests that they are more interested in working with physicians than against them. The odds of finding good trigger point therapy are somewhat higher in such offices.

An advertisement of “sports massage” is much less of a gaurantee, but it’s better than nothing: therapists interested in sports massage are a little more likely to be focused on sensible goals and techniques.

The big-red-books test

You can check on this before you even book an appointment: call therapists and just ask them if they know the work of Drs. Janet Travell and David Simons. Tell them you are looking for a therapist with specific skills. Be an assertive consumer, and just politely ask, as easy as asking for their rate: “Do you know the big red textbooks by Travell and Simons?” If they don’t immediately say, “Of course,” then thank them for their time and hang up the phone.

On the other hand, it’s another kind of good sign if they express any kind of skepticism or concern about trigger point therapy … because knowing that there is a controversy is probably more important than which side of it they are on. A therapist who doesn’t think the big red books are any kind of bible is likely a well-read and a creative and independent thinker — and more valuable to you than a therapist who has no clear opinion about it one way or the other.

Let the results speak for themselves

Try it out! If you haven’t seen some sign of progress after your first 3-6 hours of therapy, stop going: you need a compelling reason to wait any longer than that for results. There is some “wiggle room” for things getting worse before they get better, but not that much, and definitely beware of excessively poor results, like feeling too sore and sick after a strong massage (as discussed above in Troubleshooting negative reactions to treatment.)

If you’re having trouble deciding whether or not continuing with a massage therapist is worth it, see the section on measuring progress.


The Pressure Question: how much is too much?

For the whole decade I was a massage therapist, the most frequently discussed questions in my office was “the pressure question.” How much is enough? How deep is too deep? Should deep tissue massage be painful?

(There’s some duplication in this section with the troubleshooting negative-reactions section. Figuring out if a reaction is negative or not has some things in common with figuring out how much pressure is the right pressure. I’ll try not to repeat myself much. Just bear in mind that both sections are relevant to each other.)

There’s rarely any justification for extremely painful massage, unless it clearly produces a better result than gentler treatment — and that is rarely clear. It is possible that a few “brutal” massages could do the trick where gentler treatment would fail — but there is no way to know this in advance, and massage is expensive stuff. If you’re going to gamble on a treatment strategy, gamble on cheaper and less painful ones.

The reason the Pressure Question exists is that it’s hard for patients to tell the difference between nasty pain that might be a necessary part of therapy, and ugly pain that is just abusive. Not everything that hurts is therapeutic, but not every therapeutic procedure is painless! How can we tell if an intense massage technique is therapeutic or not?

Survey says: a super scientific poll of massage therapy clients

On my client intake form, I asked clients why they left their last massage therapist. The results, after several years of doing that …

Why people “fired” their massage therapists
55% too intense383
20% not intense enough
20% unfocused or wrong focus
5% other

People vote with their feet, and it seems clear from the results of this informal poll that many people have been dissatisfied with the pressure they’ve received during massage. They do not like their massage to be too painful … or too fluffy, regardless of whether or not they think it works.384

People also clearly don’t like their preferences to be ignored. Many of these clients, whether they wanted less pressure or more, have told me that massage therapists should ask about the pressure, to find out what each person wants. So there is one point, above all, that I would like to make about pressure …

Everyone’s different: massage pressure tolerance is incredibly varied

It fascinates me just how different people can be in this regard. Pressure that would be quite comfortable for one person would certainly cause severe pain and emotional distress in another, and probably even injury.385

These differences can also occur between body parts. Pressures that worked well on the back can prove to be disastrously intense in the lower legs. And pressure tolerance changes with time: pressures that seemed fine on Tuesday can be brutal on Friday.

All of this highlights the necessity of trigger point therapy that is:

That is, regardless of all other considerations, a massage therapist must talk to you about pressure, respect your preferences (they are more important than any treatment ideology), and be careful about stumbling into areas that need much less pressure (for comfort) or much more pressure (for satisfaction). Far too many therapists make the mistake of setting a “default” pressure for a client early on, and then using roughly that much pressure everywhere.

And if therapy isn’t communicative, respectful, and cautious? If the pressure feels wrong to you again and again?

Be assertive! Politely demand the pressure you want

A reader told me this alarming story by email, a typical example of unpleasantly intense massage therapy:

My massage therapist has been doing massages for 30 years. He is really aggressive. I thought that I was going to die. The pain was so intense that I honestly feel that it was worse than having children. When the massage was complete, I felt relaxed. When I got home I felt exhausted, like I had been in a major accident. Truthfully I feel like crap. I ache from head to toe, what the heck is this? I feel absolutely horrible. I had a bath before bed and it did help somewhat. But this morning I still feel like hell …

an anonymous reader

It’s tough to be assertive with a therapist like that! How much luck do you think most new clients would have telling an “aggressive” 30-year veteran of massage therapy to “ease up, please”? The trouble with most therapists like this is that they are set in their ways and are not communicative, respectful, or cautious.

You’d hope this sort of thing would be rare, but it’s not. Readers regularly tell me about massage therapists who do not ask them what they want, who dismiss their patients’ concerns about pressure, and who ignore signs that their clients are in pain. They display a “doctor knows best” arrogance — ironic for an alternative health care professional — imposing their own idea of the “right” intensity.

If you have the misfortune of hiring such a therapist, and you are not a natural masochist — hey, everyone’s different! — then by all means find another therapist. Be a consumer and shop around. Painfully intense massage therapy may be regrettably common, but it is by no means the only kind available.

And trigger point therapy needs to get this right. Although no one actually knows the characteristics of successful trigger point therapy, I could make a good case that it involves careful regulation of pressure to achieve a “just right” intensity — that both too much and too little will fail or even aggravate the problem, rather than helping it.

The Answer to the Pressure question begins with three flavours of pain …


Pain in three flavours: the good, the bad, and the ugly

Painful experiences on the massage table can be divided into three familiar categories: the good, the bad, and the ugly.

Good pain is intense but somehow welcome, a paradoxical feeling, and probably what you mostly want out of therapy. (We’ve already discussed good pain in detail earlier in the tutorial, so we won’t go over it again any more here.)

Bad pain has no component of pleasantness in it, but is not necessarily incompatible with therapy — it might have positive effects. And it might have harmful effects. It’s hard to tell.

