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Trigger point therapy & soft tissue release for sports
and massage therapists
05/03/16 2
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Who are we?
Katie’s LinkedIn: www.linkedin.com/katieemmett
Twitter: @KatiePhysiocouk
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Website: www.physio.co.uk
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Aims of today
Learn the theory of a trigger point
Learn the theory of trigger point therapy
Practice the trigger point technique to muscle groups
Use other soft tissue release techniques along side TP release
therapy?
• 1940s- Janet Travell developed trigger point injection therapy and termed the
“tender areas” described by Dr Hans “Trigger points”.
• Travell's therapy called for the injection of saline (a salt solution) and procaine
(also known as Novocaine, an anesthetic) into the trigger point.
• Travell mapped what she termed the body's trigger points and the manner in
which pain radiates to the rest of the body.
• Travell's work came to national attention when she treated President John F.
Kennedy for his back pain.
• Travell co-authored several books with David Simons which are considered
the definitive reference for trigger point therapy.
• Travell & Simons' Myofascial Pain and Dysfunction: Upper half of body
• Travell & Simons' Myofascial Pain and Dysfunction: The Trigger Point Manual
• Myofascial Pain and Dysfunction: The Trigger Point Manual, Volume 2
• Pain is felt by the individual when they are active, and are usually
what people refer to when they talk about trigger points
• These trigger points are not painful, and do not elicit a referred pain
pathway.
• It has been suggested that these points are more common in those who
live a sedentary lifestyle (Starlanyl & Copeland 2001)
• These points are “potential” trigger points and may reactivate if the
central or primary trigger point is (re)stimulated
•Dull ache
•Deep
•Pressing pain
•“Stabbing”
•Burning
•Referred pain
•Numbness
•Fatigue
•Weakness
A loss of:
•Flexibility
•Range of movement
•Muscular power and strength
https://www.youtube.com/watch?v=sltGyJvbvWw
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The Trigger Point
Theories
“Integrated trigger point hypothesis”
Muscle weakness
• Record change
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Outcome measure:
Range of movement
• Pre and post measurements
• Goniometer or visual
• Standardise to produce reliable results
• Review each session
• Used to distinguish areas to treat and
techniques types
• Valuable in the success of treatment
Temperature
Tissue may be hot or cold, indicating inflammation or ischaemia
Texture
Swelling (acute-hard, chronic – “boggy”, congested)
healthy tissues should have an even texture
Adhesions feel like tissues are “stuck” and less mobile
“audible crunching”
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Outcome measure:
Palpation
Tenderness
Pain can be indicated through response/ use vas scores
Structures that are too painful to palpate
Tone
Tissues may be hypertonic or hypotonic
Use to compare
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Practical:
Trigger point
workshop:
Symptoms
•Find the most painful TP using patient response and Numeric Rating Scale or (VAS)
•Treat the highest rated point and radiate out from this point
•Once the points are found – a good amount of pressure is applied (perform with
precaution - keep communication with patient)
•Initial pain is stimulated and you hold the pressure until the pain has eased completely or
in some cases reduced slightly
•Reapply pressure onto the same point until the pain eases off quicker or it isn’t felt
anymore
• This can depend on the severity of pain/ how deep or superficial the TP is –
subjective and variable to each patient
• Reduction in headaches
• Improved flexibility
• Improved circulation
Hemorrhage Malignancy
Advice
• Each SCM group has two divisions that originate off the mastoid process behind the ear.
The sternal division runs diagonally downward to attach to the sternum, while the clavicular
division attaches right behind it on the medial clavicle.
• Acting unilaterally, contraction of the SCM muscle turns the head towards the opposite
side, while bilateral contraction flexes the neck and head forward.
• The most important function of the SCM is to control and monitor the head’s position in
space. Proprioceptive feedback from the SCM is essential to being able to maintain one’s
balance, and is also important for interpreting visual information.
• The sternal division’s referred pain is felt deep in the eye socket (behind the eye),
above the eye, in the cheek region, around the TMJ, in the upper chest, in the back
of the head, and on the top of the head.
