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Trigger Points

By Clair Davies, NCTMB

Originally published in Massage Bodywork magazine, June/July 2002.
Copyright 2003. Associated Bodywork and Massage Professionals. All rights reserved.


It doesn't seem fair that a massage therapist should suffer from chronic pain, and yet many do.

The turnover rate in this therapeutic profession is disturbingly high, due largely to chronic pain in the forearms and hands as a result of the repetitive nature of the work we do. More and more therapists are coming out of massage school already afflicted with pain in their forearms and hands, making burnout cycles even faster.

Clinical experience suggests massage may be the most appropriate treatment for pain, but even well-experienced massage therapists are often unable to deal with their own pain effectively. In a pain crisis, many resort to popping pain pills, as if there were no other solution. But there are solutions.

Drs. Janet Travell and David Simons took the mystery out of pain with their monumental Myofascial Pain and Dysfunction: The Trigger Point Manual. Their work firmly established that trigger points were the cause of most common pain problems. Although the Trigger Point Manual can be intimidating because of its thoroughness and high measure of technicality, enough of it has filtered down to us that it has transformed the practice of clinical massage.

In developing techniques for trigger point massage, massage therapists have made better use of Travell and Simons than almost any other profession. The medical community has largely ignored this phenomenal resource, a shameful degree of neglect that continues to rob the public through misdiagnosis and antiquated, needlessly expensive treatments.

You know the basic facts about trigger points. They're characterized chiefly by referred pain but can be responsible for a variety of other discomforting effects, including numbness, tingling, burning, swelling, hypersensitivity, muscle weakness, joint stiffness and a wide variety of autonomic symptoms. When symptoms occur in the hands, physicians uninformed about trigger points are likely to interpret them as indicating arthritis, bursitis, tendinitis, carpal tunnel syndrome or a neurological defect. These words have become so familiar that members of the public often draw the same conclusions when they self-diagnose. Massage therapists can fall into the same trap when they don't readily recognize myofascial symptoms and are not sufficiently skilled at finding and treating trigger points.

When confronted with pain, numbness, tingling, stiffness, burning or swelling in the hands and fingers, the universal tendency nowadays is to immediately apply the "carpal tunnel syndrome" label. This, then, becomes an unhappy situation when the "carpal tunnel" is the treatment of choice. We've all seen people who have had the operation and still have their pain and numbness. The fact is that trigger points in the scalene, brachialis and forearm muscles are the most common cause of symptoms in the hands, although certain other muscles of the upper back, shoulders, arms and the hands themselves may sometimes be involved. Because of this displacement of symptoms, treatment focusing on the hands is likely to give only partial or temporary relief, if any at all.

Similarly, pharmaceutical relief can only be transitory because the treatment is directed at symptoms, not causes. Pain pills don't solve the problem; they only deaden your awareness of it.

If you work with trigger points at all, you know that every trigger point discussed by Travell and Simons is treatable with massage. They are all self-treatable too (except the intrapelvic), if you know the tricks. The idea of working on yourself may not be very appealing if your hands already hurt from working all day on other people. But you don't have to "trash" your hands; in fact, you don't have to use your hands at all. There are many great massage tools commercially available. For many parts of the body, the best tool imaginable is simply a tennis ball (or lacrosse ball) held against a wall.

Actually, there's no reason to give up entirely on using your hands, if you use them intelligently with scrupulous attention to ergonomics. Safe massage for the hands requires the introduction of some new ideas and the abandonment of some old ones. As an example of the kinds of things that need rethinking, consider the most natural way to use the hands -- gripping with the thumb in opposition to the fingers. Grasping with the hands is so extremely taxing to the muscles of the forearms and hands that it's wise to avoid it whenever possible if you hope to make any progress in combating work-related pain.


Deep Stroking Massage
Massage therapists have traditionally treated trigger points with ischemic compression, which requires pressing and holding the point for a specified length of time. This concept originated with Bonnie Prudden in her book Pain Erasure, first published in 1980. At the time, it was a stimulating new idea that precipitated the development of several new methods of massage.

Ischemic compression, however, turned out to cause some problems. The trouble with pressing and holding a trigger point is that it requires the sustained contraction of muscles in the therapist's shoulders, arms, hands and fingers, which can become extremely tiring in a very short time, resulting in trigger points in the therapist. Static pressure on a trigger point can also elicit intolerable pain in the client when the overriding intention is to force a trigger point into submission. Large numbers of the public have been turned away from trigger point therapy after a single experience with a therapist who applied it too aggressively.

An alternative approach to trigger point therapy is deep stroking massage, the application of a series of slow, deep strokes directly to the trigger point nodule. Deep stroking gets results quicker than the static pressure of ischemic compression, with less irritation to the trigger point, less pain inflicted on the person receiving treatment and much less risk to the hands doing the therapy.

