There exists as a ubiquitous part of the human condition a vicious cycle of myofascial pain and compensation that is self-perpetuating and inescapable, and quite relevant to the job of a fitness professional. Welcome to Trigger Points 101.
Myofascial pain is rough. Those familiar with it will use such terms as “sharp, dull, achy, tight, tender, throbbing, pinching, sore,” all of which boil down to types of pain. But to move past basic descriptors and actually define pain, we’d want to turn to the myofascial expert, Thomas Myers, who rightfully argues, “Pain is simply a sensation accompanied by the motor-intention to withdraw.”
I think we all know this intuitively, and so does our body…which is where trigger points come in. When parts of our myofascial system are beat up, unconsciously we do everything we can to avoid those areas – poking, pressing, or even basic movement might cause that pain to resurface, and compensation patterns begin to develop to work around these painful spots. A perfect example is someone with a limp. They are usually displyaing a behavior called antalgia – leaning away from their pain to avoid that exact pain, while inadvertently creating a whole host of other neuromusculoskeletal issues. Think of it as the body choosing the path of least resistance in order to function with less pain.
History of Trigger Points
To understand trigger points (TPs or TrPs) better, we’ll turn to the reigning TP gods, Travell and Simmons, whose work is known the world over and represents the gold standard for TP care: “Trigger points are a focus of hyperirritability in a tissue that, when compressed, is locally tender and, if sufficiently hypersensitive, gives rise to referred pain and tenderness, and sometimes to referred autonomic phenomena and distortion of proprioception.” – Myofascial Pain and Dysfunction, The Trigger Point Manual.
Fun facts: Dr. Janet Travell was first female Personal Physician to the President of the United States, and worked under the administrations of John F. Kennedy and Lyndon B Johnson. Travell, who was already a successful consulting physician, instructor, and research fellow, was spurred to further success after she received a referral from JFK’s orthopedic surgeon, who requested complementary care for JFK’s excruciating back pain.
More fun facts: JFK commanded Navy Patrol Torpedo boats in World War II. One of his ships was ambushed and split in half by an enemy destroyer, leaving him towing an injured crew member and swimming 4 miles with 10 other crew to the nearest island, all surviving 15 hours in the water, carving a message on a coconut husk and handing it off to a local islander which took it to an Australian spy, leading to their rescue 6 days later. True story. Next time you think your TP pain is bad, think of JFK.
Some other good definitions of trigger points include the following:
1. Localized hypercontractions of overstimulated sarcomeres, which sensitize pain sensors (nociceptors) locally and in other predictable areas around the body.
2. Exquisitely tender spots in discrete taut bands of hardened muscle that produce local and referred pain, among other symptoms.
Trigger Point Etiology
TP’s may sound scary, but they’re not too bad when we understand how they happen in the first place.
- Add direct trauma OR overuse with sustained repetitive contraction to impair Aerobic Metabolism
- Promote Anaerobic Metabolism to cause ATP Depletion and Lactic Acid Build Up in muscle Cells
Done! You did it. The rest is all hands-off:
- ATP depletion leads to accumulation of Calcium ions without the ability to pump them out, causing muscle fatigue
- Lactic Acidosis lowers pH balance of the muscle cells
- Lower pH leads to involuntary sustained muscle cell contraction
- Lower pH also leads to excitation of nociceptors, causing pain and increasing sensitivity to pain
- When enough muscle cells and fibers and fascicles are affected, you have your very own trigger point!
So essentially low level sustained muscle contraction (or other damage) can cause ischemia (limited blood flow), hypoxia (limited oxygen), and the resulting ATP deficiency (from anaerobic glycolysis) leads to increased acidity, Calcium ion accumulation, and contracture. Then the cycle begins….the contracted portions limit bloodflow and oxygenation further, causing an intramuscular perfusion decrease, and leading to more peripheral sensitization (increased reaction to pain). The pain causes further contraction….causing further pain….voilá. Compensation and trigger points abound!
Facing TPs in Fitness
Ultimately, the more we know, the more we can prepare. Hopefully this info has armed you with enough knowledge to recognize trigger points in your own and your clients’ bodies. If we know that motor neurons cause ACh release, causing sodium/potassium pumps to create action potential in our muscles, stimulating calcium release for contraction…but we damage our body’s ability to uptake and re-release those Calcium Ions, we just stay in a contracted state – with our little Actins and Myosins just remaining stuck together. Also, if we allow Anaerobic Glycolysis to go on for too long, the Acidic environment can go so far as to increase pain sensitivity and damage cells by denaturing proteins.
When a trigger point gets really bad (larger clusters of affected cells), it will trigger referred pain in other areas of the body – a good example is pressing on the traps and feeling a headache. This is the “autonomic phenomena” that Travell and Simmons were talking about. It’s a little neuroscience-y but essentially these pathways cause pain in various somatic structures which are innervated by similar segmental levels of the spinal cord (dermatomes, peripheral nerves, visceral afferents, etc.).
We’re also more likely to have trigger points in our fast-twitch fibers (our proverbial White Meat versus Dark Meat) because they rely less on oxidative glycolysis. Remember: Motor units are recruited in order of increasing size. Slow oxidative > Fast Oxidative > Fast Glycolytic
Our ducks out there tend to be safer than our chickens. Duck = Dark meat (long-distance runners), Chicken = white meat (sprinters)
The only way primary personal trainers can tackle trigger points is by instructing your clients to engage in self-myofascial release, utilizing such tools as foam rollers, balls, PVC pipes, or their own fingers. Remember, it is outside the scope of practice for a personal trainer to perform massage therapy of any kind, including a muscle release! Get some qualified professionals in your network and refer out if your client is unable to mitigate muscular trigger point pain.
For the issues that you are able to tackle, be sure to assess and evaluate what is causing these maladaptive patterns and help your clients by stretching those overactive areas post-release, and strengthen lagging muscle groups in order to break the cycle.