Ugly pain is particularly extreme and a bad idea in every way. It is nothing but bad news as far as trigger points are concerned — they will probably be aggravated by it.

Ugly pain in massage therapy

Ugly pain in massage therapy is, by my definition, never okay. Ugly pain is often caused by things that are not going to offer even minimal, delayed benefits, and may even be dangerous. It’s important to be able to spot ugly pain for what it is and completely eliminate it from any therapy you’re receiving. What kinds of handling may cause “ugly” pain?

“Ugly” pain is inflicted only by careless, incompetent therapists. Ugly pain should simply never happen. Yet it does happen, and a shocking number of therapists will actually attempt to justify it or minimize the concern.

For instance, many poorly trained therapists do not know the endangerment sites, and will carelessly dig their thumbs into that hollow between your jaw and your ear, where there are exposed nerve bundles and salivary glands that can really smart when poked.386

Another alarmingly common example is the sensation of skin tearing. This has been inflicted on me personally on at least three occasions, and not by poorly trained therapists — quite the opposite, the perpetrators were all well-trained massage therapists doing a kind of “fascial release” therapy that they clearly thought of as an “advanced” technique. (This philosophy of treatment is discussed in another section.)

This may come as a surprise, but in fact there is no therapeutic benefit to stretching skin so hard that it feels like it is going to tear! And it is a completely different and uglier sensation than how fascial stretching can feel and should feel (more like a good massage)387 When I complained about this (politely), the therapists made no distinction between skin-tearing and fascial stretching, and more or less tried to tell me that I was objecting to perfectly good therapy. Needless to say, I never returned to those therapists.

There are massage therapists who seem to believe that any painful sensation is simply part of the process, and if they poked you in the eye they would call it “ocular release therapy.”

Ugly pain can be a sign of real dangers, one more obvious than the other:

  1. Direct injury. Tissues may actually tear, break, bruise. Significant damage is unlikely, of course, but it’s not impossible. For instance, I even know of a patient whose femur (the big leg bone!) was fractured by a massage — it was a weak and injured femur already … but wow!
  2. Sensory injury. A painful, alarming experience can actually dial up pain sensitivity — even long term.388 Vulnerability to this awful phenomenon is much more common and significant in desperate patients who already have chronic pain — so they seek and tolerate intense therapy.

Consequently, ugly pain in massage therapy is all too common and tragic. I cringe to think how many people have been abused this way. If you have a therapist you suspect of carelessly or deliberately inflicting ugly pain, just say no!

For more information about the potential hazards of intense manual therapy, see the section Troubleshooting negative reactions to treatment, or the article Massage Therapy Side Effects: What could possibly go wrong with massage? The risks and side effects of massage therapy are usually mild, but “deep tissue” massage can cause trouble.

Now, let’s move on to “bad” pain.

Bad pain in massage

Bad pain in massage comes with no obvious benefits. If there is anything good about it, there is no way to tell from the sensation alone. Bad pains are usually sharp, burning, or hot. Such pain is usually caused by excessive but more or less harmless pressure on your muscles, or by pressure on nasty active trigger points. As bad as it feels, it probably won’t hurt you — maybe a little bruising — but there’s also a good chance that it won’t be therapeutic either.

Once again, the Pressure Question is basically about whether or not bad pain is ever justified. If unpleasant pain is therapeutic, then I would call it “bad pain” — unpleasant, but worthwhile. If it’s not therapeutic, and you are paying to experience pain with no benefit, then it should be considered ugly pain — both unpleasant and pointless!

But how do you know?

For starters, you bear in mind the things described above that tend to cause ugly pain, and you avoid that kind of therapy like the plague. Then you look for some clues that painful pressure is okay. Here are at least three reasons (below) why unpleasantly intense pressure might be therapeutic — “bad pain,” but not ugly. In each of these situations, it might be acceptable to tolerate sensations so intense and painful that the only thing about them that is pleasant is the part where it stops.

Bad pain can be therapeutic, but it’s possible that it may not be therapeutic much. The main problem with pain in trigger point therapy is that pain causes activation of “fight-or-flight” neurology, which might make trigger point release more difficult or impossible. But there are also some ways in which unpleasantly intense pressure might also be therapeutic. For instance, motor end plate destruction …

Motor end plate destruction. As previously discussed, we know that muscle knots may be caused by something that goes wrong with the “motor end plate” — where a nerve ending attaches to a muscle cell — and research has suggested that it may actually be possible to physically destroy the motor end plate with strong massage, thereby “deactivating” the trigger point. When it regrows — these are microscopic structures, so it doesn’t take them long to heal — the trigger point may be gone for good, or at least for a while. It’s just a theory: no one knows if this is actually effective. However, it may explain why so many massage patients report a “gets a bit worse before it gets much better” response to quite painful treatments: motor end plates are (painfully) destroyed by strong pressures, and then that tissue is quite sensitive and a bit weak as it heals over a day or two … and then you finally feel much better after that!

We also don’t know how this process might balance out against the neurological aggravation that may be caused by intense pain. The most we can know is that there is some reason to believe that painful pressures on muscles might be therapeutic for some people, some of the time. Pretty decisive, eh?389

Somatoemotional release. Mental and emotional context is a major factor in how we experience pain. Painful sensations are unusually good at stimulating catharsis — the expression of strong or repressed emotion. — because physical pain often strongly “resonates” with emotional pain.390 For instance, the pain of an injury may blur together with the emotional frustrations of functional limits and rehab. That’s a basic example, and much more complex interactions between emotional and physical pain are obviously possible. Whether it is the clear goal of therapy, or simply a natural side benefit, experiencing very strong sensations can certainly be a meaningful part of a personal growth process “just” by changing your sense of yourself, how it feels to be in your skin, and perhaps bumping you out of some other sensory rut.391

Flushing. If massage can “improve” any tissue — unknown! — one way it might do it is through simple hydraulics. It’s probably a myth that massage increases circulation. Either it doesn’t do it at all, or so little compared to exercise that it’s unimportant. I review the evidence in Does Massage Increase Circulation? But let’s keep an open mind: what if massage really does increase circulation in some specific situations that just haven’t been studied yet? It’s possible. While the existing evidence suggests otherwise, it’s obviously incomplete evidence. Or what if increasing circulation just matters more in some circumstances, in the same sense that an aspirin matters more to someone with a headache?