• The clavicular division’s referred pain is felt in the forehead, deep in the ear,
behind the ear, and in the molar teeth on the same side.
Related symptoms
• Sore Neck
• Tension Headaches
• Migraine
• Dizziness
An example, the simple act of flexing the head to the right requires:
•Contraction of the lower trapezius on the right side to fix the right shoulder blade in
place.
•Contraction of the right upper trapezius to pull the neck and head to the right.
•Relaxation of the left lower trapezius to allow the left shoulder blade to rise.
•Relaxation of the left upper trapezius to allow the neck and head to move to the right.
This type of complexity makes it easy for trigger point activity to spread quickly
through the muscle group as a whole.
• The mental and emotional stress of modern day life often takes physical form as trigger
points in the lower and upper trapezius muscles.
• The lower trapezius trigger point is the most sensitive to psychological and projects
pain and tenderness upward into the neck and shoulder region.
• The anterior trigger point refers pain to the side of the neck, jaw, and face, but it is
notorious for producing a throbbing headache in the temple region. This headache
pain may also be described as “behind the eye.”
• Middle trapezius trigger point, which produces a localised burning-type pain along the
spine. It will often recruit the rhomboid trigger points as they share a similar intra-
scapular pain pattern.
• Location: The rhomboid muscle group is found between the spine and the scapula
in the mid- back region. It lies deep to the Trapezius muscle and is composed of
the rhomboid major and rhomboid minor muscles.
• Structure: The rhomboid minor is smaller than and lies above (superior to) the
rhomboid major. Both muscles originate along the thoracic spine with their fibers
running diagonally downward and outward to attach along the inside border of the
scapula.
• Function: In everyday life, the rhomboid muscles function to position the scapula
during various movements of the shoulder and arm.
•The rhomboid minor originates on the spinous processes of C7 and T1 and attaches to
the medial border of the scapula near the root of scapular spine.
•The rhomboid major originates from the spinous processes of T2 to T5 and attaches
along the lower half of the scapular border.
It should be noted that all three of the rhomboid trigger points lie beneath the trapezius muscle and
may be difficult to palpate if there is tension or trigger point activity in the trapezius.
• If you don’t, you will never be able to accurately locate the rhomboid
trigger points by palpation. Even with a relaxed trapezius muscles, these
trigger points will feel rather deep to your touch (even though they really
aren’t that deep)
Positions:
• Side-lying position to allow more forward movement of their shoulder
• Prone to allow more pressure to be applied
This muscle group has three subsections that each have a distinct fiber direction:
• The Iliocostal fibers (shown in the following picture as blue) attach on the Iliac Crest
and run vertically upward to attach to the 12th rib.
• The iliolumbar fibers (shown in the following picture as green) attach on the Iliac Crest
and run diagonally upward and medially to attach to the transverse processes of the
lumbar vertebrae (L1 > L4)
• The lumbocostal fibers (shown in the following picture as red) attach on the lumbar
vertebrae and run diagnonally upward and laterally to attach to the twelfth (lowest) rib
• If one muscle develops trigger point activity, the muscle on the other side will
become overloaded and develop trigger points as well.
• From a clinical perspective, you should always address the trigger points in both
the left and right QL muscles, even if the pain is limited only to one side.
The distribution of the referred pain from each TP is:
• Prone position
• Extended side-lying position
Function:
• Its function is primarily to control movement of the leg during the stance phase of
walking.
• It also works to keep the pelvis level when the opposite leg is raised off the ground
during walking (assisting the gluteus medius and gluteus minimus muscles).
•It may also help to stabilise the knee joint during weight bearing activity.
•Two functionally distinct sections, the anterior and posterior
fibers.
•The anterior fibers become tendinous as they run down the
outside of the thigh and attach to the connective tissue
encapsulating the knee joint.
•The posterior fibers join the iliotibial tract (a central thickening of
the large fascial sheath covering the outside thigh) and attach to
the lateral tubercle of the tibia leg bone.