Compressing the trigger point is the right idea, but it needs to be more of a squeegee effect, a repeated milking action to efficiently move the blood and lymph fluid out. Picture how you rinse out a dirty cloth. Wetting and wringing it out only once won't get it clean no matter how long and hard you twist it. You need to run fresh water through it over and over and wring it repeatedly until the water runs clear. The same process works with a trigger point.

The idea with deep stroking massage is to work slowly, about one stroke every two seconds. The strokes need to be only an inch or so long, just enough to move from one side of the trigger point to the other. Rather than sliding your finger across the skin, move the skin with the fingers. Release at the end of the stroke, then go back to where you started, reset and repeat. Each time you release the pressure fresh blood immediately flows in bringing a renewing charge of oxygen and nutrients. The trigger point has been deprived of these essential substances because the knotted-up muscle fibers have been keeping a stranglehold on the capillaries that supply them.

Although we have been taught to always move the fluid toward the heart, it's not a critical issue with these very short strokes. You can depend on the system to carry the junk away, once you get it squeezed out of the trigger point. In doing self-applied massage, apply the strokes in whatever direction is easiest. If you don't find ways to make self-massage easy, you won't do it.

Another benefit of deep stroking massage is that it helps get the stretch back into the muscle fibers within the trigger point. The effect is similar whether massage is done parallel to the fibers or across them. This focused stretching, limited to the trigger point itself, should be thought of as a microstretch, as opposed to the macrostretch of the whole muscle that is done with conventional stretching exercises. With a microstretch, applied directly to the trigger point, there's little chance of overstretching the taut band of muscle fibers leading from the trigger point to the muscle's attachments. Abuse of this taut band risks irritating the trigger point and making it hold on tighter. This is why conventional stretching can place undue strain on the muscle's attachments, unless done conservatively.

The level of pain caused by massage is a useful measure of safety and effectiveness. To gain maximum benefits, you should exert enough pressure to make it hurt a little, but it should feel like a good hurt. Aim at a pain level of seven on a scale of 1-10. Pressure greater than seven risks causing the muscles to tighten defensively. Self-applied massage is best done in very short sessions, 15 or 20 seconds per trigger point. Several brief sessions during the day do more good than intensive treatments once or twice a week. Keep in mind that massage only helps create conditions for healing; it's the body itself that does the real work.

Deep stroking massage may occasionally cause bruising in tender areas. This is usually a sign that massage is being applied to the wrong place, particularly if little improvement is being shown. Trigger points ordinarily respond well to massage. Most treatment failures with trigger point massage are the result of working the wrong spot.


Brachialis
The brachialis muscle is the workhorse of the elbow, doing much of the work normally credited to the biceps. Trigger points in a brachialis muscle make it difficult to straighten the elbow, but the pain they create is felt primarily at the base of the thumb. There may also be an oppressive ache or tightness on the outside of the forearm and upper arm near the elbow. Trigger point-sponsored tightness in the brachialis can compress the radial nerve, causing numbness in the thumb and the back of the forearm. It's natural to massage the thumb when it hurts, but remember that it's a waste of time when the pain is being sent from somewhere else.

Massage therapists can have an unusual amount of trouble with brachialis muscles when the strain of giving massage is added to activities that are more mundane. The brachialis can be overworked by carrying heavy bags of groceries, carrying a baby around, picking up growing children or carrying a purse hanging on the forearm. Brachialis muscles are stressed by holding heavy tools for long hours and by any repetitive action of the elbow on the job. You can foster trigger points in your brachialis muscles working out with weights or by any other strained flexion of the elbow in exercise or sports activity.

Working all day at a computer keyboard with your arms held out in front necessitates continuous contraction of the brachialis muscles of both arms. For this reason, computer users nearly always have brachialis trigger points. Musicians often work these muscles to exhaustion in simply holding up their instruments. Oboe players, for example, often suffer from chronic pain and numbness in the thumb of their right hand, which has to support the weight of the oboe. Though the trouble may seem to be in the thumb itself because that's where the pain is felt, the real problem is in the brachialis muscle that has to stay contracted all the while the oboe is being played.

Brachialis trigger points are found under the outer edge of the biceps, just above the crease of the elbow. Push the biceps aside to access the trigger points and massage them against the bone with a supported thumb. Notice that the arm getting the work is braced against the thigh. The trigger point that causes nerve entrapment lurks in a slippery sort of lump in the muscle, a short way above the elbow on the outside of the arm. Occasionally, trigger points occur under the inner edge of the biceps. The inner trigger points must be worked with the supported thumb. Massage the outer ones with a tennis ball or lacrosse ball against a wall. A lacrosse ball is actually the superior tool because it gives you better control. You can apply deeper pressure with a lacrosse ball with much less force and it won't slip and slide around on the wall like a tennis ball will. Either kind of ball can be placed in a long sock to provide a handle, which will keep you from having to chase the ball all over the room when you drop it.


Forearm Muscles
Trigger points in the hand and finger extensors cause pain in the outer elbow and in the back of the forearm, hand, wrist and fingers. They also cause hand weakness, finger stiffness, numbness, tingling, knuckle tenderness and clumsiness.

