The Trigger Point Therapy Workbook YOUR SELF-TREATMENT GUIDE FOR PAIN RELIEF Clair Davies, N.C.T.M.B. Foreword by David G. Simons, M.D. New Harbinger Publications, Inc.Publisher's Note "This publication is designed to provide accurate and authoritative information in regard to the subject matter covered. Iti sold with the wx- derstanding that the publisher is not engaged in rendering medical, psychological, financial, legal, or other professional services. f expert as- sistance or counseling is needed, the services of a competent profesional should be sought Care has been taken to confirm the accuracy of the information presented and to describe generally accepted practices. However, the authors, editors, and publisher are not responsible for errors or omissions or for any consequences from application of the information in this book ‘and make no warranty, express or implied, with respect to the contents of the publication. Some drugs and metioal devices presented in this publication may have Food and Drug Administration (FDA) clearance for limited use in restricted research settings. Its the responsibilty ofthe healthcare provider to ascertain the FDA status of each drug or device planned for use in their clinical practic Distributed in the U.S.A. by Publishers Group West; in Canada by Raincoast Books; in Great Britain by Aislift Book Company, tds in South Africa by Real Books, Ltd.; in Australia by Boobook; and in New Zealand by Tandem Press. Copyright © 2001 by Clair Davies New Harbinger Publications, Inc. 5674 Shattuck Avenue ‘Oakland, CA 94609 Cover design by SHELBY DESIGNS AND ILLUSTRATES ustrations by Clair Davies Eaited by Clancy Drake Text design by Michele Waters ISBN 1-57224-250-7 Paperback All Rights Reserved Printed in the United States of America New Harbinger Publications’ Web site address: www.newharbinger.com eB 2 oO wo 9 8 7 6 5 £ 3 2This book is dedicated to my daughter Amber Davies. I could not have written it without her steady faith in me. Her patience, constant encouragement, tactful criticism, and undying enthusiasm for trigger point therapy continually renewed my faith in myself and in the value of this project. Amber has been my number-one disciple. As a longtime sufferer of debilitating chronic pain, she was highly motivated to test and validate every new idea regarding self-treatment. My greatest reward has been in seeing her become relatively pain free and self-reliant due to our combined efforts. Amber has gone on to become a skilled massage therapist and is now devoted to helping bring the benefits of trigger point therapy to others.CHAPTER 1 CHAPTER 2 CHAPTER 3 CHAPTER 4 CHAPTER 5 CHAPTER 6 CHAPTER 7 CHAPTER 8 CHAPTER 9 CHAPTER 10 Contents Ilustrations Foreword Acknowledgments Introduction A New Life All about Trigger Points Massage Guidelines Head and Neck Pain Shoulder, Upper Back, and Upper Arm Pain Elbow, Forearm, and Hand Pain Chest and Abdominal Pain Midback, Low Back, and Buttocks Pain Hip, Thigh, and Knee Pain Lower Leg, Ankle, and Foot Pain Epilogue Resources Bibliography References Index vii xvii xix 15 35 7 125 154 177 209 247 251 253 257FIGURE 2.1 FIGURE 2.2 FIGURE 3.1 FIGURE 3.3 FIGURE 3.4 FIGURE 3.2 FIGURE 3.5 FIGURE 3.6 FIGURE 4.1 FIGURE 4.2 FIGURE 4.3 FIGURE 4.4-4.6 FIGURE 4.7 FIGURE 4.8 FIGURE 4.9 Ficure 4.10 FIGURE 4.11 FIGURE 4.12 FIGURE 4.13 FIGURE 4.14 FIGURE 4.15 FIGURE 4.16 FIGURE 4.17 FIGURE 4.18 Figure 4.19 Tliustrations Magnified contraction knots (trigger points) in muscle fibers Orientation of muscle fibers: (A) parallel; (B) parallel with tendinous inscriptions; (C) bipennate; (D) unipennate Key to pictorial devices Supported fingers Supported fingers nearly perpendicular to skin Supported thumb Thera Cane The Knobble massage tool Stemocleidomastoid muscles Stemocleidomastoid, sternal branch: trigger points and referred pain pattern Sternocleidomastoid, clavicular branch: trigger points and referred pain pattern Sternocleidomastoid massage between fingers and thumb ‘Trapezius number 1 trigger point and referred pain pattern: front view Trapezius number 1 trigger point and referred pain pattern: side view Trapezius number 2 trigger point and referred pain pattern ‘Trapezius number 3 trigger points and referred pain patiern Trapezius number 4 trigger points and referred pain pattern Massage of number 1 trigger point with fingers and thumb Trapezius massage with supported thumb against ball on the wall or bed Upper trapezius massage with Thera Cane Middle trapezius massage with Thera Cane over the opposite shoulder Lower trapezius massage with Thera Cane Lower trapezius massage with ball against wall Levator scapulee trigger points and referred pain pattern Suboccipital muscles’ trigger points 21 37 40 a ai 49 50 52 53 SRSRRRL88 56 59viii The Trigger Point Therapy Workhook FiguRE 4.20 FIGURE 4.21 FIGURE 4.22 FIGURE 4.23 FIGURE 4.24 FIGURE 4.25 FIGURE 4.26 FIGURE 4.27 FIGURE 4.28 FIGURE 4.29 FIGURE 4.30 FIGURE 4.31 FIGURE 4.32 FIGURE 4.33 FIGURE 4.34 FIGURE 4.35 FIGURE 4.36 FIGURE 4.37 FIGURE 4.38 FIGURE 4.39 FIGURE 4.40 Figure 4.41 FIGURE 4.42 FIGURE 4.43 FIGURE 4.44 FIGURE 4.45 FIGURE 4.46 FiGuRE 4.47 FIGURE 5.1 Figure 5.2 Figure 5.3 Figure 5.4 Figure 5.5 FIGURE 5.6 FIGURE 5.7 FIGURE 5.8 g, FIGURE 5.9 FIGURE 5.10 Suboccipitals’ referred pain pattern 59 Posterior neck massage with Thera Cane 59 Position of hands for posterior neck massage with ball or Knobble in hand. 60 Use this position while lying down First hand in place for posterior neck massage with supported fingers 60 Second hand in place for posterior neck massage with supported fingers 60 Splenius capitis trigger point and referred pain pattern 61 Splenius cervicis trigger point number 1 and referred pain pattern: through the 64 hhead to the back of the eye Splenius cervicis trigger point number 2 and referred pain pattern 61 Semispinalis capitis number 1 trigger points and referred pain pattern 61 Semispinalis capitis number 2 trigger points and referred pain. pattern 62 ‘Multifidi and rotatores trigger points and referred pain pattern 62 Masseter trigger points and referred pain pattern 63 Masseter massage with thumb and fingers (thumb inside the mouth) Medial pterygoid trigger points and referred pain pattern 65 Medial pterygoid massage with thumb 85 Lateral pterygoid trigger points and referred pain pattem 65 Lateral pterygoid massage with index finger in mouth