Trigger points could be one of those biological situations where an effect on circulation might be more meaningful. We know from Shah et al that TrPs are probably “polluted” with stagnant tissue fluids, which implies a greater need for and sensitivity to flushing, and it’s also possible that mere exercise won’t do the trick.392 So it could make sense to vigorously massage an entire muscle, casting a wide net, hoping to flush whatever trigger points might be present, and that doing it more firmly could also be more effective — potentially worth doing even if it’s uncomfortable.

Connective tissue stimulation. A lot of therapists are keen on stretching connective tissues — tendons, ligaments, and layers of Saran-wrap-like tissue called “fascia.” I’m not a huge fan of this style, not so much because I don’t think it works, but just because I think trigger point therapy works better. (I explain this more in the fascial release chapter.) However, I can imagine reasons why strong manipulations of connective tissue might be therapeutic (independently of treating trigger points). Certainly it’s a way of generating many potent and novel sensations, which may be inherently valuable to us — another form of touch. Although “improving” the fascia itself is implausible and unproven, perhaps fascial manipulations affect bodies indirectly, just as a sailboat is affected by pulling on its rigging. People have written whole books full of speculation along these lines. So, as long as the sensations are not like skin tearing (that’s an ugly pain for sure), you might choose to tolerate this kind of massage if it seems to be helping you.

The choice is yours

In massage therapy, so much can be achieved while inflicting only good pain on patients that bad pain must be justified by vivid, quick, and somewhat lasting benefits — which is a high bar to clear. All health care practices must be justified by benefits. As risk and pain and expense increase, the benefits must also. There is simply no point in tolerating — and paying for — painful treatment without an obvious return on the investment.

I’ll refer you again to the troubleshooting negative-reactions section for help judging exactly how long you should tolerate a lack of results. But obviously a persistent lack of results should make you question any kind of therapy, especially a very painful therapy.


Training your therapist

Believe it or not, if you can’t find a therapist who already understands trigger point therapy, another realistic option is to train your massage therapist yourself.

A confident and assertive client can often direct therapy. After reading this tutorial, you will know significantly more about trigger point therapy than roughly 90% of the massage therapists in the world, most of whom are unlicensed or earned their license with no more than a few hundred hours of training. Yet they have hands and hearts and talents. Many if not most of them are humble, good people who have no illusions about their own lack of training.

So, simply go ask for massage of the trigger points you suspect you need help with.

Any therapist who is respectful, attentive and provides good customer service will respond by giving you what you want. As long as they are cooperative and massage some of your trigger points, it hardly matters what else they might believe, or what they do or do not know about trigger points. In most cases, if you are polite and friendly about it, therapists will appreciate working with a client who knows what he or she wants!

A few therapist training tips:

  1. Ask them if it’s okay if you’re bossy. Why not? Be up front about it! Ask permission. “I have a clear idea what I want. Will you mind if I clearly ask for what I want and set good boundaries?” Who’s going to mind when you ask like that?
  2. Don’t just lie there. Give clear and immediate feedback. Say, “That spot feels really relevant to the problem. I think that spot is important!”
  3. Report results. Give clear feedback when you return for your next appointment. Tell your therapist exactly what you think worked best for you the last time. And what didn’t.
  4. Use a pain scale. Tell your therapist that you are familiar with using a pain scale, and tell them what range is acceptable to you, and then actually use the scale a few times during the appointment. Just say, “That pressure there on that spot is a 6 out of 10.”
  5. Recommend this tutorial. 😉


Other kinds of therapies

So far in the “getting help” sections above I’ve introduced you to the different kinds of professionals, and to the ins and outs of massage: the overall best option for trigger point therapy. However, there are dozens more specific therapies or “modalities” — modes of treatment — that patients will encounter in the wild. Some of these are excellent and interesting options to consider. Others are literally dangerous and/or utterly bogus. I’ve chosen about a dozen to focus on: not the best dozen, but the most popular or familiar out of ten times as many possibilities.

Incredibly, even after immersing myself in this subject matter for more than a decade, it is still actually common for me to get email from readers asking about treatment modalities I have literally never even heard of. “What do you think of ______ treatment method? Does it work?” There are a gazillion of ‘em! Treatment systems and widgets of every description!

The answer is always basically the same: nobody really knows, and there’s not really any way to know.

In most cases these treatments are close cousins to one of the more popular ones, perhaps even barely distinguishable. And most of the more obscure treatments are obscure for a reason: poorly conceived and promoted, they are usually the work of a lone therapist trying to create a new income stream from a branded technique, their own “modality empire” (a concept that will come up several times). Such therapies usually reek of amateurism and snake oil salesmanship. Their websites are cluttered with red flags: big promises, heavy reliance on testimonials, sloppy logic, and so on.

My point is that anything that isn’t discussed below probably isn’t worth discussing!

Bear in mind that all trigger point treatment methods and systems are essentially experimental. The scientific situation is that we have a pretty good idea what trigger points are, and a reasonably good idea of what tends to aggravate them, but only a very foggy idea of what makes them go away.

I have seen trigger points respond to a truly wacky variety of inputs ... or fail to respond.

So here are three dazzlingly insightful rules of thumb to bear in mind regarding essentially any trigger point therapy system or product:

  1. It might work.
  2. It might not.
  3. So beware of anyone who claims to “know.”

What you mostly need to know about treatment methods is that anyone who claims to know how to release trigger points in most people, most of the time, is seriously overconfident! Please, do not trust any treatment claim that seems “too good to be true.” Watch out for marketing language that claims that a particular approach is highly effective. You might prefer not to give your money to a person or company that acts like God’s gift to trigger point release.

That said, let’s look more closely at the options …


How about spray and stretch therapy?

Spray and stretch therapy is a stretching and movement therapy enhanced by a chill on the skin, usually delivered by a cooling spray. This appears to have some effects on several kinds of pain, including trigger points. Its mechanism of action is probably mainly neurological.

The effectiveness of spray and stretch has yet to be confirmed by any well-designed scientific tests, and it has been a long time now. It might pass those tests if they are finally done: the technique is based on some sound, evidence-based reasoning, and it is well established that there is a pain-relief phenomenon at work here. Many professionals use the technique regularly, and it has the additional benefits of being quite safe, relatively inexpensive — it does not require a long series of appointments — and in many cases (depending on the tissues involved) patients can learn to spray and stretch themselves.

