Trigger Points & Myofascial Pain Syndrome
A guide to the unfinished science of muscle pain, with reviews of every theory and self-treatment and therapy option
Paul Ingraham, updated Aug 13, 2019
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Trigger points or muscle “knots” are sensitive spots in soft tissue, and too many of them is “myofascial pain syndrome.” They 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.
Trigger point therapy mostly consists of rubbing and pressing on trigger points — which can feel like an amazing relief. Dry needling is a popular (and dubious) method of stabbing trigger points into submission with acupuncture needles. Treatment is not rocket science5 — it’s much too experimental to be so exact! It’s a bit of a crapshoot, lots of trial and error, but anyone can learn enough to relieve some minor pain problems cheaply and safely, and maybe some bigger ones, too. Advanced therapy for people with many stubborn trigger points goes beyond fighting brush fires and in search of medical factors.
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.
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Does your body feel like a toxic waste dump?
It may be more literally true than you realized! Some evidence shows that a knot may be a patch of polluted tissue: a nasty little cesspool of waste metabolites. If so, it’s no wonder they hurt & no wonder they cause so many strange sensations: it’s more like being poisoned than being injured. Back pain is the best known symptom of the common muscle knot, but they can cause an astonishing array of other aches & pains. Misdiagnosis is much more common than diagnosis.
Trigger point therapy is not a miracle cure for chronic pain — but it helps
Trigger point therapy isn’t “too good to be true” — it’s just ordinary good. It’s definitely not miraculous.6 It’s experimental and it often fails.7 Good therapy is hard to find (or even define), because many practitioners are amateurish hacks8 and some treatment methods are way out in left field and potentially harmful (to your wallet at least). They are often barking up the wrong tree, treating so-called trigger points when there’s actually another problem.
PRO Attention physicians & therapists: This massive tutorial is written for both patients and professionals. It includes analysis of recent research that you won’t find in any text, crafted to suit any skill level.9 Footnotes add a optional layer of advanced detail that you can take or leave.
Trigger points are more clinically important than most health professionals realize, and body pain seems to be a growing problem.10It’s a rewarding topic for doctors and therapists, that makes clear path to helping quite a few people you probably couldn’t help before. Even if you already know about myofascial pain syndrome, you will get new ideas here.
And yet good trigger point therapy is under-rated. 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.11 Done wisely, it’s worth dabbling in (or even basing a career on it).
For beginners with average muscle pain — a typical case of 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 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 will get you as close to a cure as you can get; I can give you a fighting chance of at least taking the edge off your pain. And maybe that is a bit of a miracle.
About footnotes. There are 412 footnotes in this document. Click to make them pop up without losing your place. There are two types: more interesting extra content,1 and boring reference stuff.2 Try one!
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About green links. Standard blue links go to other pages on PainScience.com, or on other websites, as expected. But green links go to other sections of this page, like this link to the top of the article.
What exactly are muscle knots?
When you say that you have a “muscle knot,” you are talking about a myofascial trigger point (TrP).[Wikipedia] A few trigger points here and there is usually just an annoyance, but many bad ones is myofascial pain syndrome (MPS). [Mayo]
TrPs are to MPS as pimples are to acne.
There are no actual knots in there, of course — it just feels like it. Although their true nature is uncertain, the usual explanation is that a trigger point is a small patch of tightly contracted muscle, a micro-cramp afflicting just a tiny patch of muscle tissue (as opposed to a whole-muscle spasm like a “charlie horse”13). 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.
TrPs can be vicious. They can cause far more discomfort than most people believe is possible. Its bark is much louder than its bite, but the bark can be painfully loud. It can also be a weird bark — trigger points can generate some odd sensations, and the source may not be obvious.
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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!14
Trigger points show up like party crashers: whatever’s wrong, you can count on them to make it worse & in many cases they actually begin to overshadow the original problem.
Muscle pain matters. Aches and pains are an extremely common medical complaint,15and trigger points seem to be a factor in many of them.1617 They are involved in headaches (including migraines)1819, neck pain and low back pain, and (much) more. What makes trigger points clinically important — and fascinating — is their triple threat. They can:
cause pain problems,complicate pain problems, andmimic other pain problems.
Muscle just hurts sometimes. Trigger points can cause pain directly. Trigger points are a “natural” part of muscle tissue.20 Just as almost everyone gets some pimples, sooner or later almost everyone gets muscle knots — and you get 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.21 A perfect example: shin splints.22
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 a bit disappointing.23 Trigger points are under-explained and over-hyped. They aren’t a flaky diagnosis,24 but they’re not exactly on a solid scientific foundation either. Some critics have harshly criticized conventional wisdom about them.25
The science of trigger points is a bit shabby. They are under-explained.
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 going on, and everyone agrees that something painful is going on. 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?
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.
Why are trigger points so neglected by medicine?
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Family doctors aren’t really equipped for troubleshooting chronic pain. Cartoon by Loren Fishman,HumoresqueCartoons.com
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.26 Chronic pain with no obvious cause is a relatively unstudied epidemic, and not many doctors know what to do with it or 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.”27 Muscle tissue is the largest organ in the body, complex and vulnerable to dysfunction, and 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.”28
Family doctors are particularly uninformed about the causes of musculoskeletal aches and pains29 — 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 aren’t all helpful to 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,30 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 world31), 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?