Buccinator trigger point and referred pain pattern Obicularis oculi trigger points and referred pain pattern 67 Zygomaticus and levator labii trigger point and referred pain pattern 67 Zygomaticus and levator labii massage with fingertips 67 Kneading the zygomaticus between fingers and thumb 67 Diagastric trigger points and referred pain pattem 68 Posterior digastric massage with fingertips 68 Anterior digastric massage with fingertips 68 Longus colli massage with fingertips 69 Temporalis trigger points and referred pain pattern 69 Temporalis massage with supported fingers 70 Scalene trigger points 75 Scalene referred pain patter, front view 75 Scalene referred pain pattern, back view 75 Location of scalene muscles behind the stemocleidomastoid 76 Scalene massage behind the sternocleidomastoid with fingertips 7 Scalene massage behind the sternocleidomastoid attachment to the collarbone 78 Posterior scalene massage at the junction of the trapezius and the collarbone 78 Bones of the shoulder, front view 79 Bones of the shoulder, back view 79 Locating the superior angle of the shoulder blade 80Figure 5.11 FIGURE 5.12 FIGURE 5.13 FIGURE 5.14 Figure 5.15 FicurE 5.16 Ficure 5.17 FIGURE 5.18 FIGURE 5.19 FIGURE 5.20 FIGURE 5.21 FIGURE 5.22 Figure 5.23 FIGURE 5.24 FIGURE 5.25 FIGURE 5.26 FIGURE 5.27 FIGURE 5.28 FIGURE 5.29 FIGURE 5.30 FIGURE 5.31 FIGURE 5.32 Figure 5.33 FiGuRE 5.34 FiGuRE 5.35 FIGURE 5.36 FIGURE 5.37 FIGURE 5.38 FIGURE 5.39 FIGURE 5.40 FIGURE 5.41 FIGURE 5.42 FIGURE 5.43 FIGURE 5.44 FIGURE 6.1 FIGURE 6.2 FIGURE 6.3 Mustrations ix Rhomboid trigger points and referred pain pattern 81 Serratus posterior superior trigger points 82 Serratus posterior superior referred pain pattern 82 Serratus posterior superior massage with Thera Cane (hand at opposite 82 shoulder) Supraspinatus trigger points and referred pain pattern 84 Supraspinatus massage with the Thera Cane 85 Infraspinatus trigger points 86 Infraspinatus referred pain pattern 86 Axrow shows outward rotation for locating infraspinatus with isolated 87 contraction Infraspinatus massage with Thera Cane 88 Teres minor trigger points and referred pain pattern 88 Subscapularis trigger points and referred pain pattern 89 Position of the fingers for the subscapularis massage ot Position of the thumb for the subscapularis massage o Position of the arms for the subscapularis massage 91 Subscapularis massage with arm hanging down between legs 4 Deltoid trigger points 92 Posterior deltoid pain pattem 92 Lateral deltoid pain pattern 92 Anterior deltoid pain pattern 92 Teres major trigger points and referred pain pattern 94 Latissimus dorsi trigger points and referred pain pattern 94 Latissimus dorsi and teres major massage between fingers and thumb 94 Coracobrachialis trigger points and anterior referred pain pattern 95 Coracobrachialis posterior referred pain pattern 95 Coracobrachialis massage with thumb 95 Biceps trigger points and referred pain patter 96 Biceps massage with knuckles 96 ‘Triceps number 1 trigger point and referred pain pattern 97 Triceps number 2 trigger point and referred pain pattern 97 ‘Triceps number 3 trigger point and referred pain pattern 97 ‘Triceps number 4 trigger point and referred pain pattern 98 ‘Triceps number 5 trigger point and referred pain pattern 98 ‘Triceps massage with knuckles and ball 98 Avoid grasping with thumb and fingers 105 Bones of the forearm and hand: (A) radius; (B) ulna; (C) carpals; (D) 106 metacarpals; (E) phalanges ' ‘7 Brachialis ‘rigger points and referred pain patternx The Trigger Point Therapy Workbook Figure 6.4 FIGURE 6.5 FIGURE 6.6 FIGURE 6.7 FIGURE 6.8 FIGURE 6.9 FIGURE 6.10 FiGuRE 6.17 FIGURE 6.12 FIGURE 6.13 FIGURE 6.14 FicurE 6.15 FIGURE 6.16 FIGURE 6.17 FIGURE 6.18 FIGURE 6.19 FIGURE 6.20 FIGURE 6.24 FIGURE 6.22 FIGURE 6.23 FIGURE 6.24 FIGURE 6.25 FIGURE 6.26 FIGURE 6.27 FIGURE 6.28 FIGURE 6.29 FIGURE 6.30 Figure 6.34 FIGURE 6.32 FIGURE 6.33 FIGURE 6.34 FIGURE 6.35 FIGURE 6.36 FicuRE 6.37 i, FIGURE 6.38 , FIGURE 6.39 Brachialis massage with supported thumb Extensor carpi radialis longus trigger point and referred pain patter (the drawings show the outer side of the forearm and hand) Locating the extensor carpi radialis longus by isolated contraction Extensor carpi radialis longus massage with supported thumb Extensor carpi radialis longus massage with ball against a wall (the ball is between the arm and the wall, which is not shown here) Brachioradialis trigger point and referred pain patter Supinator trigger point and referred pain pattern Extensor carpi radialis brevis trigger point and referred pain pattern. Locating extensor carpi radialis brevis by isolated contraction Extensor carpi radialis brevis massage with ball against the wall Extensor carpi ulnaris trigger point and referred pain pattem Locating extensor carpi ulnaris by isolated contraction Extensor carpi ulnaris massage with ball against the wall Anconeus trigger point and referred pain pation Locating the anconeus by isolated contraction. Extensor igitorum trigger point and referred pain pattem Extensor indicis trigger point and referred pain pattern Locating extensor digitorum by isolated contraction Locating the extensor indicis Extensor digitorum massage with ball against the wall Flexor carpi radialis trigger point and referred pain pattern Locating flexor carpi radialis by isolated contraction Flexor carpi radialis massage with supported thumb Flexor carpi radialis massage with ball against the wall Flexor carpi ulnaris trigger point and referred pain pattern Locating flexor carpi ulnaris by isolated. contraction Palmaris longus trigger point and xeferred pain. pattern Locating palmaris longus by isolated contraction Flexor digitorum trigger points and referred pain pattern Pronator teres and pronator quadratus trigger points and referred pain pattern Locating pronator teres by isolated contraction Locating pronator quadratus by isolated contraction Hlexor pollicis longus trigger point and referred pain pattern Locating flexor pollicis by isolated contraction Opponens pollicis trigger points and referred pain pattern Opponens pollicis massage with supported thumb Adductor pollicis trigger points and referred pain pattern 108 109 109 110 110 110 111 a1 114 112 112 112 113, 113 13 “114 114 114 115 115 116 116 116 116 7 117 17 118 118 119 119 19 120 120 3 121 121Ilustrations xi FIGURE 6.41 Locating the