Basically, the therapist stretches you while spraying the skin with a coolant in a specific pattern. The muscle is elongated to take up the slack, and then the spray is applied before and during stretch.

An illustration of stretch & spray technique.

One of the advantages of stretch and spray therapy technique is that it does not require precise localization of the trigger point, only identification of where in the muscle the taut bands are located, to insure that those fibers are stretched. However, considerable skill is required to coordinate the course of the spray so that it covers those fibers that are being placed on maximum tension by passive stretch. Thus the technique should be applied by a skilled therapist for maximum benefit, although obviously there is some potential for patients to treat themselves this way.

How do you find a “spray and stretch” therapist? It’s not nearly as widespread as it probably should be. Even though the technique is widely regarded as the “workhorse” of trigger point therapy, and is constantly referred to in Travell & Simons texts — which every good trigger point therapist has — I have never actually met a spray and stretch practitioner in the wild (although of course the very act of publishing these words has produced a few emails from therapist-readers who do practice it). It doesn’t seem to have caught on to any great degree.


How about the Paul St. John Method of Neuromuscular Therapy?

Neurosomatic Educators Inc. is the current official source of training and certification related to the work and teachings of Paul St. John, a massage therapist who made a name for himself as a trainer in trigger point therapy and related ideas. However, the current manifestation of his certification program offers training in a bunch of stuff that Travell and Simons probably would not approve of, including “Posturology” and “Neuro-Certification” and “Somatic Certification” — a grab bag of miscellaneous ideas about physical therapy, many of which are not evidence-based in my opinion, and stray far from straightforward trigger point therapy as defined by Travell and Simons.

Therapists with one of the various St. John-inspired certifications are fairly common, and they are probably a better choice for trigger point therapy than the average bodyworker. There are several certifications, so identifying them isn’t straightforward — a reference to the name “St. John” is probably the thing to look for. See their website for more information, but unfortunately it’s not helpful for finding therapists. If you’re in Florida (Clearwater), or willing to travel, you could go see Mr. St. John himself at his clinic, the St. John-Clark Pain Treatment Centre.

However, I consider St. John-inspired therapists to be a distant second choice to any therapist who simply knows “the big red books” well. I’ve simply met too many Paul St. John trainees who had never heard of Travell & Simons, which is just terrible. I’ve been unimpressed by the St. John videos I’ve seen. I was unimpressed by the instructor at my college who was a St. John therapist. Also, I know that the method is highly preoccupied with posture and alignment, a treatment philosophy that I criticize thoroughly for its lack of scientific basis in many of my articles, as previously mentioned.

Not exactly a ringing endorsement. Still, it’s prevalent and probably better than nothing. A therapist with one of the St. John certifications may be the best bet you have available to you in your area.


How about transcutaneous electrical nerve stimulation therapy? (TENS or ENS)

TENS is routinely offered in physiotherapy and chronic pain clinics. There are even consumer TENS units on the market. TENS has a wide following of people who believe it works, without much evidence,393 while others maintain that it is ineffective. The truth is surely in the middle: the jury is simply “out.” There are many kinds of pain. TENS is probably somewhat effective for some types of pain some of the time, and not at all for other types of pain at other times, and it depends on a bunch of variables that simply haven’t been sorted out yet. A major problem, for instance, is simply that no one knows which of the many types of TENS might or might not have the desired effect under certain circumstances. I don’t think anyone really doubts that there are therapeutic effects buried amongst all the variables — but no one knows how to get those benefits reliably! Bear that in mind when your therapist recommends TENS with unqualified enthusiasm.

A 2007 analysis of scientific studies going back many years showed that TENS is an effective treatment for chronic musculoskeletal pain.394 However, the conclusions of that paper are flatly contradicted by a much more credible source, The Cochrane Collaboration, the gold-standard source for evidence-based care, which has slammed the quality of TENS research.395

Interestingly, one study of ENS specifically for treating trigger points found positive results. It was a tiny study, but promising.396 Unfortunately, the available evidence makes it perfectly clear that TENS/ENS is a bit of a crapshoot therapy — it might work, and that’s all we really know.


How about ultrasound therapy? (ESWT and “Sonic Relief™”)

Therapeutic ultrasound is an interesting technology: its effects on tissue are complex, and there are many different ways that it might aid in healing. There is a great deal of general evidence that ultrasound has effects on tissues … but a great deal less evidence that it is helpful for any particular kind of problem. Your mileage will vary. It will vary widely.

Extracorporeal Shock Wave Therapy (ESWT), or high-intensity ultrasound, is a technology that uses strong sound waves to “stimulate healing” in tissues. It can be painfully intense. Think of it as a high-falutin’ version of “regular” ultrasound. It comes in many flavours and intensities.

There is also a prominent ultrasound product for consumers available on the internet called Sonic Relief™. It’s not the same as ESWT, but we’ll discuss it as well.

ESWT has recently become quite popular in the treatment of musculoskeletal conditions. That popularity is probably premature in the sense that it is sold to patients with much greater confidence than it has yet earned scientifically. And yet ESWT is in the process of being proved effective. In fact its efficacy is increasingly evidence-based.397 Two recent, decent quality scientific experiments have shown that ESWT was good for trigger points specifically.398399 Yay! I discuss one of those a little more below.

However, even with these encouraging results, I will still not be recommending ESWT therapy to most patients, simply because there are other highly effective, cheaper, and more comfortable alternatives. This is only an option for people who are running out of options — but it is a good option for those patients.

What about Sonic Relief™ and “regular” ultrasound? This is an ultrasound machine intended for home use, manufactured and marketed by a Canadian company called Home Therapeutics and retailing for about $200 (give or take $80 over the years). Home Therapeutics publishes a Sonic Relief™ advertisement web page for virtually every musculoskeletal condition known to humankind — and generally speaking they do it more responsibly, with less hard selling and better quality information, than most companies selling health care products online. That’s a good sign, although there are also a few bad signs,400 and typical selling silliness like calling it “medical grade” ultrasound, which means nothing at all.

