The best treatment for trigger points

If you have pain from trigger points you have a large number of options ranging from a variety of professional therapies through to several home remedies. When looking for your best option there are obvious considerations such as the cost, pain, and whether you like needles.

The other obvious consideration is how effective they are, but that’s not so easy. There have been a lot of clinical trials?but practically all just measure how effective the therapy is at relieving pain, not actually getting rid of the problem.

It’s nice to get you out of pain, but it’s not much good having course of expensive and maybe painful therapy then have the pain come back again. Of course when it does the underlying problem will have been there longer, so relapses tend to be worse and harder to relieve.

If you just want a bit of pain relief we’ll summarise the results of those trials.?However, we’ll assume that you’d like to actually be rid of your problem, so luckily there is a very effective strategy and a simple home care option for that so we’ll give you the details.

The way we’ll do this is to:

1. Give you some background so you understand what trigger points are and why all those therapies just relieve pain and not get rid of the problem.
2. We’ll use what scientists have found about trigger points plus data from the rare trials that tested whether trigger points are eliminated to show you your options for getting rid of your problem properly. We include one very effective therapy you can easily do yourself.

What are trigger points

Trigger points are those tender lumps in your muscles that therapists find. They are arguably the biggest cause of musculoskeletal pain syndromes such as back neck and shoulder pain (1,2) . For more details please see our article?Trigger Point Basics, but in summary.

Symptoms

The symptoms of trigger points are:

• easy fatigue, muscle pain (often increases with activity)
• reduced flexibility (includes muscle tears and pains)
• trigger points refer pain, which can mimic a host of conditions including headaches and sciatica
• pain, fatigue and disrupted sleep can cause feelings of being run down, emotional and psychological problems

Diagnosis

Trigger points do not show up in medical laboratory tests or imaging. However they are easily diagnosed by examining the muscle looking for:

• tight bands of muscle
• tender lump that refers pain when pressed upon
• (sometimes) the muscle will twitch when the trigger point is pressed (the “jump sign”)

What the lumps are

It is worthwhile having a quick look what is actually going on with your trigger points.?That helps understand why the therapies just relieve pain and not get rid of the problem, and also helps understand how to deal with them properly.

As this diagram shows those lumps in your muscles are actually a combination of muscle spasm, muscle tightness, reduced blood flow and a build up of waste products, all locked in what is called a positive feedback loop. A positive feedback loop is like what happens when you put a microphone in front of a loud speaker and get a huge squeal until you switch it off.?In this case, once the trigger point starts to develop:

• spasm tightens the muscle
• the tightness presses on blood vessels restricting blood flow
• the restricted blood flow causes a build up of waste products
• the build up of waste products becomes toxic causing spasm.

This cycle keeps going around and around in circles, with the trigger points gradually growing.

Why most trigger point therapies just relieve pain

As shown in the diagrams below, trigger points eventually get to the stage where all you need to do is aggravate them and they will start shooting pain on their own. When they do start shooting pain they are said to be “active”, and this process is called “activation”.?Most applications of therapy just reverse this step. The process is called “de-activation”.?The pain goes and to the un-informed it appears to fix the problem, but of course the trigger point is still there just the way it was before being aggravated.?With the trigger point still there all it needs is to be re-aggravated and it’s pain all over again.

Proof that the trigger points don't go

If you are recommended a course of trigger point therapies such as needles, laser or massage you would expect the problem to be fixed, but unfortunately that’s not the case.?If you do ask you'll be told that treatments are only said to “de-activate” the trigger points, which as we’ve seen just means to (temporarily) stop them hurting.

This deceptive conduct stems from the research scientists who conduct trials of the various therapies. To “prove” their therapies they just check whether the trigger points are de-activated and very conveniently don’t check whether the trigger points actually go (3). That way they can write up the report as a success, encouraging treating professionals to buy the needles, lasers or whatever and recommend these treatments to the public.

This chart proves that the trigger points don’t go.?In a trial some of the best PhD trigger point scientists in the world did 12 weeks of very extensive trigger point therapy and 2/3 of the trigger points were still there (4) . If the best in the business did that and only eliminated 1/3, your typical courses of therapy from a professional will barely make a dent in the trigger point population.

Trigger points cause problems even when not shooting pain

The obvious problem when trigger points are just deactivated is that they will eventually be re-aggravated and start causing pain again. However, even when not shooting pain the muscles containing the trigger points are still tight with reduced blood flow and a build up of waste products. As listed in the?appendix below?even without pain this causes a lot of problems.

Our strategy to get rid of trigger points

While the 12 week trial discussed above shows that most courses of trigger point therapy will barely make a dent in your trigger point numbers they did relieve the pain and eliminate 1/3 of the trigger points. This suggests that if you continue effective therapy you will eliminate more and maybe get rid of them altogether. Of course for most at least some of that therapy will need to be self applied, otherwise it will get very expensive. Lets look at which therapies may be suitable.