abductor pollicis. To feel the muscle contract, press the thumb — 121 against the side of the hand. FIGURE 6.42 Adductor pollicis massage with supported thumb 122 FIGURE 6.43 Dorsal interosseous trigger points and referred pain pattern 122 FIGURE 6.44 First dorsal interosseous trigger points and referred pain pattern 122 FIGURE 6.45 ——_Locating first dorsal interosseous by isolated contraction 123 FIGURE 6.46 Dorsal interosseous massage with supported thumb 123 FIGURE 6.47 Eraser massage of interosseous 124 FIGURE 6.48 Spring clamps and erasers for massage of interosseous muscles * 124 FIGURE 6.49 First dorsal interosseous massage with supported thumb 124 FIGURE 7.1 Pectoralis major, clavicular section: trigger points and referred pain pattern 130 FIGURE 7.2 Pectoralis majot, sternal section: trigger points and referred pain pattern 130 FIGURE 7.3 Pectoralis major, costal section: trigger points and referred pain pattern 130 FIGURE 7.4 Pectoralis major, arrhythmia trigger point 130 FIGURE 7.5 Pectoralis major massage with ball against the wall 131 FIGURE 7.6 Pectoralis major massage with supported fingers 131 FIGURE 7.7 Pectoralis major massage of lateral border 134 FIGURE 7.8 Subclavius trigger points and referred pain pattem 132 FIGURE 7.9 Stemnalis trigger points and referred pain pattern 132 FiGuRE 7.10 Pectoralis minor trigger points and referred pain pattern 134 FIGURE 7.11 Locating pectoralis minor: the hand behind the back is pushing against the 135 wall FIGURE 7.12 Serratus anterior trigger point (trigger points may be found in any of the 136 muscle’s bellies) FIGURE 7.13 Serratus anterior referred pain pattern in the side 136 FIGURE 7.14 Serratus anterior referred pain pattem in the back 136 FIGURE 7.15 — Serratus anterior massage with ball against the wall 137 FIGURE 7.16 Upper abdominal trigger points and referred pain pattern 141 FIGURE 7.17 Midabdominal trigger points and referred pain pattern 141 FIGURE 7.18 Pseudoappendicitis trigger point and referred pain pattern 141 FIGURE 7.19 Lower abdominal trigger points and referred pain pattern 144 FIGURE 7.20 Abdominal trigger points and referred pain patterns in the back 142 FIGURE 7.21 Supported fingers for upper abdominal massage 143 FiGuRE 7.22 Supported fingers for lower abdominal massage 143 FIGURE 7.23 Supported thumbs in opposition for midabdominal massage 143 FIGURE 7.24 ‘Massage of midabdomen. 144 FIGURE 7.25 Psoas trigger points and referred pain pattern in the back 145 FIGURE 7.26 Psoas trigger points and referred pain pattern in the groin and thigh 145 FIGURE 7.27 Supported fingers for psoas massage 146 FIGURE 7.28 —Psoas massage with supported fingers 147xii The Trigger Point Therapy Workbook FIGURE 8.1 Deep spinal muscles: sample trigger points and pain patterns 155 FIGURE 8.2 (A) Semispinalis; (B) multifidi; (C) rotatores; (D) levator costae muscles 155 FIGURE 8.3 Massage of deep spinal muscles with Thera Cane 157 FIGURE 8.4 Longissimus sample trigger points and referred pain pattem. 159 FIGURE 8.5 Miocostalis sample trigger points and referred pain patterns 159 FIGURE 8.6 Serratus posterior inferior trigger points and referred pain pattern 160 FIGURE 8.7 Serratus posterior inferior massage with ball in a sock against the wall 161 FIGURE 8.8 Quadratus lumborum: superficial trigger points and referred pain pattem 162 FIGURE 8.9 Quadratus lumborum: deep trigger points and referred pain pattern 162 FIGURE 8.10 Locating quadratus lumborum by isolated contraction with hip hike 163 FIGURE 8.11 Quadratus lumborum massage with ball against the wall 163 FIGURE 8.12 Quadratus Jumborum massage with Thera Cane 163 FIGURE 8.13 Gluteus maximus number 1 trigger point and referred pain pattem 164 FIGURE 8.14 luteus maximus number 2 trigger point and referred pain patter 164 FIGURE 8.15 Gluteus maximus number 3 trigger point and referred pain pattern 164 FIGURE 8.16 Massage of gluteal muscles with ball against the wall FIGURE 8.17 Massage of gluteal muscles with ball on the floor or the bed FIGURE 8.18 Massage of gluteal muscles with Thera Cane - FIGURE 8.19 luteus medius number 1 trigger point and referred pain pattern FIGURE 8.20 luteus medius number 2 trigger point and referted pain pattern FIGURE 8.21 luteus medius number 3 trigger point and referred pain pattern FIGURE 8.22 Feeling the greater trochanter (A) and the top of the hipbone (B) FIGURE 8.23 Locating gluteus medius by isolated contraction with weight shift to right foot 169 FIGURE 8.24 luteus medius massage with ball against the wall 169 FIGURE 8,25 Gluteus minimus number 1 trigger point and referred pain pattern 170 FIGURE 8.26 — Gluteus minimus number 2 trigger point and referred pain pattern 170 FIGURE 8.27 Locating sluteus minimus by isolated contraction with weight shift to right 174 foot FIGURE 8.28 — Gluteus minimus massage with ball against the wall 171 FIGURE 8.29 Piriformis number 1 trigger point and referred pain pattern 172 FIGURE 8.30 ——_Piriformis number 2 trigger point and referred pain pattern 172 FIGURE 8.31 (A) pitiformis; (B) the other short hip rotators; (C) the sciatic nerve 173 FIGURE 8.32 Locating piriformis by isolated contraction 174 FIGURE 8.33 Piriformis massage with ball against wall 174 FIGURE 8.34 Piriformis stretch 175 Figure 9.1 Tensor fasciae latae trigger point and referred pain pattern 181 FiGure 9.2 Locating tensor fasciae latae by isolated contraction with weight shift 182 FiGuRE 9.3 Tensor fasciae latae massage with Thera Cane 182 FIGURE 9.4 Tensor fasciae latae massage with ball against wall 182FIGURE 9.5 FIGURE 9.6 FIGURE 9.7 FIGURE 9.8 FIGURE 9.9 FIGURE 9.10 Figure 9.11 Figure 9.12 Figure 9.13 FIGURE 9.14 FIGURE 9.15 FIGURE 9.16 FIGURE 9.17 FIGURE 9.18 FIGURE 9.19 FIGURE 9.20 FIGURE 9.21 FIGURE 9.22 FIGURE 9.23 FIGURE 9.24 FIGURE 9.25 Ficure 9.26 FIGURE 9.27 FicurE 9.28 FIGURE 9.29 FIGURE 9.30 FIGURE 9,31 FIGURE 9.32 FIGURE 9.33 FIGURE 9.34 FIGURE 9.35 FIGURE 9.36 FIGURE 9.37 FIGURE 9.38 FIGURE 9.39 FIGURE 9.40 FIGURE 9.41 FIGURE 9.42 Ilustrations Sartorius trigger points and referred pain pattern Sartorfus referred pain pattern near the knee Locating sartorius by isolated contraction, by raising the leg forward Sartorius massage with supported fingers Quadriceps muscle Rectus femoris number 1 tigger point and refered pain pattern Rectus femoris number 2 trigger point and referred pain pattern Locating rectus femoris by isolated