But … is a Sonic Relief™ machine a good idea for self-treating trigger points? Well, who knows? Nobody. Although ultrasound is generally well-studied, its effect on trigger points specifically is not. There haven’t even been enough experiments for a scientific review. What little evidence we have to work with is contradictory and weak, but leans a bit towards the positive. The sour notes are:

Three other science experiments since then have seemed a little more optimistic, while still falling short of impressing anyone:

And then there’s that good-news-bad-news paper I promised to bring up again. On the one hand, they reported bad news for regular ultrasound. But on the other …

I can’t emphasize enough that all of these experiments are small and have weaknesses, despite their cheerful conclusions. What’s a consumer to do with such findings? Such a mix of results is probably trying to tell you something: that ultrasound is either not particularly powerful, and/or “it depends” on too many things for it to be reliable. Although Majlesi et al give me some hope for ESWT ultrasound, that treatment is not yet widely available, and much more expensive in any case.

Sonic Relief is a bit pricey for a shot in the dark (though less so at the new $130 price point). Thanks to reader Michael B. for pointing out that there are now some even cheaper devices on the market, like these, in the $50–60 zone. As he put it, “like many other people, I am not too eager to experiment with a $250 device, but for around $60 I’m suddenly a whole lot more interested.” All other things being equally uncertain, price certainly does matter.


How about chiropractic joint adjustment and popping? Spinal manipulative therapy

The idea of “adjusting” the spine refers to many different manual therapies that wiggle, pop and otherwise manipulate spinal joints. Other joints may be adjusted as well. Such adjustments probably have some effect on trigger points.

The correct umbrella term for these treatments is “spinal manipulative therapy” or SMT. Expert opinions on SMT range widely, with some prominent medical scientists expressing strong concern and skepticism. Its provenance in chiropractic subluxation theory is dubious, its benefits are not major, and there are serious risks, even including paralysis and death in the case of SMT for the joints of the neck.

The topic of SMT, including its effects on trigger points, is covered exhaustively in the special supplement, Does Spinal Manipulation Work? A few more highlights are summarized here.

Despite all the controversy, there has been little high quality scientific research to determine whether or not SMT is safe and really works. Major reviews of that literature published in recent years came to “underwhelming” and generally inconclusive conclusions.407 Thus, SMT fails the “impress me” test — it can’t possibly be working any miracles. And if SMT doesn’t work all that well for neck and back pain in general, then it can’t possibly be doing much for trigger points in particular.

And yet spinal joint popping is something that people crave, and most clinicians — including me — believe that some forms of SMT can be helpful to some of their patients, some of the time.

There is no definitive evidence that spinal manipulative therapy is more effective than other forms of treatment for patients with acute or chronic low-back pain. However, manual therapists know from experience that spinal manipulation is often more effective for providing immediate short-term relief for some types of back pain.

chiropractor Sam Hom in “Can Chiropractors and Evidence-Based Manual Therapists Work Together?”408

There seems to be almost no doubt that there is something of therapeutic interest going on in SMT. Most likely joint popping, just like several other forms of manual therapy, provides a blast of novel sensory input to tissue that is feeling stuck and stagnant, both the joint and/or the muscle tissue around it. It’s like a little massage, deep in the joint, that scratches an itch that is otherwise very difficult to reach. Joint and muscle dysfunction probably reinforce each other, and SMT sometimes provides some helpful stimulation that may help to break the vicious cycle.

Sounds good, doesn’t it? However, there’s a list of reasons to curb your enthusiasm. As with stretching, it’s just as clear that these benefits — while probably real — are also dependent on many other factors and thus highly variable, generally modest, rarely lasting, have much less effect on more severe and chronic pain, and are associated with some of the significant risks of SMT,409 and mostly limited to spinal pain in any case. Granted, spinal pain is certainly a major part of most cases of myofascial pain syndrome, but trigger points can affect any region of the body, and joint adjustment has much less potential to help trigger point pain in the extremities.

For more information about how to find a chiropractor, see my article The Chiropractic Controversies, the special supplement Does Spinal Manipulation Work?, or pick up a copy of Dr. Samuel Homola’s book, Inside Chiropractic: A patient’s guide.


How about myofascial release and fascial stretching?

Many forms of myofascial release (MFR) are often touted as a particularly effective approach to treating myofascial trigger points. There are numerous flavours of this kind of therapy. What they all have in common is a fashionable focus on “fascia” — the Saran-wrap-like sheets of connective tissue that contain and permeate us. Absolutely everything in our anatomy is fractally “wrapped” in fascia, fractacally enclosing every anatomical structure, from whole muscles and large subdivisions, down to individual cells. A great many massage therapists and other manual therapists attribute great importance to the idea of “tight” fascia.

There is considerable public and even professional confusion about the terms “myofascial” and “fascial” in combination with the words “therapy” and “release.” “Myofascial release” can mean practically anything.

Patients often asked me, “What do you think of myofascial release?” But “myofascial release” is such a vague and abused term that it could refer to virtually anything I was doing to them at the moment they happened to ask. I usually replied, “You tell me! We’re doing it right now.” I’m a real wit.

The words “myofascial release” have been particularly co-opted to refer to a branded treatment modality. MFR is one of the classic “modality empires,” characterized by big promises and expensive therapy and workshops. The short story is that I have almost little good to say about it, and there is absolutely no evidence that it works: in the only half-decent effectiveness test it’s ever been subjected to, it wasn’t even as useful as a simple clench-release therapy method.410

Worse still, fascial therapists often seem reckless to me: they are so focused on trying to stretch connective tissues, that they ignore the patients’ comfort and the state of their nervous systems. This can be disastrous, causing “sensory injury.” One of my readers suffered a particularly serious incident of this kind. Her story is told in my review.

In this section, I focus on debunking the more specific claim that MFR and MFR-ish therapies are particularly good for trigger points. Basically, if a therapist tries to tell you that MFR is the only way to release trigger points, please turn your bollocks detector up to 11.

Fascial therapists will often say that trigger points are being “held in place” by fascial restriction, and that trigger points can’t “release” in this state. They are usually referring to the phenomenon of contractured trigger points, discussed in detail above, and it’s accurate insofar as there probably is such a thing as a “stuck” trigger point, and fascia is certainly involved in that equation in some way. However, fascial therapists imply that most or all trigger points suffer from adhesions and therefore require release, and this is an excessive interpretation: adhesions are probably a factor only in a minority of older and more severe trigger points.