• Pain and/or soreness in the hip joint (greater trochanter) and down the outside
thigh during movement of the hip.
• Pain prevents them from walking quickly.
• Unable to sit in a deep (or low) chair or flex their hip more than 90°.
• Unable to lie on the affected hip during sleep and unable to lie on the unaffected
side during sleep without a pillow between their knees.
• Adduction of the thigh at the hip is limited to 15° or less.
• Swinging the leg on the affected side up and to the side (hip abduction) may be
painful.
• The Vastus Lateralis
• The Rectus Femoris
• The Vastus Medialis
• The Vastus Intermedius
• They refer pain all along the outside of the thigh and knee, from the pelvic crest
down to the lower leg region just below the knee.
• The pain may also be experienced as going “through the knee” and into the back of
the knee, especially if it occurs in children.
The semitendinosus
•Medial aspect of the posterior thigh
•Originates on the ischial tuberosity of the pelvis and runs down the leg to attach below
the medial condyle on the tibia.
•The belly of this muscle is found in the top portion of the posterior thigh.
The semimembranosus
•Also lies on the medial aspect of the posterior thigh
•It attaches to the ischial tuberosity of the pelvis and runs deep to the other hamstring
muscles to attach to the medial condyle of the tibia just below the knee joint capsule.
• It has two heads that lie on the lateral aspect of the posterior thigh; the long
head and the short head.
• The medial cluster can
contain up to 5 trigger points
that are located about mid-
thigh, along the inside of the
leg.
• The lateral cluster can
contain up to 4 trigger points
that are located about mid-
thigh along the outside aspect
of the leg.
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Hamstring Pain
• The medial cluster trigger point(s) refer pain strongly upward to the gluteal
fold/upper posterior thigh region and down the back of the thigh to the medial calf
region.
• Posterior thigh or posterior knee pain, worse when walking, often causes a limp.
• Pain in buttocks, back of the thigh and/or knee while sitting
• Leg pain that disturbs sleep
• Quadriceps femoris trigger point symptoms due to the prominent antagonistic
relationship between these muscle groups.
+ Active Release Technique
• Tensile force, works as a mechanical pump
• Increases fluid flow encourages venous and lymphatic return
• Increases tissue mobility
• Dilation of capillaries
• Can increase or decrease tone depending upon speed
• A group of techniques that are applied with pressure and
are deep and compress the underlying muscles
• Movements should be slow and repetitive with pressure in
order to loosen the muscles and increase blood flow to the
area
• Promotes relaxation
• Increases fluid flow
• Increases mobility of fibrous tissue
• Decreases tone
• It takes up to two days post-massage to experience full effects.
• Essential to use other techniques to restore good functioning
and reduce tension.
• need to stretch the collagen fibres that have been “knotted” to
allow them to regain their full length.
•Static stretches are usually held for at least 30 pain free seconds.
•Research suggests static stretches should be repeated from 2 to 4 times.
As further repetitions do not promote any further muscle elongation
(Bandy, 1997).
Fernandez-de-las-penas, 2006
•Aim: To highlight the presence of trigger points in subjects complaining of
mechanical neck pain within the upper trapezius, sternocleidomastoid, levator
scapulae and suboccipital muscles.
•Results: the mean number of TrPs present on each neck pain patient was 4.3
(SD: 0.9), of which 2.5 (SD: 1.3) were latent and 1.8 (SD: 0.8) were active TrPs. All
the examined muscles evoked referred pain patterns contributing to patients'
symptoms. Active TrPs were more frequent in patients presenting with mechanical
neck pain than in healthy subjects.
•Link: http://www.manualtherapyjournal.com/article/S1356-689X(06)00031-
2/fulltext?refuid=S1479-2354(07)00108-3&refissn=1479-2354
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Effectiveness of Myofascial Trigger Point Manual Therapy Combined
With a Self-Stretching Protocol for the Management of Plantar Heel Pain:
A Randomized Controlled Trial
•Method: 60 patients with plantar heel pain were divided into 2 groups a)self-stretching b) self-
stretching and trigger point therapy.