contraction Rectus femoris massage with paired thumbs Rectus femoris massage with Thera Cane Rectus femoris massage with ball against the wall Vastus intermedius trigger point and referred pain pattern Vastus medialis number 1 trigger point and referred pain pattern Vastus medialis number 2 trigger point and referred pain pattern Vastus medialis massage with paired thumbs Vastus medialis massage with supported fingers Vastus medialis massage with elbow Vastus lateralis number 1 trigger point and referred pain pattern Vastus lateralis number 2 trigger point and referred pain pattern Vastus lateralis number 3 trigger point and referred pain pattern Vastus lateralis number 4 trigger points and referred pain pattern Vastus lateralis number 5 trigger point and referred pain pattern ‘Vastus lateralis massage with supported fingers ‘Vastus lateralis massage with Thera Cane Vastus lateralis massage with ball against the wall Inner thigh muscles Pectineus trigger point and referred pain pattern Locating pectineus by isolated contraction, raising the inner leg forward Pectineus massage with paired fingers Adductors longus and brevis trigger points and referred pain pattern 183 183 184 184 185 186 186 187 187 188 188 188 189 189 190 190 190 191 191 191 191 191 192 192 193 193 194 195 195 196 Locating adductor longus (A) and abductor magnus (B) by isolated contraction, 197 raising right leg from bed Grasping adductor longus between fingers and thumb Grasping adductor magnus between fingers and thumb Adductor massage with supported fingers Adductor magnus number 1 trigger points and referred pain pattern Adductor magnus number 2 trigger points and referred pain pattern ‘Adductor magnus number 1 massage near the sit bone with Thera Cane Position of ball for adductor magnus number 1 trigger point massage on ‘wooden chair 198 198 198 199 199 200 200xio The Trigger Point Therapy Workbook FIGURE 9.43 —Gracilis trigger points and referred pain pattern 201 FIGURE 9.44 (A) hamstrings; (B) sit bone; (C) femur; (D) tibia; (B) fibula 201 FIGURE 9.45 Biceps femoris trigger point and referred pain pattern 202 FIGURE 9.46 Hamstring massage with ball on wooden bench or chair 203 FIGURE 9.47 Semitendinosus and semimembranosus trigger point and referred pain patiem 204 FIGURE 9.48 —_Popliiteus trigger point and referred pain pattern 205 FiguRE 9.49 ——_Popliiteus massage with fingers of both hands 206 FIGURE 9.50 Popliteus massage with thumbs 206 FIGURE 9.51 —_—_Plantaris irigger point and referred pain pattern 207 FIGURE 10.1 (A) shin muscles; (B) tibia; (C) fibula 214 FIGURE 10.2 Tibialis anterior trigger point and referred pain pattem 216 FIGURE 10.3 Locating tibialis anterior by isolated contraction 217 FIGURE 10.4 Tibialis anterior massage with supported fingers or Knobble 217 FIGURE 10.5 —Tibialis anterior massage with Thera Cane 217 FIGURE 10.6 —_Tibialis anterior massage with the heel as the tool 218 FIGURE 10.7 Tibialis anterior massage with heel 218 FIGURE 10.8 Extensor digitorum longus trigger point and referred pain pattern 219 FiGURE 10.9 Extensor hallucis longus trigger point and referred pain pattern __ 219 FIGURE 10.10 Locating extensor digitorum longus by isolated contraction 220 FIGURE 10.11 ‘Locating extensor hallucis longus by isolated contraction 220 FIGURE 10.12 (A) peroneus muscles; (B) tibia; (C) fibula; (D) fifth metatarsal 224 FIGURE 10.13 Peroneus longus trigger point and referred pain pattern 222 FIGURE 10.14 Locating peroneus longus by isolated contraction 223 FIGURE 10.15 Peroneus longus massage with paired thumbs 223 FIGURE 10.16 —_Peroneus brevis trigger point and referred pain pattern 224 FIGURE 10.17 Locating peroneus brevis by isolated contraction 224 FIGURE 10.18 —Peroneus tertius trigger point and referred pain pattern 225 FIGURE 10.19 Locating peroneus tertius by isolated contraction 225 FIGURE 10.20 Peroneus tertius massage with paired thumbs 225 FIGURE 10.21 Peroneus tertius massage with ball on the edge of the bed 226 FiGuRE 10.22 — Gastrocnemius number 1 trigger point and referred pain pattern in the instep 227 FiGure 10.23 Other gastrocnemius trigger points and local pain pattern 227 FiGURE 10.24 — Gastrocnemius massage with supported fingers 228 FIGURE 10.25 — Gastrocnemius massage with opposite knee 228 FIGURE 10.26 Gastrocnemius massage with opposite knee 228 FIGURE 10.27 Soleus number 1 trigger point and referred pain paterrn 230 FIGURE 10.28 Soleus number 2 trigger point and referred pain pattern 230 FIGURE 10.29 Soleus number 3 trigger point and referred pain pattern in the low back 230 FIGURE 10.30 Tibialis posterior trigger points and referred pain pattern 232FIGURE 10.31 Figure 10.32 Figure 10.33 Figure 10.34 Figure 10.35 FIGURE 10.36 FIGURE 10.37 FIGURE 10.38 FIGURE 10.39 FiGURE 10.40 Figure 10.41 FiGuRE 10.42 FIGURE 10.43 FIGURE 10.44 FIGURE 10.45 FIGURE 10.46 FIGURE 10.47 FIGURE 10.48 FIGURE 10.49 FIGURE 10.50 FIGURE 10.51 FIGURE 10.52 FiGuRE 10.53 Figure 10.54 Figure 10.55 FIGURE 10.56 FIGURE 10.57 Mlustrations Flexor digitorum longus trigger point and referred pain pattern Flexor hallucis longus trigger point and referred pain pattem. Flexor digitorum longus massage with paired thumbs Locating flexor hallucis longus by isolated contraction ‘Morton's foot: (A) second metatarsal; (B) first metatarsal; (C) calluses Locating the metatarsal heads Pads under the first metatarsal heads Extensor digitorum brevis and. extensor hallucis brevis trigger points referred pain pattern . Sample interosseous trigger point and referred pain pattern Locating the short extensors by isolated contraction Inierosseous massage with supported thumb Abductor hallucis trigger points and referred pain pattern Locating abductor hallucis by isolated contraction Abductor hallucis massage with supported thumb Massaging the bottom of the foot with small nipple on the Thera Cane ‘Massaging the bottom of the foot with the Knobble Massaging the bottom of the foot with a small hard rubber ball on the floor Abductor digiti minimi trigger points and referred pain pattern Locating abductor digiti minimi by isolated contraction Flexor digitorum brevis trigger points and referred pain pattern Locating flexor digitorum brevis by isolated contraction Quadratus plantae trigger point and referred pain pattern Adductor hallucis trigger points and referred pain pattern Flexor hallucis brevis trigger