In any case, just because a trigger point is adhered doesn’t mean it requires “fascial release.” The adhesions that probably do form in older trigger points are a consequence of the trigger point, not its cause, and it’s unknown whether or not the formation of adhesions even complicates the problem. It’s certainly possible, even likely, that a trigger point could stop actively contracting and hurting despite adhesions: like a man in handcuffs who has been straining to break them, and then stops and relaxes. The problem here is that all this is speculation, and no one really knows — including MFR therapists — and it really gets my knickers in a twist that they act as if they do know when they so clearly do not. Gr.

And then there’s the treatment problem. For the sake of argument let’s say that adhesions are a significant factor in most trigger points — a huge “if.” Is fascial stretching going to fix it? Fascia is tough stuff, essentially indestructible, and it is probably impossible to loosen it, even by pulling on it in anatomical locations where you have the leverage to exert some real force.412 But trigger points are small and awkward to manipulate: trying to “stretch” the adhesions in a trigger point with fingertips or elbows is analogous to trying to loosen a tight lug nut without a wrench. Above and beyond that, MFR therapists face all the same practical problems in treating trigger points as anyone else.

What about fascial contraction? I’ve also heard fascial therapists claim that fascia is actively “squeezing” the trigger point. For instance, a client wrote to me once concerned that his trigger points were being perpetuated by “tight fascia” and that he might need “fascial therapy.” His explanation, given to him by a fascial therapist, was: “Fascia can have a compressive force of up to 2000 lbs/ sq. inch, and therefore that compression can result in pain.” It certainly would be painful … if it were possible.


By any measure, fascial contractions are dramatically less powerful than muscular contractions. If anything, this diagram gives far too much credit to the power of fascia, which would barely register at all if depicted more accurately.

Fascia is indeed contractile — it contains a thin scattering of muscular cells — but only weakly.413 The forces generated by fascia are dwarfed by that of muscle itself, in rough proportion to the number and size of muscle cells involved. Even the largest sheets of connective tissue in the body (i.e. the thoracolumbar fascia) are able to generate only modest forces; the fascia right around and inside a trigger point is mostly microscopic, extremely fine wisps, a lot of it barely more substantial than cell membranes. Fascia is present throughout muscle, surrounding increasingly small subdivisions, but most of this is so fine and delicate that we literally cannot detect it — it’s in every single bite of steak, for instance, but we don’t notice. We only notice the larger bits of gristle, which do not wrap trigger points but much larger sections of muscle. There are simply no normal physiological circumstances under which fascia exerts or is even subjected to extreme pressures.414

So please don’t let a therapist tell you that your fascia is dysfunctional or “squeezing” your muscles and causing garden variety pain problems and trigger points and needs “releasing.” The idea that you’ve got muscles that are being aggravated by fascial pressures is disconnected from anatomical and pathological reality.

Fascial therapists cannot be doing anything special, because they are clearly no more effective at treating trigger points in general than anyone else, and arguably less so than by some other methods. What primarily holds trigger points in place — what makes them what they are — is almost certainly sarcomere activity, not fascial restriction.

Doubtless when you wrench fascia around, I’m sure that you get some “bonus” therapeutic effects — some relaxation, a little trigger point release just from miscellaneous stimulation of trigger points, etc. But you can get these benefits (and get them better) from proper trigger point therapy! There is no reason to believe that “fascial release” is a good way to treat trigger points in particular. Don’t get “fascial therapy” — just get proper trigger point therapy. Even if fascial therapy works, “regular” trigger point therapy almost certainly works much better, simply because it isn’t limiting itself to a single dubious idea about how trigger point therapy should work.


Maybe stabbing will help! Dry needling

  • Nov 8, 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.

“Dry needling” is a widely practiced but unproven and controversial method of treating suspected trigger points by puncturing or lacerating them with fine-gauge, solid needles (acupuncture needles). It has been popular since the early 2000s and is now the subject of many scientific papers and a handful of books.415 It’s called “dry” needling to distinguish it from the injection of wet stuff (medications or even just saline solution). It is a minimally invasive procedure, with some inherent risks, from wasted money to worsened pain to (!) lung puncture.

Needling is provided mostly by physical therapists, chiropractors, and a few physicians.

There’s no question that needling feels potent to the patient. Which seems like an unsurprising result of deliberately stabbing acutely sore spots (even with extremely fine needles). So there are definitely effects… but whether those effects are actually helpful, whether they work out well or badly in the end on average, is not yet scientifically clear.

We are getting there, though.

Patients have a love/hate relationship with needling. Anecdotes about the results are rarely neutral, and vary from horror stories to cure claims. The professional muscle needlers mostly only hear the good stories from their patients, and are much less aware of the bad ones — because patients are far more likely to share their complaints with people like me, and share them they do.418

Any dry needler who thinks that all their patients are satisfied has drunk way too much of their own Kool-Aid.

The good news: the most positive results of the best study

One of the more rigorous tests of dry needling was conducted by Couto in 2013.419 They reported that dry needling reduced pain more than fake needling420 over four weeks in 70 women. It wasn’t a dramatic difference, but it was a clinically significant one.421 Just barely. This is the usual damning-with-faint-praise problem that afflicts so many “positive” studies of pain treatments.

I’m also just not sure I trust these authors, because they seem really biased to me, and statistical jiggery pokery is nearly inevitable when you combine bias and complexity.422 But, as reported, it’s a great result: dry needling really did seem to help women with chronic MPS.

That’s the best, I think, but it’s not the only one.

Another notable example is Müller et al, with an interesting twist: the before/after size of the trigger points was measured with some interesting ultrasound techniques.423 I’ll bring this one up again in the acupuncture section, because it was ostensibly a study of acupuncture, but they did treat “up to two relevant ashi points,” which is basically how trigger points are labelled in the world of acupuncture. As with Couto et al, the results were definitely positive.

So that’s the good news … and just about all there is in this chapter. Remember, in the 21st Century we can always find positive trial results for anything, even some extremely silly things. A couple promising studies really don’t mean much on their own… especially in the context of a larger number of negative ones, and a generally flawed concept to begin with. The bigger picture has to be considered. And consider it we will.

Schools of thought and method

There are many sources of dry needling training, certification, and justification, and most of them have a distinctly amateurish vibe: small businesses looking to cash in on a huge trend, selling a service for top dollar. Only a few stand out:

So why lacerate trigger points anyway? Mechanisms of inaction

All modern dry needling is done with fine acupuncture needles, far smaller than the syringes Dr. Travell used. She thought acupuncture needles were too delicate!