Finding the best trigger point therapy

There have been a large number of clinical trials of trigger point therapy. We have summarised the results of these?below. However:

1. none are really suitable for self application, and
2. because the researchers typically just measure symptoms rather than trigger point elimination the trials are only of limited use.

Because of that we have to look at what trigger points are and how trigger point therapies are said to help.

How trigger point therapies work

Disrupting the feedback loop

As we’ve seen trigger points are a mixture of muscle spasm, tightness, reduced blood flow and a build up of waste products all aggravating each other forming a positive feedback loop.?The purpose of trigger point therapies is to slow or stop that cycle. This can be done at any part of the loop. That is why we have so many different trigger point therapies. As long as they address one or more of the issues they will help (5–8) .

Trigger points are entrenched and stubborn

All the scientific information and clinical experience tell us that trigger points build up very slowly over time and become very entrenched. Therefore each application of therapy can only diminish the loop slightly. If the treatment is continually repeated the feedback loop will continue to diminish, but of course if treatment is stopped after after the trigger points stop hurting they will gradually re-develop and become re-aggravated.

The ideal trigger point therapy

The best trigger point therapy is one we have been using in clinic for a long time: vibration massage. This has been scientifically proven to target all four parts of the trigger point feedback loop, and is easy to self apply. Further, there are no needles and no pain.

The trigger point treatments

In this section we will:

1. point you in the right direction to use vibration massage (the best choice)
2. show you some other useful home therapies, plus the ones to avoid
3. review the common professional therapies

Vibration massage (the best therapy)

We have a lot of information on how to treat trigger points using vibration massage in the articles linked below. However, basically all you need to do is get a suitable massager then sit it on the muscle over the trigger point. You don’t need any special skill or knowledge of massage.

• How to use a hand held massager
• How to treat trigger points at home
• How to choose a massager?(most are not suitable)

Alternative useful self therapies

Effective therapy one: simple self massage by hand to muscles you can easily get at

In our?video on self massage for forearm muscles?we show a simple effective self massage technique for treating trigger points. This is suitable for smaller muscles you can easily reach.

Effective therapy two: safe, conservative self pressure techniques

In a trial of a traditional Thai self massage technique (8) trigger points were successfully treated by each day using five repetitions of five seconds of mild pressure to each of the trigger points. As discussed in?our article on foam rollers?we are concerned about self users copying the painful techniques some therapists use, but repeated mild pressure done each day should be fine.

Therapies we don't recommend

Massage guns

As we discuss in our article?should I get a massage gun?don’t even consider using one for trigger point therapy:

• they tend to use percussion rather than vibration. Percussion is less effective and more dangerous
• They have stupid handles which mean you cannot effectively use them on a lot of your body.
• The market is flooded with machines from manufactures who know and care very little about making an effective therapeutic device.

Foam rollers

As we discuss in our?article on the use of foam rollers?clinical trials show that even when used under ideal circumstances their effects are only marginal, and there are significant concerns about their safety when used unsupervised.

The professional therapies

Depending on your finances you may choose to have either some or all therapy done by a professional. With this in mind the section below summerises what the scientific reviews say about each of the common trigger point therapies (9-15) . Keep in mind though that the trials just measure symptoms so you will need a lot more than they suggest to help eliminate your problem.

Dry needling

Most trials show that dry needling provides some short term pain relief and improved function. The risks and potential to cause pain are obvious. The mode of how needles work is still speculation. Where dry needling had been compared with laser the laser has given slightly better results.

Laser

Trial results for laser have been marginally better than those for dry needling, but still only temporary relief. Scientists attribute it’s effect to increasing micro-circulation, improving oxygenation and helping remove waste products. However, this is something that can easily be achieved, if not better, by any competent massage therapist.

The big concern with laser is the sheer number of applications of therapy sessions needed for only temporary benefits. For example one trial (16) used 10 daily applications of laser on patients with upper back and neck pain to get a reduction in pain and tenderness for three weeks. Further, according to one review (17) applications of laser should be given from 2-3 times a week though to 5 times a week, with a total of 30 applications of therapy for long term cases.?Keep in mind this is just to achieve deactivation, not to eliminate the problem. Assuming each laser consultation costs $50 and takes an hour out of your day that’s $1,500 and 30 hours of your life just for some temporary pain relief, leaving you to front up again next time the problem is aggravated.

Manual therapies

There are various types of manual therapies that involve pressure, massage and stretching of muscles. The trial results for them tend to be similar to those of laser and dry needling. However, according to one review (10) one study did show residual benefit after six months.

Appendix: trigger points cause problems even when not referring pain

As stated, according to the scientists the goal of these therapies is to return the trigger points to a state where they are not referring pain. The obvious issue is potential re-aggravation and more pain, but even without referring pain trigger points cause the following problems. These are discussed in our article?Trigger point basics.