points and referred pain pattern Locating adductor hallucis and flexor hallucis brevis by isolated contraction ‘Adductor hallucis and flexor hallucis brevis massage with supported thumb Flexor digiti minimi brevis tigger point and referred pain pattern x0 233 233 234 234 235 236 236 237 238 239 239 240 240 241 241 241 244 242 242 243 244 244 245Foreword By David G. Simons, M.D. Clair Davies possesses a fortunate combination of attributes: He is a skilled practitioner, has good writing skills, and: shows a remarkable determination to help relieve mankind of unnecessary suffering. The message of this book is a voice in a wilderness of neglect. Muscle is an orphan organ. No medical specialty claims it. As a consequence, no medical specialty is concerned with promoting funded research into the muscular causes of pain, and medical students and physical therapists rarely receive adequate primary training in how to recog- nize and treat myofascial trigger points. Fortunately, massage therapists, although rarely well trained medically, are trained in how to find myofascial trigger points and frequently become skilled in their treatment. Since there is no well-established body of research on this subject, there is no well- recognized etiology. Nevertheless, a credible hypothesis based on solid scientific research is available to serve as a model for further research to clarify the nature of myofascial trigger points. Much research needs to be done on this neglected subject. It is becoming increasingly clear that nearly all fibromyalgia patients have myofascial trigger points that are contributing significantly to their total pain problem. Some patients are diagnosed as having fibromyalgia when in fact they only have much more treatable mul- tiple trigger points. Inactivation of the trigger points of fibromyalgia patients requires espe- cially delicate and skilled treatment. Skilled clinicians recognize myofascial trigger points as the most common cause of ubiquitous enigmatic musculoskeletal pain, but finding a truly skilled practitioner can be frustratingly difficult. The guidance in this book can serve practitioners who have yet to understand the nature of their own musculoskeletal pain and can also benefit patients who are unable to find a practitioner adequately skilled in this neglected subject. There is no substitute for learning how to control your own musculoskeletal pain. Treating myofascial trigger points yourself addresses the source of that kind of common pain and is not just a way of temporarily relieving itAcknowledgments I’m fortunate to have been influenced by so many good people during the development of this book and throughout my own evolution. The following deserve special notice: ‘Ann Luray Bailey of Lubbock, Texas (formerly Ann Gyor of Lexington, Kentucky), my first massage therapist, “the one I liked so much,” the wondrous woman who introduced me to trigger points and then moved away, making it necessary for me to draw on my own. resources and ultimately produce this method of self-treatment. If all healthcare practitioners had Ann’s mind, hands, and heart, there would be very little pain in the world. Barbara G. Cummings, the illustrator for Travell and Simons’ Myofascial Pain and Dys- function, The Trigger Point Manual, whose insight, imagination, and graphic skills made it possible to comprehend the reality of trigger points for the first time. The complex medical innovations of Janet Travell and David Simons would have been virtually incomprehensible without Barbara’s drawings. She made the Trigger Point Manual work. Her illustrations were a constant inspiration while I was struggling to create my own illustrations for this book. All my friends in the Piano Technicians Guild, who fostered my growth, not only as a piano technician, but also as a writer and illustrator in the Piano Technicians Journal. I con- tinue to feel their support, even after leaving the fold and taking on this disconcerting new identity. ‘My instructors and classmates at the Utah College of Massage Therapy, who helped bear the “old man” into a new world of caring and healing. So many new experiences! What a trip! “My daughter Maria, my son-in-law (and former apprentice) Wayne Worley, my former wife (and best friend) Janice Lipuma, her son Will Drane, my mother-inlaw Ruth Quigley Smith, and my grandsons Michael and Adam, who were all always in my corner, even when I was too preoccupied to notice. ‘The editors and staff at New Harbinger Publications, who know exactly what they’re doing in putting a book together and caring for an ignorant and apprehensive new author. Special thanks to Clancy Drake, Heather Gamos, Kasey Pfaff, Spencer Smith, Amy Shoup, and Michele Waters. To avoid the disgrace of forgetting someone, I won't try to name the numerous clients and personal friends who have given me so much of their confidence and trust as I rediscov- ered myself in the transition from piano mechanic to massage therapist and teacher of self-care.Introduction Jennifer, twenty-eight, who loved to run for her health every day in the fresh morning air, has had to stop running and is reluctant even to walk any distance because of relentless pain in her knees and heels. Larry, fifty-two, can think of little else but the constant pain in his back. It’s hard to get in and out of bed. His back hurts whether he’s sitting, standing, or lying down. Tt makes him hate his job and has ruined his love life. ‘Melanie, thirty-six, spends her days at a computer keyboard and her nights worrying about her future and the unremitting pain in her arms and hands, As a single mother, she has to keep working no matter what. Jack, forty-five, has shoulder pain that wakes him up at night. He can’t raise his arm to comb his hair. Reaching up to scratch his back is impossible. A sudden movement brings a jolt of pain that feels like an electric shack and doubles him over, grimacing and breathless, Is this the start of the inevitable decline into old age, disability, and death? Howard, twenty-three, is a gifted violin student. After years of hard work under some of the best teachers in the country, he now fears a professional career is out of reach because of constant pain and an unexplained, increasing stiffness in his fingers. Do you know anybody like these people? They’re everywhere—on every job, in every office, in every home. The thing