By Julie A. DeGeyter, PT, DPT (September 2017)
“Ow, it really hurts when I turn my head.” “I have this knot in my shoulder that is killing me and won’t go away.” As a physical therapist I commonly hear these complaints, which are often the result of muscle knots or spasms. These knots are called trigger points, which can occur in any muscle, often causing or contributing to many common pain complaints such as tension headaches, shoulder pain, neck pain, low back pain, hip pain and even some tendinopathies. In this blog I am going to discuss why we get trigger points, how they can cause pain and how they can be treated.
We often think of pain coming from problems in joints, such as arthritis, or from tendons, such as tendinitis, but frequently we overlook how much pain can be coming from muscles. Trigger points are very common and occur in our muscles and fascia. They are typically felt as a dull, aching pain and can limit our ability to move easily, often causing morning stiffness or limiting our range of motion. Severe trigger points can also result in sharp, intense debilitating pain with certain movements.
A myofascial trigger point is the term used to describe the taut band or “knot” in the muscle or fascia. These points often have distinct patterns of pain that can refer far from their own location. For example, when you press hard on the trigger point in your shoulder it may shoot pain down into your arm or reproduce a faint, familiar headache pattern. This would be an active trigger point and when it is compressed or that particular muscle is placed on stretch it will provoke a pain response, often referring pain away from its own location. So why do we have these trigger points in our muscles and fascia?
There are several theories as to what causes trigger points that can be put into two broad categories: neuromuscular dysfunction and radiculopathy. The first, neuromuscular dysfunction theory, suggests that when a muscle is subject to an acute injury (macrotrauma), repeated overuse (microtrauma), or is receiving increased neural input (the stress response of holding your shoulders up by your ears) the muscle fibers will continually contract and shorten, losing the ability to release. The second theory, radiculopathy, suggests that the muscles and fascia are under stress due to decreased neural input. This theory suggests that compression happens at the level of the nerve root, near the spine, decreasing neural input and resulting in hypersensitivity of any tissues that it connects with. This results in a repeated shortening of a muscle and fascia that becomes the knot in your shoulder.
So why are these trigger points so painful? These tight bands have been shown in studies to have biochemical changes and decreased pH levels compared to other muscles. They have a more acidic pH, which has been linked to ischemia (lack of blood flow) and the biochemical changes detected in trigger points are associated with inflammation and increased sensitivity of pain receptors. So when your muscle has a trigger point, it has decreased blood flow, increased sensitivity to pain and more inflammation inhibiting your ability to move freely and potentially causing pain. So how can we break the cycle and promote normal function?
There are many methods of treatment used to relieve or manage trigger point and myofascial pain such as massage, exercise, heat therapy, cryotherapy (cold), stretching and more. One very effective treatment for trigger point pain is dry needling. Dry needling is performed by a trained physical therapist and is the use of a thin, monofilament needle to penetrate the skin and stimulate the trigger point in order to reset the dysfunctional pattern. When the trigger point has been successfully stimulated a patient often has immediate relief from pain and improved movement.
How does inserting a needle into a trigger point relieve pain? When the needle is inserted into the trigger point or taut band it elicits a localized twitch response, which is a rapid depolarization (contraction) of the muscle. The localized twitch response allows the connective tissue to reset, normalizing the tone and improving circulation to the area. However, needling to both trigger point and non-trigger point regions has been shown in studies to provide pain relief and restore functional movement. The needle is thought to stimulate sensitive neural loci or neurovascular bundles providing a strong neural impulse and eliciting a spinal reflex. This causes the nervous system to send messages to the connective tissue to relax, getting rid of that persistent knot in your shoulder.
Three most frequently asked questions are “how long do the needles stay in, how deep do they go and is it painful”. There are multiple techniques that can be used with dry needling including superficial and deep, brief insertion versus letting the needles sit, as well as the addition of electrical stimulation to the inserted needles. The technique used, in my opinion, should be based off patient’s response and best clinical judgment. I strongly believe that any treatment administered by a therapist should be tailored to the patient in front of them and their specific complaint in order to achieve optimal results. Dry needling is a safe, effective modality used by physical therapists to assist in reducing pain and promoting movement. For more acute injuries, 1-2 sessions in conjunction with education and instruction in basic exercises can suffice in eliminating pain. However, dry needling should be used in conjunction with a comprehensive plan of care for the treatment of more chronic conditions in order to achieve long-term pain relief.
The most important point is that if you are having acute pain from recent overuse or you have chronic pain that is persistent despite the use of pain medication, joint manipulation or exercise, you may have undiagnosed trigger points. Myofascial pain is treatable and as a physical therapist I can assist in relieving your pain with a recipe of exercise, manual therapy and potentially dry needling that is unique to you as an individual.
Julie DeGeyter, PT, DPT is a physical therapist at Flagstaff Bone and Joint. DeGeyter treats patients with a variety of impairments including orthopaedic injuries, vestibular disorders, chronic pain, pelvic floor dysfunction, and postoperative rehabilitation. Her primary focus is treatment with manual therapy and functional exercise to restore pain-free motion and improve a person’s quality of life.