Extensor carpi radialis longus trigger points are an extremely common cause of lateral epicondylitis or tennis elbow. They also provoke a kind of burning pain in the outer side of the forearm and the back of the wrist and hand. Trigger points in the extensor carpi radialis brevis cause pain in the back of the wrist and hand and a sense of tightness, burning or aching in the back of the forearm. Sometimes tightness in this short extensor can trap the radial nerve and cause numbness and tingling in the hand. Extensor carpi ulnaris trigger points send pain to the ulnar side of the wrist that feels like a sprain. These three hand extensors can easily be overworked to the point of exhaustion when working at a computer keyboard because of their importance in keeping the hands in the up position.

Trigger points in the extensor digitorum are the prime cause of stiff fingers. They also send pain to the outer elbow, the back of the forearm and the second knuckle of the middle and ring fingers. Referred pain in the knuckles can be mistaken for evidence of osteoarthritis.

Pain caused by trigger points in the hand and finger flexor muscles is sent to various locations on the inner side of the forearm, wrist, hand and fingers. Flexor carpi radialis trigger points send pain to the inner wrist near the base of the thumb. This pain is commonly mistaken for a wrist sprain. Flexor carpi ulnaris trigger points also mimic sprains by sending pain to the ulnar side of the wrist. When this muscle stays tight, it can compress the ulnar nerve, causing a weakened grip and a sensation of burning or numbness in the fourth and fifth fingers. Trigger points in the flexor digitorum send sharp pain to the inner side of the fingers. Trigger points in the pronator teres and palmaris longus also cause forearm and hand symptoms that may be mistakenly diagnosed as carpal tunnel syndrome.

Self-treatment of the brachialis and all of the forearm muscles is surprisingly easy when done with a ball against a wall, allowing massage of the supinator and brachioradialis, whose trigger points coincide approximately with those of the extensor carpi radialis longus.

Strictly speaking, to position the hand for massage to the extensor digitorum, turn the hand palm up to work the extensor carpi radialis brevis; turn the palm to the floor for massage of the extensor carpi ulnaris. These different positions of the hand bring different muscles in contact with the ball.

The muscles of the inner forearm can be efficiently and effectively worked with the arm behind the back. In all cases, move the arm so that the ball rolls slowly along the muscle toward the elbow. To exert pressure, lean against the arm with the body. The worst trigger points will be found within three inches of the elbow.

The supported thumb is an effective tool to use for any of the muscles in the forearm. Used properly, the supported thumb minimizes involvement of the forearm and hand muscles. The wrist should not be bent in any way. You should be able to draw a straight line from the tip of the elbow to the tip of the thumb. With these conditions established, the hand and forearm can remain relatively relaxed and the major force will come from the shoulder.


Hand Muscles
Trigger points in the thenar muscles at the base of the thumb are one more cause of counterfeit sprains, sending pain to the radial side of the inner wrist and the side of the thumb. Massage the thenar muscles with the supported thumb of the opposite hand. Trigger points in the dorsal and palmar interosseous muscles refer pain to the sides and undersides of the fingers and to the distal finger joints, contributing to finger stiffness, weakness and awkwardness. Trigger points in the first dorsal interosseous muscle have a much wider referral pattern, sending pain to the palm, little finger, back of the hand and all surfaces of the index finger. They often refer a deep ache to the entire ulnar side of the hand. All the interosseous muscles can be massaged with a large wedge-shaped eraser held in a small spring clamp.

Massage therapists are especially prone to overuse of the interosseous muscles, which assist the forearm muscles in the techniques of effleurage and petrissage. Working at a computer keyboard can subject these muscles to double jeopardy.

Note that trigger points in the scalenes, pectoralis minor, triceps and other muscles of the upper back and shoulders can occasionally contribute to pain and other symptoms in the forearms and hands. More information about these muscles can be found in The Trigger Point Therapy Workbook; Your Self-Treatment Guide For Pain Relief.


Conclusion
Myofascial trigger points should be suspected as a major cause of pain and other symptoms of repetitive strain suffered by massage therapists. Self-applied trigger point massage can be an efficient and economical way for massage therapists to manage their own work-related pain. Therapists who want to learn more about trigger points would do well to first study them on their own bodies. This kind of intimate experience with trigger points builds skill, understanding and intuition and will lead to significantly greater success in the treatment of clients' repetitive strain problems. If massage therapists can learn how to interpret their own referred symptoms and to locate and treat their own trigger points, they will know exactly what to do when they encounter similar problems in their clients. Nothing could be a more perfect expression of the ancient maxim, "Physician, heal thyself."

Clair Davies, NCTMB, is the author of The Trigger Point Therapy Workbook; Your Self-Treatment Guide For Pain Relief, 2001, New Harbinger Publications. He also conducts trigger point therapy workshops for massage therapists with his daughter, Amber Davies, NCTMB. For information on his work, visit www.triggerpointbook.com.




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