all these people have in common, other than chronic pain, is that they aren't getting the help they need. It’s not that they haven't looked. They've gone the rounds. They've seen doctors, had tests, done physical therapy, and filled out insurance forms, or—sick at heart—have paid the exorbitant bills themselves. They've tried chiropractic, acupuncture, magnets, pain diets, and herbal therapy. They take their pain medicine and dutifully do their stretching exercises. Sometimes they feel better for a while, but the pain always comes back. Nothing really seems to get to the bottom2 The Trigger Point Therapy Workbook of the problem. They fear surgery may be the only solution, despite being told there are no guarantees of success. They’re beginning to wonder if anybody really knows anything about ain. If all this describes your own situation or that of someone you care about, this book may provide the help you've been seeking, It proposes to give you a sensible explanation of what's wrong and help you find the real cause of your pain. Even better, it may well show you how to get rid of the pain yourself, hands-on. No doctors. No pills. No bills. There is growing evidence 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. Pain clinic doctors skilled at detecting and treating trigger points have found that they’re the primary cause of pain roughly 75 percent of the time and are at least a part of virtually every pain problem. Even fibromyalgia, which is known to afflict millions of people, is thought in many instances to have its beginning with trigger points. (Travell and Simons 1999: 12-19; Gerwin 121; Fishbain 181-197). Trigger points are known to cause headaches, neck and jaw pain, low back pain, the symptoms of carpal tunnel syndrome, and many kinds of joint pain mistakenly ascribed to arthritis, tendonitis, bursitis, or ligament injury. Trigger points cause problems as diverse as earaches, dizziness, nausea, heartburn, false heart pain, heart arrhythmia, tennis elbow, and genital pain. Trigger points can also cause colic in babies and bed-wetting in older children, and may be a contributing cause of scoliosis. They are a cause of sinus pain and congestion. They may play a part in chronic fatigue and lowered resistance to infection. And because trigger points can be responsible for long-term pain and disability. that seem to-have no means of relief, they can cause depression. The problems trigger points cause can be surprisingly easy to fix; in fact most people can do it themselves if they have the right information. That’s good, because the time has come for ordinary people to take things into their own hands. The reason this is so is that an appallingly high percentage of doctors and other practitioners are still pretty much out of the loop regarding trigger points, despite their having been written about in medical jour- nals for over sixty years. There has been, and continues to be, great resistance to the whole idea. Why has the medical profession not embraced the idea of trigger points? Partly it’s because trigger points are commonly confused with acupressure points. Acupressure, which has come down to us from ancient Chinese medicine, is alleged to have a positive effect on supposed flows of energy throughout the body. Although acupressure and other Eastern methods of healing do seem to have a beneficial effect, they’re very resistant to solid scien- tific investigation and are viewed by many doctors and a large segment of the public as quack medicine with no proven results. If you don’t know the difference, the claims about trigger points sound like quack medicine too. Our knowledge of trigger points, however, comes right out of Western medical research. Trigger points are real. They can be felt with the fingers. They emit distinctive elec- trical signals that can be measured by sensitive electronic equipment. Trigger points have also been photographed in muscle tissue with the aid of the electron microscope. (Travell and Simons 1999: 57-67) Most of what is known about trigger points is very well documented in the two-volume medical text Myofascial Pain and Dysfunction: The Trigger Point Manual, by Janet Travell and David Simons, These books tell virtually all that is known about trigger points, and the ‘pros- Pects for pain relief are very exciting. Much of the information in The Trigger Point Manual isIntroduction — 3 couched in difficult scientific terms, but basic trigger point science isn’t hard to grasp if it’s put into everyday language. Travell and Simons describe a trigger point as simply a small contraction knot in mus- cle tissue. It often feels like a partly cooked piece of macaroni, or like a pea buried deep in the muscle. A trigger point affects a muscle by keeping it both tight and weak. At the same time, a trigger point maintains a hard contraction on the muscle fibers that are directly con- nected to it. In turn, these taut bands of muscle fiber keep constant tension on the muscle’s attachments, often producing symptoms in adjacent joints. The constant tension in the fibers of the trigger point itself restricts circulation in its immediate area. The resulting accumula- tion of the by-products of metabolism, as well as deprivation of the oxygen and nutrients needed for metabolism, can perpetuate trigger points for months or even years unless some intervention occurs. It’s this self-sustaining vicious cycle that needs to be broken (Travell and Simons 1999: 71-75). The difficulty in treating trigger points is that they typically send pain to some other site, Most conventional treatment of pain is based on the assumption that the cause of pain will be found at the site of the pain. But trigger points almost always send their pain else- where. This referred pain is what has always thrown everybody off, including most doctors and much of the rest of the health-care community. According to Travell and Simons, con- ventional treatments for pain so often fail because they focus on the pain itself, treating the site of the pain while overlooking and failing to treat the cause, which may be some distance away. Even worse than routinely treating the site of the pain is the pharmaceutical treatment of the whole body for what is usually a local problem. Painkilling drugs, the increasingly expensive treatment of choice these days, give us the illusion that something good