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The Big Red Books
Must-have text books for any therapist treating trigger points.
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 Dysfunction32 — and “the blue book,” Muscle Pain33 These are not easy reading!34
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 just too historically important not to have. So, if you don’t see dog-eared copies, ask about them — it’s a fair, effective, polite way to check a therapist’s competence. Muscle Pain (the blue one) is just as important. I highly 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.
A brief note about the relationship between fibromyalgia and myofascial pain syndrome
Fibromyalgia (FM) is an illness of “hurting all over” — widespread chronic pain and decreased pain threshold. It is also associated with fatigue, sleep disturbance, and “fibro fog” (mental confusion). It is defined by its unexplained symptoms,35 so “no one has FM until it is diagnosed.”36 Here’s a good 1-minute primer on fibromyalgia from One-Minute Medical School:
MPS is actually one of many possible explanations for the pain of fibromyalgia, but they may also be separate conditions. FM might be a more clearly neurological disease, while MPS may be more of a problem with muscle tissue. It would be nice if such a clear distinction were established someday. Fibromyalgia & myofascial pain syndrome are harder to tell apart than mischievous twins who deliberately impersonate each other.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.37
Whatever the causes or labels, therapeutic approaches for MPS seems to be helpful for some FM patients as well,38 although pure FM cases seem to be mostly immune to massage.39 But this book is still useful for many FM patients, insofar as it overlaps with our main topic.
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Trigger points may explain many severe and strange aches and pains
Got a bizarre pain that just flared up one day? Sure, it could be something scary or rare. But in many cases it’s more likely to be a trigger point.
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 a muscle in their armpit (subscapularis).40 Seriously. I’m not making that up!
This odd phenomenon of pain spreading from a trigger point to another location is called “referred pain.” The neurology will be explained in detail below. Here are some other examples of interesting referred pain leading to misdiagnosis:41
Sciatica (shooting pain in the buttocks and legs) is often caused by pain in the piriformis or other gluteal muscles, and not by irritation of the sciatic nerve. Many other trigger points are mistaken for “some kind of nerve problem.” (And, to be fair, some kinds of nerve problems can be mistaken for trigger points! More on this to come.)Chronic jaw pain, toothaches, earaches, sinusitis, ringing in the ears (tinnitus), and dizziness may be symptoms of trigger points in the muscles around the jaw, face, head and neck.4243A sore throat or a lump in the throat is often caused or aggravated by trigger points anywhere around the throat.44“Appendicitis pain” often turns out, sometimes after surgery, to be caused by a trigger point in the abdominal muscles. Wow.Severe MPS is often mistaken for fibromyalgia (and other causes of pain hypersensitivity).
Sometimes trigger points cause such severe 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. 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 and quickly relieved by massaging a trigger point in her psoas major muscle.45
I once suffered a dramatic case of a “toothache” that was completely relieved by a massage therapist the day before an emergency appointment with the dentist: a particularly vivid experience.
However, the vast majority of 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.
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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 relationship between trigger points and mild-to-moderate pain is often 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 they do make me seem like a miracle worker, because they are such a clinical “slam dunk” for garden variety persistent pain — pain undiagnosed and untreated by a string of other health professionals.
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.46 But she had a prominent gluteus maximus trigger point47 that, when stimulated, felt exactly like her symptoms — a deep ache in the region of the low back and upper gluteals. In just three appointments, her pain was completely relieved. 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. I did not believe any of these were likely, 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 good trigger point therapist has a bunch of treatment success stories like this. 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 shows 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.48 The idea is an annoyance to all honest, humble professionals who know better … and more or less impossible to believe if you know the basics about pain and muscle knots. The skill of a therapist is only one relatively minor factor among many that affect the success of massage therapy for trigger points — or any therapy, for any pain problem.
Even the best therapists can be defeated by a no-win situation & nearly any therapist can luck out & get great results with the occasional patient when all the planets are aligned.
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.49 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. It really depends.
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.
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DIAGNOSIS
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.50 Because of their medical obscurity and the half-baked science, they are often the last thing to be considered in spite of their clinical importance and distinctive characteristics. There are several things you can look for that will help you to feel more confident that, yes, muscle pain is the problem instead of something else. The next several sections will discuss all of them in detail, comparing and contrasting with other conditions.
Whether you knew it or not, you were probably already familiar with trigger points even if you’d never heard of them before starting this tutorial.
Almost everyone has a head start in self-diagnosing trigger points, because almost everyone already more or less knows what it’s like to have a muscle knot. If you have ever had muscle stiffness, wrenched your neck around trying to stretch and wiggle your way free of discomfort, or gotten a friend or partner to dig into that nagging sore spot in your back, then you already have some experience with this — you have trigger points. You have pain and stiffness that feels like it’s in your muscles. You have sensitive patches of soft tissue, much more tender that the surrounding tissue, in locations where there’s no obvious reason for it.
But there may be many things you don’t yet know about how trigger points behave and feel…
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