Despite a lot of fancy talk, the rationale for dry needling boils down to this: “Let’s see if stabbing your muscles helps!” There is no clear, specific biological rationale for this method that has actually been validated — it’s all fairly thin speculation based on the barely-there biology of trigger points. For instance, a 2011 paper by Jann Dommerholt — arguably the most credible and sophisticated proponent of dry needling since the 2000s — unfortunately fails to explain anything specific about how it supposedly works.426

Surely there’s other expert speculation available? Yes, there’s a long tradition of spitballing about this. One of the earliest examples was from mighty Melzack himself, a legendary figure in pain science, the Canadian who brought us the “gate control theory of pain” in 1965. In 1981 he used it to try to explain dry needling: “Pain may be relieved by ‘closing the gate’… .”427 Distinguished as Melzack was (and still is), this is a dubious hypothesis today: counterstimulation is certainly real but probably mostly trivial. It is possible that the effect could be more robust, but that remains highly speculative.

In 2012, Chou et al opined that “the most likely mechanism of pain relief through needle stimulation is hyperstimulation analgesia,” citing Melzack.428 It’s a bit lame to even bring it up in 2012, and calling it “the most likely mechanism” is weak sauce. And even if this is actually how needling works, it’s a mechanism that isn’t exclusive to needling: any strong stimulation would do it. If you’re trying to explain the value of needling, you need something unique to needling, or you might as well just stick to safer methods.

A 2013 paper by Cagnie et al is another good representative example of the few papers dedicated to the biological reasons for needling. The authors acknowledge that “the exact mechanisms of action of direct needling in the deactivation of trigger points are not yet unraveled” (which amusingly makes it sound like the “inexact” mechanisms have been unravelled and we’re just waiting for the details to get hammered out now). They aim to explain the “potential underlying mechanisms,” so it’s clearly just more speculation, but it’s as good a summary of the possibilities as I have found … which isn’t saying much. The first third of the paper just reviews basic pain science, and the rest marches through an assortment of predictable old chestnuts of therapeutic mechanisms cloaked in technical language: boosting circulation,429 pain gating again (citing Chou et al, who was in turn just citing Melzack, who was wrong), and endogenous opioids.430 They conclude only that the effects of needling must be “highly complex and recruit central and peripheral networks with physiologic and psychological responses”… but “it’s complicated” is not even a hypothesis.

Perhaps if we go back to the origins of needling we’ll get some insight? The term “dry needling” came from Dr. Janet Travell herself. In the original big red books, she used the term to describe lancing a trigger point with a hypodermic needle, but not injecting anything. (Ouch!) She did not go into any detail, but her method is distinct from modern dry needling, which is much more directly inspired by acupuncture.431 Although Travell never explained her rationale for dry needling, she did explain why she never used an acupuncture needle: she thought they were too delicate!432

Her co-author Dr. David Simons did offer a (clearly speculative) rationale, years later: “… because it mechanically disrupts the integrity of dysfunctional endplates.433 Translation: needling breaks the muscle. And this is another disappointing “highlight” of needling theory, the best that this well-known text about muscle pain has to say on the subject.

And it’s highly problematic. There’s no evidence of it.434 The motor endplate is the connection between a nerve ending and a muscle fibre, the neuromuscular junction, analogous to synapses in the brain. They tend to be larger than neuron-to-neuron synapses — but we’re still talking about a super tiny structure here, measured in tens of hundredths of millimetres, roughly an order of magnitude smaller than an acupuncture needle. To say that it requires “precise localization” to hit one of those — as Simons does — is an understatement! It’s like trying to stab a raisin with a spear. If the raisin was under a metre of Jello. Covered by a blanket (of skin).435

Or with a harpoon, if you’re doing it like Janet did it.

Assuming you want to do such a thing. “Hey guys, look at me—I’m trying to destroy my neuromuscular junctions!” What could possibly go wrong?

Presumably the goal isn’t to destroy any particular endplate, but a bunch of them in a specific area, but in that case why bother with a fine needle? Which is still going to miss many of them. You can’t really have it both ways: the fantasy of precision is directly at odds with the goal of wrecking endplates. If you go for precision, you’re simply going to fail. If you want to lacerate endplates, a fine gauge needle is obviously a poor choice. But it’s not clear that a larger one would do much better. Even if the nature of trigger points was settled — ha! — trying to fix them by lacerating them seems like a suspiciously bad idea, as likely to aggravate any vicious cycle as disrupt it.

Four motor endplates, at the ends of branching motor neurons, attaching to muscle fibers. Each one is about 3µm (.03mm) wide, about a tenth the diameter of an acupuncture needle. Trying to hit one of these with an acupuncture needle would be like trying to use a spear to stab a raisin.

Like religious beliefs, these theories about how needling works can’t all be right. The fact that Dr. Travell disapproved of acupuncture needles is particularly fascinating and irksome — she is virtually worshipped by most practitioners, and her book is still the trigger point bible, and yet no one using acupuncture needles today has offered an explanation of why they are ignoring her opinion on this. If she was wrong, then it casts doubt on the Mother of Trigger Point Therapy — the kind of doubt that is absent from nearly all references to her work. If she was right about this, then almost all modern dry needlers have been barking up the wrong tree, teaching and selling a technique that the great Dr. Travell thought was silly!

Or perhaps they are all wrong. Because how dry needling might work is all a moot point if it doesn’t work. So does it work?

Does dry needling actually reduce the soreness of trigger points?

John Ware is an articulate and well-informed PT of my acquaintance, and he is not a fan of dry needling:

Tender spots certainly exist, but it seems the only purpose for insisting that they exist in a muscle is to justify jabbing, poking, squeezing or otherwise assaulting them with various implements, including needles.

John Ware, PT, commenting on “The trigger point strikes … out!

John is not impressed by needling, and for good reason. Predictably in the context of its dubious origins and unclear rationale, much evidence of efficacy for dry-needling is either overtly negative or is technically positive but fails to impress. For instance, directly contradicting Couto et al (a positive study described above), another good quality and fairly large 2017 test of needling for shoulder pain found no effect at all: everyone did equally well, with or without needles in their shoulders.436 So, shocker, we have contradictory results to try to make sense of. We all saw that coming, right?