is hap- pening, when in reality they only mask the problem. Most common pain, like headaches, muscle aches, and joint pain, is a warning—a protective response to muscle overuse or trauma. Pain is telling you that something is wrong and needs correction. It’s not good med- icine to kill the messenger and ignore the message. When pain is seen in its true role as the messenger and not the affliction itself, treatment can be directed to the cause of pain. Luckily, referred pain is now known to occur in predictable patterns. The valuable medical advance made by Travell and Simons and their brilliant illustrator, Barbara Cummings, has been in delineating these very patterns. Once you know where to look, trig- ger points are easily located by touch and deactivated by any of several methods. Unfortunately, the two clinically oriented methods put forth in The Trigger Point Manual don’t lend themselves to self-treatment. The goal of this book is to build on the work of Travell and Simons and provide a more practical and cost-effective approach to pain ther- apy: a classic do-it-yourself approach, rather than a reliance on multiple professional office visits. This new approach is a system of self-applied massage directed specifically at trigger points. Significant relief of symptoms often comes in just minutes. Most problems can be eliminated within three to ten days. Even long-standing chronic conditions can be cleared up in as little as six weeks. Results may be longer in coming for those who suffer from fibromyalgia, chronic fatigue, or widespread myofascial pain syndrome, but even they can experience continuing progress and can have genuine hope of significant improvement in their condition. Self-applied trigger point massage works by accomplishing three things: it breaks into the chemical and neurological feedback loop that maintains the muscle contraction; it increases circulation that has been restricted by the contracted tissue; and it directly stretches the trigger point’s knotted muscle fibers. The illustrations in this book show you how to find4 ‘The Trigger Point Therapy Workbook the trigger points that are generating your specific problems, as well as the exact hands-on techniques for deactivating them. Special attention has been given to designing methods of massage that do no damage to hands that may already be in trouble from overuse. This book’s primary use is as a self-instruction manual, but it can also be used as a text- book for classroom use. This simplified and direct approach to treating pain with self-applied massage can constitute a foundational course in trigger point therapy in any professional training curriculum. Students in chiropractic colleges, physical therapy depart- ments, and massage schools will derive particular benefit. If they can learn how to interpret their own referred pain and how to find and treat their own trigger points, they will know exactly what to do when they encounter similar problems in their future clients. A class in self-applied trigger point massage would be a boon in medical schools for exactly the same reasons. When new doctors can learn how to fix their own pain with self-applied massage, they are in better touch with the realities of pain and with the great potential in the treatment of trigger points. Such an addition to medical education would profoundly improve the treatment of pain and lower much of its cost. And it’s not too late for physicians already in practice to learn about trigger points and myofascial pain and put the knowledge to good use. They will find this book a quick and practical introduction to the magnificent work of Travell and Simons and this neglected branch of medicine. Hopefully, many will be encouraged to go to Travel and Simons’ Trig- ger Point Manual for a deeper scientific understanding and for even greater benefit to their practice. A large segment of the public needs help and encouragement in learning how to deal with their trigger point-induced pain. No one is better positioned to provide this help than the medical community. The medical profession is not unaware of the deficiencies of current methods of treating pain. Doctors hurt too. Many of them worry like the rest of us about the relentless popping of pills, and many experience frustration with their inability to offer better solutions to their patients. Trigger point therapy, whether self-applied or administered by a professional, has the potential to truly revolutionize pain treatment throughout the world.CHAPTER 1 A New Life Iwas sixty years old when, at the height of my success in a business I'd pursued for almost four decades, I decided to dump it all and start at the bottom in a completely new field. Piano rebuilding had been my trade and it had been a good one. My income had exceeded one hundred thousand dollars in some years; as a massage therapist, I knew I'd be lucky to make twenty thousand. The old life was full of rewards, not the least of which was intense satisfaction in the work itself, great prestige in my community, and unquestioned status among my peers. The new life would be full of anxieties and uncertainties, with little likelihood of ever equalling the success I'd enjoyed in the old one. What was my motive for making such a wrenching change? In a word, the motive was pain. Through a difficult personal struggle with pain, I believed I had learned something worth sharing with the world. I believed I’d discovered something new in the treatment of pain that could change lives as it had changed mine. I couldn't be content with keeping it to myself. ‘You wouldn’t be reading this book if you weren’t in the midst of your own unresolved struggle with pain—or if you weren't motivated to help those who are in pain. I hope my story will show you what can be done when nobody is able to help you—when you hurt so bad you'd sometimes almost rather die than live. ‘Vladimir Horowitz's piano tuner taught me to tune pianos. It was 1960 and I was an apprentice at Steinway & Sons in New York. It was a great start, After I left Steinway, I had my own business in New York for several years, tuning in homes, churches, concert halls, recording studios, and theaters all over town. New York was cheap, a lot of really famous people knew my name, I rode a motorcycle, I had girlfriends—life was good. In the late sixties, I moved to Kentucky, seeking cleaner