Trigger Point Therapy with Neuromuscular Massage

Pain is perhaps the most frequent presenting symptom in medical practice in the modern
industralized world. Muscular pain forms a major element of that category of symptoms.
One common form of muscular pain which is growing in awareness and attention is that of myofascial trigger points (TrPs). TrPs can be defined as hyperirritable spots in skeletal muscle that are associated with a hypersensitive palpable nodule in a taut band. TrPs are a very common and painful part of nearly everyone's life at one time or another and constitute a major source of musculoskeletal pain and dysfunction. They affect normal range of motion and flexibility of joints while also creating weakness in muscle. Fortunately effective treatments exist which help heal and alleviate the effects of TrPs. Most effective treatment of TrPs may include massage and manual therapy techniques from a skilled therapist, cold spray and stretch, as well as injection techniques. Additional perpetuating factors such as diet, stress, allergies, and postural imbalances need to be addressed to prevent reoccurance of TrP's.

The term "trigger point" was coined by Dr. Janet Travell in 1942 to describe a clinical finding with four primary characteristics. These include pain related to a discrete, irritable point within skeletal muscle or fascia, not caused by acute local trauma, inflammation, degeneration, neoplasm or infection. Secondly, the painful point can be felt as a tumor or band in the muscle, and a twitch response can be elicited upon stimulation of the trigger point. Third, palpation of the trigger point reproduces the patient's complaint of pain, and the pain radiates in a distribution typical of the specific muscle harboring the trigger point. Lastly, the pain is unable to be explained by findings on neurological examination.

The most important and significant first documentation of TrP's and their referral patterns was by Janet G. Travell and David G.Simons. Their classic books 'Myofascial Pain and Dysfuction: The Trigger Point Manual; Vol 1 (the upper extremity) andVol. 2 (the lower extremity), initial publication  in 1983, second edition in 1999, are the most comprehensive and widely accepted books on the topic of trigger points. Prior to this significant publication the study of muscular pain syndromes and areas of tenderness and zones of induration in muscles had been studied in medicine for many years, with terms and diagnoses such as muscular rheumatism, non-articular
rheumatism, fibrositis, etc often having been used to describe what is nowtypically referred to as  trigger points.

While the exact physiological mechanism of TrP's is not fully understood, Travell and Simons have presented a model that most fully represents the understanding as to the etiology of trigger points. Travell believed a taut band to be a contracture of muscle fibers that were damaged in the initial trauma to the muscle. Muscle contraction is typically controlled by the rapid release and reabsorption of calcium by the sarcoplasmic reticulum of individual muscle fibers. The energy for contraction of sarcomeres, the contractile units of muscle fibers, is provided by Adenosine triphosphate (ATP). The combinationof calcium and ATP cause the sarcomeres to shorten. Normally as calcium is reabsorbed, contraction ends. However a damaged sarcoplasmic reticulum would permit calcium to spill onto the sarcomeres. This sets up a uncontrolled, sustained contraction of the affected sarcomeres. As the sarcomeres shorten, they begin to bunch and a contracture knot forms. This knot is the 'nodule' or palpable characteristic of the trigger point.


Trigger points can be classified into several types depending upon their symptoms and location. Two main types of trigger points are active and latent TrP's. An active trigger point is painful at rest and with movement of the muscle containing it. The TrP in the taut band prevents the muscle from fully lengthening and reduces its strength. Ischemia, or lack of blood flow producing lowered oxygen supply, occurs in the tissue local to the TrP. When compressed, the TrP refers pain in a pattern that is typically specific and predictable for the particular muscle.

A latent trigger point produces pain only when it is palpated. These TrP's can influence muscle quality producing lack of flexibility and muscle lengthening along with pain. Latent TrP's are more common than active TrP's and can potentially persist for years after the initial injury. They can be reverted to an active state by such means as overuse, overstretching, and referred pain from active TrPs.

Trigger points of recent origin are often easier to treat than trigger points of long standing
duration. In cases of chronic pain, most patients are more aware of general pain than specific pain. Since trigger points of recent origin are easier to locate, it normally takes less time to identify all points and apply treatment.

The diagnosis of Trp's is primarily performed by examining signs, symptoms, pain patterns and manual palpation. Usually there is a taut band in muscles containing trigger points, and a hard nodule can be felt. Often a twitch response can be felt in the muscle by running your finger perpendicular to the muscle's direction; this twitch response often activates the "all or nothing" response in a muscle that causes it to contract. Pressing on an affected muscle can often refer pain. Clusters of trigger points are not uncommon in some of the larger muscles, such as the gluteus group (gluteus maximus, gluteus medius, and gluteus minimus). Often there is a heat differential in the local area of a trigger point, and many practitioners can sense that. A healthy muscle does not contain TrP's.

The most common and effective treatment of TrP's consists of massage and manual therapies, cold spray and stretch, and various injections. Many methods and modalities of massage and manual therapy are available and effective in the treatment of TrPs. Ischemic compression and pressure is one of the primary methods of massage therapy utilized. Finger, thumb, and elbow pressure, depending upon the skill level of the therapist, are slowly applied to the TrP. Pressure is maintained at the client's pain tolerance level. Appropriate pressure is applied slowly and maintained until the trigger point reduces and subsides. This make take between 20 seconds to 1 minute, occassionally longer. Pain will diminish as the TrP softens and melts. Proper communication and feedback between therapist and client is necessary during this process

As TrP's are identified and deactivated, the structures affected need to be elongated along their natural range of motion and length. In the case of muscles, which is where most treatment occurs, this involves stretching the muscle using combinations of passive and active technique. Active isolated stretching (AIS), muscle energy techniques (MET), and proprioceptive neuromuscular facilitation (PNF) are several such methods that are effective. Fascia surrounding muscles should also be treated, possibly with myofascial release, to elongate and resolve strain patterns. Otherwise muscles may simply be returned to positions where trigger points are likely to re-develop. The results of manual therapy are related to the skill level of the therapist. If trigger points are pressed too short a time, they may activate or remain active; if pressed too long or hard, they may be aggravated.


Cold spray and stretch involves applying cold spray to the length of the muscle followed by stretching. It is important that the spray be applied before or concurrently with the muscle being stretched, not after. The effectiveness of the spray for assisting the stretch to achieve pain-free range of motion and release of TrP's depends upon the coolant spray's suppression of pain and irritation from the TrP's.


Injections provide more immediate relief and can be effective when other methods fail and for extremely painful areas of muscle. Various injections can be used including saline, local anesthetics such as procaine or lidocaine, or steroids. Use of steroids may cause tissue damage. Usually, a brief course of treatment will result in sustained relief, although there is debate over its effectiveness. Injections are given in a doctor's office and usually take just a few minutes. Several sites may be injected in one visit. If a patient has an allergy to a certain medication, a dry-needle technique (involving no medications) can be used. In most cases stretching exercises and physical therapy are performed after injections.

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