– Physical function and bodily pains assessed through a quality of life questionnaire.
– pressure pain thresholds were assessed over affected gastroc, soleus muscles and over the
calcaneus using a mechanical pressure algometer.
•Results: trigger point therapy and self-stretching is superior to stretching alone in the treatment of
patients with plantar heel pain.
•Link: http://www.jospt.org/doi/full/10.2519/jospt.2011.3504
Li et al, (2007)
•Aim: To compare the effects of trigger pointing and transcutaneous electrical nerve
stimulation (TENS) on patients with cervicogenic headache.
•Results: Trigger pointing was superior to TENS in headache frequency, lasting time and
ROM scores. Response rate of trigger pointing treatment was 94.5%, significantly higher
than 64.5% of TENS treatment.
•Link: http://europepmc.org/abstract/med/17631795
•Results: For the primary outcome measure of pain reduction the odds of a patient
improving with activator trigger point therapy was 7 times higher than a patient treated with
myofascial band therapy or sham ultrasound.
•Link: http://www.sciencedirect.com/science/article/pii/S1479235407001083
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Cervicogenic headache caused by myofascial trigger points in the
sternocleidomastoid: a case report
Case report:
•45 year old male patient with 25 year history of chronic headaches and neck pain.
•Patient had seen many medical specialists and had received multiple facet
blocks, radiofrequency ablation, selective C2 nerve blocks, occipital nerve blocks,
multiple pharmacological regimes and behavioural therapy. All producing no
change in symptoms.
•Patient was referred back to physical therapy to assess musculoskeletal
contributions to head pain.
•Patient reports 5/5 pain scale, had a slumped sitting posture, restricted right
cervical rotation, extension and muscular tightness in right pectoral muscles and
active trigger points in sternocleidomastoid muscle which on palpation reproduced
the patients pain.
•Patient given treatment including kinesiology taping, trigger point therapy and
postural training.
•After 4 weeks he reported pain reduction of 70%.
•6 months after being discharged from 16 sessions he reported being pain free
approximately half of the time with only mild discomfort the rest.
•Link: https://deepblue.lib.umich.edu/bitstream/handle/2027.42/74754/j.1468-
2982.2007?sequence=1
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Supporting
Evidence:
Other STR techniques
•Method: 64 patients with LBP were divided to two groups A) lumber traction and
deep tissue massage or B) lumber traction who both received treatment twice a
week for 3 weeks.
•Link: http://www.sciencedirect.com/science/article/pii/S0254627213600667
•Link:
http://www.sciencedirect.com/science/article/pii/S1360859212002434
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Case Studies
SH- final year art student with a sudden increase in workload as final project is
due in 2/12. Carry heavy art portfolio to and from university. Attends a LBP class
at the gym 1 x a month.
SH- Started going to the gym 1/12 ago after a 5 year break. Doesn’t do any
stretching because he doesn’t know how to. Works on the 8 th floor of a
office building.
DH- analgesics
DH-nil to note
• Reduction in headaches
• Improved flexibility
• Improved circulation
The semimembranosus
•Also lies on the medial aspect of the posterior thigh
•It attaches to the ischial tuberosity of the pelvis and runs deep to the other hamstring muscles to
attach to the medial condyle of the tibia just below the knee joint capsule.
• The long head of the biceps femoris attaches to the ischial tuberosity and runs diagonally
downward and laterally to attach to the head of the fibula bone.
• The short head of the biceps femoris attaches along the linea aspera on the shaft of femur
bone and runs diagonally outward to join the tendon of the long head as it attaches to the head
of the fibula.
Hemorrhage Malignancy
• The clavicular division’s referred pain is felt in the forehead, deep in the ear,
behind the ear, and in the molar teeth on the same side.
Related symptoms
• Sore Neck
• Tension Headaches
• Migraine
• Dizziness