There was very little direct evidence about dry needling at all for a long time, and the indirect, half-relevant evidence from acupuncture research was quite discouraging.437 But even the direct evidence, as it has emerged, has been discouragingly weak. A 2009 review of seven shabby little studies was clearly negative.438 A 2013 review was probably the first review covering a few more substantial trials. Although it had a rather sunny bottom line, it’s not as nearly good as it looks from reading the abstract. Lorimer Moseley, Neil O’Connell, and Daniel Harvie reviewed that review (Kietrys et al) of the evidence for Body In Mind.439 And did it make the grade for these experts? Here’s how scientists say “booooo”:

Dry needling is not convincingly superior to sham/control conditions and possibly worse than comparative interventions …

That was truly expert commentary—those guys are heavyweights. What do the authors of the paper think? They “recommend (Grade A) dry needling, compared to sham or placebo, for decreasing pain (immediately after treatment and at 4 weeks).” But digging into the actual results, it doesn’t take me long to start rolling my eyes and sympathizing with the critics: there’s just not much there. I don’t know why anyone would “recommend” dry needling based on that data.

Same with Cagnie et al: positive conclusion, disappointing data. Mildly encouraging at best, seriously misleading at worst.440

Liu et al? Same!441 And Liu et al. again in early 2018, this time focusing on back pain?442 Still damned with faint praise.

A 2014 study is worth highlighting because the research group leader was César Fernández-de-Las-Peñas of Myopain Seminars, and one of the most prolific trigger point researchers — both extremely knowledgeable and also probably quite biased.443 And yet this study was pretty clearly a loss for needling.444

It was a biggish short-term study of dry needling for trigger points, comparing it to massage in 94 neck pain patients. Pain, disability, range of motion, and sensitivity to pressure were all measured before and then up to two weeks after treatment. There was no difference on the first three of the four outcomes measured, and only a small one on the fourth and least important measure (pressure sensitivity on the tip of the C7 vertebrae, which is an odd choice). In my opinion, that one difference is not meaningful.

Those results strongly suggests that there is no advantage at all to needling over massage for trigger points: they are either equally effective for neck pain, or equally ineffective. If massage and needling both produce similar results, there’s definitely no justification for the greater risks of needling, especially in the neck.

The most negative result from the best study (twice)

Way back at the beginning of the chapter I highlighted “the most positive results of the best study.” I will conclude with the most negative results of the best study: a good design, with enough statistical power to be persuasive. Stieven et al compared standard guideline-based physio to a combination of that with dry needling in more than a hundred patients, with follow-up at 1, 3, and 6 months.445 Their sad conclusion:

Adding dry needling to guideline-based physical therapy resulted in a small, not clinically meaningful, reduction in average neck pain intensity at one-month post-randomization, but not at 3 and 6 months in participants with chronic neck pain. Clinicians should not consider dry needling in addition to physical therapy as an approach to managing chronic neck pain.

I put much more stock in the most negative good study I can find than the most positive good study I can find. Even good studies can find “positive” results that can’t be replicated by other good studies, happens all the time. But the reverse is almost unheard of: when good studies can’t find an effect, it’s almost certainly because it isn’t there to find.

One last twist: this most-negative-best-quality study? It is not “just one study”! It has a nearly identical twin: Gattie et al446 also studied needling for neck pain, also had a decent sample size and follow-up… and they used a better control group, with sham needling.447 Nothing’s perfect, but these are both good studies, and Gattie et al came to an amazingly similar conclusion: “Dry needling should not be part of a first-line approach to managing neck pain.” Is there an echo in here?

And so what the evidence so far says seems quite clear to me (and experts like Moseley, O’Connell, and Harvie): it probably doesn’t work very well! If it did, the evidence would be much better. With the usual disclaimers that it might work for certain types of patients, or done in a more skilful or specific way (possibilities that we can never ignore but will probably be murky indefinitely).

But for the average pain client, most of the time, it almost certainly doesn’t work — and to the extent that it seems to, it’s because it’s obviously a champ at generating placebo effects. “Dramatic” treatments always are. It’s extremely likely that the most potent mechanism involved here is the only one that needling proponents never mention: DNIC, or “descending noxious inhibitory control,” which is temporarily treating pain by “distracting” the nervous system with a new kind of discomfort.448 Squirrel!

Needling risks and harms

Needling is “invasive” — it breaks the skin — and therefore it has risks. All needles are what we’d call “minimally invasive” compared to surgery, especially hair-thin acupuncture needles, but it’s still invasive. Bacteria do not need a big hole in the skin to commute from the outside world to inside you.

Treatment and safety standards for dry needling are basically nonexistent: this is a virtually unregulated practice, with no clearly established best practices at all. Practitioners are free to do it pretty much any way that they want. Including without “standard precautions” (the formal term for infection prevention practices in medical settings).

Severe adverse events of needling are probably quite rare, but no one has ever actually studied it well enough to know. The only survey I know of is badly flawed.449 I am personally aware of two cases of punctured lungs (pneumothorax, haemothorax) here in Vancouver in the last few years, and of course any treatment that breaks the skin can lead to infection. This is well-known risk of acupuncture, “which may not be so uncommon.”450 It is hard to justify any risk unless the confidence in the treatment is reasonably high.

How about minor risks? According to Brady et al, about 1% of needling patients get worse instead of better, and I suspect the real number is much higher.451 Bruising, bleeding, and pain during and after treatment are all common (2-8% at a bare minimum). There are a few rarer minor problems as well: headache, nausea, shaking, itching, and numbness.

Needling trigger points is a notoriously painful treatment, often more intense than the deepest massage — imagine a massage therapist with needles for fingers! In my experience, needling is less of a problem for people who are already in a lot of pain and have “nothing to lose,” but for most others the intensity of the cure may well be worse than the disease. Vancouver is a needling hotspot, so I’ve met many patients who’ve experienced it, and many of those claimed to have been harmed.

For all of the above reasons, I have long felt that the safety concerns outweigh the uncertain, minor, and controversial benefits. Life is risky, and medicine is risky, and that’s fine if the potential reward is clear — but the rewards are not clear here.

Dry needling practitioners have paid a lot for their certification and — here’s a shocker — they tend to promote it with an enthusiasm that cannot be supported by the evidence. It also distorts their clinical judgement: they’ve got a big ol’ expensive hammer, and so all they see is nails, and want to treat every pain problem like it needs a needle.

I do not think dry needling is a good option: it is plausible and interesting theoretically, but also has risks, costs a lot, and hurts like hell. Few p