• restrict ranges of motion
• cause muscle weakness
• cause muscle fatigue
• alter muscle activations (affecting neurological control of your movements)
• induce muscle cramps, and
• affect posture and joint function, creating further issues.

On top of that, scientists are now finding that latent trigger points still produce sub-threshold levels of pain that over time sensitises the nervous system. This is a major cause of issues such as fibromyalgia and migraines (7)

Try this therapy with a sample massager (professionals only)

Most of our massagers sell through colleagues using our machines and recommending the therapy to patients/clients, so we are very happy to send appropriately qualified professionals a complimentary sample machine to trial. For more info please see our Professional sample page or see the video below.

References

1. Chiarotto A, Clijsen R, Fernandez-de-las-Penas C, Barbero M.?The prevalence of myofascial trigger points in spinal disorders: a systematic review and meta-analysis. Physiotherapy. 2015;
2. Celik D, Mutlu EK.?Clinical implication of latent myofascial trigger point topical collection on myofascial pain. Curr Pain Headache Rep. 2013;17(8).
3. De Las Pe?as CF, Sohrbeck Campo M, Fernández Carnero J, Miangolarra Page JC.?Manual therapies in myofascial trigger point treatment: A systematic review. J Bodyw Mov Ther. 2005;9(1):27–34.
4. Bron C, De Gast A, Dommerholt J, Stegenga B, Wensing M, Oostendorp RAB.?Treatment of myofascial trigger points in patients with chronic shoulder pain: A randomized, controlled trial. BMC Med. 2011;9.
5. Jafri MS.?Mechanisms of Myofascial Pain. Int Sch Res Not. 2014;2014:1–16.
6. Zhuang XQ, Tan SS, Huang QM.?Understanding of myofascial trigger points. Chin Med J (Engl). 2014;127(24):4271–7.
7. Bron C, Dommerholt JD.?Etiology of myofascial trigger points. Curr Pain Headache Rep. 2012;16(5):439–44.
8. Shah J et al.?Myofascial Trigger Points Then and Now: A Historical and Scientific Perspective. HHS Public Access. 2015;7(7):746–61.
9. Wamontree P, Kanchanakhan N, Eungpinichpong W, Jeensawek A.?Effects of traditional Thai self-massage using a Wilai massage stickTM versus ibuprofen in patients with upper back pain associated with myofascial trigger points: a randomized controlled trial. J Phys Ther Sci. 2015;27(11):3493–7.
10. Boyles R, Fowler R, Ramsey D, Burrows E.?Effectiveness of trigger point dry needling for multiple body regions: A systematic review. J Man Manip Ther . 2015;23(5):276–92.
11. Denneny, Diarmuid et al.?Trigger point manual therapy for the treatment of chronic noncancer pain in adults: a systematic review and meta-analysis. Arch Phys Med Rehabil. 2019;100(3):562–77.
12. De Las Pe?as CF, Sohrbeck Campo M, Fernández Carnero J, Miangolarra Page JC.?Manual therapies in myofascial trigger point treatment: A systematic review. J Bodyw Mov Ther. 2005;9(1):27–34.
13. Tough EA, White AR, Cummings TM, Richards SH, Campbell JL.?Acupuncture and dry needling in the management of myofascial trigger point pain: A systematic review and meta-analysis of randomised controlled trials. Eur J Pain 2009;13(1):3–10.
14. Cagnie B, Castelein B, Pollie F, Steelant L, Verhoeyen H, Cools A.?Evidence for the use of ischemic compression and dry needling in the management of trigger points of the upper trapezius in Patients with Neck Pain: A Systematic Review. Am J Phys Med Rehabil. 2015;94(7):573–83.
15. Espejo-Antúnez L, Tejeda JFH, Albornoz-Cabello M, Rodríguez-Mansilla J, de la Cruz-Torres B, Ribeiro F, et al.?Dry needling in the management of myofascial trigger points: A systematic review of randomized controlled trials. Complement Ther Med . 2017;33(December 2018):46–57.
16. Rickards LD.?The effectiveness of non-invasive treatments for active myofascial trigger point pain : A systematic review of the literature. 2006;9:120–36.
17. Hakgüder A, Birtane M, Gürcan S, Kokino S, Tura FN.?Efficacy of Low Level Laser Therapy in Myofascial Pain Syndrome: An Algometric and Thermographic Evaluation. Lasers Surg Med. 2003;33(5):339–43.
18. Uemoto L, Nascimento De Azevedo R, Almeida Alfaya T, Nunes Jardim Reis R, Depes De Gouvêa CV, Cavalcanti Garcia MA.?Myofascial trigger point therapy: Laser therapy and dry needling. Curr Pain Headache Rep. 2013;17(9).