air and a place to park my new car. I settled down, got married, and started raising two spunky daughters. In succeeding years, I rebuilt and refinished hundreds of grand pianos and tuned tens of thousands of pianos of all kinds. The business was full of rewards for a restless, creative spirit: I invented dozens of new tools for the piano trade, and through the many articles I wrote for the Piano Technicians Journal, piano tuners all over the world became acquainted with my tools, my6 The Trigger Point Therapy Workbook methods, my name. I gained a reputation as someone who was good at finding simple solu- tions for difficult problems. But during my time in the piano business I had a lot of trouble with pain—neck pain, back pain, every kind of pain you'd expect to get from hard physical work. As time went by, I grew increasingly concerned about how long I could continue. I had gradually become aware that the happiness and the very livelihood of virtually every piano technician I’d ever known had been threatened at one time or another by work-related pain. I remembered one of my teachers at Steinway had once been so crippled by a bad shoulder that he could hardly do his work. When I eventually came down with a bad shoulder of my own, I had to face the fact that there really weren't any good solutions for pain. Basically, you popped a pill and tried to live through it. I discovered that the worst thing about pain was that doctors and others who were supposed to help didn’t really help: many almost seemed to be faking an understanding. And they all charged an arm and a leg whether they helped you or not. The situation made me so mad and desperate that I made up my mind to fix my shoulder myself, if there was any possible way. Before I was done, had not only gotten rid of my shoulder pain, but I had retired from my work with pianos and had graduated from massage school. Instead of tuning pianos I ‘was now tuning people. I had discovered the most important work of my life. Nobody Understood Shoulders Ironically, my life-changing crisis with pain wasn’t caused directly by piano work—though Tm sure my job set me up for it. The trouble began one January morning when I came in from shoveling snow in my driveway with an oppressive little pain in my shoulder. As I went on with my shop work that day and in the days that followed, I favored the shoulder more and more. Everything I did irritated my condition—whatever that condition was. Before long, I could hardly raise my arm. Soon, I couldn’t pick up my grandson, reach across to get my seat belt, or crawl under a grand piano to do a repair without excruciating pain. It got so bad that a sudden move would give me a jolt of pain that felt like an electric shock, doubling me over, grimacing and breathless, for several minutes. I couldn’t sleep. I’d get up in the night seeking relief with ice rubs and hot showers, but nothing I did had any lasting effect. The ice would dull the pain long enough to let me get back to sleep, but in the momn- ing the pain was back in full force. Some years earlier, I had gone to a massage therapist for a back spasm. I had gone as a last resort, not really hoping for or expecting much. But she fixed me, and then went on to fix the chronic pain I had in my arms and hands. I couldn’t have been more pleased—or sur- prised. I had barely been aware that massage therapy existed, let alone having any notion that it actually worked. I had figured the pain in my arms and hands was just the inevitable and all-too-precipitous decline of old age. But in only three sessions, my massage therapist succeeded in ridding me of an affliction that had possessed me for as long as I could remem- ber. Unfortunately, I was at a loss with the new shoulder problem. This wondrous woman had moved away and I had no choice but to try to find someone else with a similar gift for healing. It was a fruitless search. Variations on the theme of “exercise and stretch” were all I heard, despite my protests that stretching made my pain worse, not better. At one point, I realized that the physical therapist who was treating me for my frozen shoulder was herselfChapter 1A New Life 7 secretly suffering from exactly the same affliction! She couldn’t fix herself and she couldn’t fix me, but she expected payment just the same. Thad a sense that nobody really understood shoulders. I tried a series of massage thera- pists, looking for the grand resullts I’d had before, but they all just seemed to tinker with my shoulder problem. From previous experience, I had no faith in chiropractic for this problem. Talso had no reason to think doctors would offer me anything but painkillers, or worse, sur- gery. You also hear about doctors forcibly manipulating frozen shoulders. Not in this life- time, I thought; thanks just the same. In the midst of my frustrating search for effective treatment, I decided to go to the annual convention of the Piano Technicians Guild. There were classes all week on various aspects of piano technology, and I had always felt revitalized by the dynamic exchange of ideas there. I was determined to go despite my disability, and was hoping a break from work would help. But sitting all day in classes holding my arm defensively and motionless at my side only seemed to aggravate the problem. I rubbed at my shoulder continuously; I squeezed it; I tried to relax it; I tentatively and cautiously flexed it. The only result was an ache that rose in intensity throughout the week. My every thought was of pain. On the last night, the pain was so unremitting that not even the ice treatments had any effect. I lay in bed in my hotel room at two o’clock in the morning and cried like a baby. Evi- dently, all I could hope for was to somehow outlive the problem. I had heard that it took about a year for a shoulder to heal itself—if it did heal itself. Lying there in my misery, I happened to remember a pair of medical books I had seen years earlier on the desk of that first massage therapist I'd liked so much. She told me she teferred to those books constantly, and she had been the only person who really seemed to know what she was doing in regard to pain. I realized I was going to have to find a way to take care of this problem myself and those medical books might at least be a place to start. It was a spark of hope. A New Technology When I got home from the convention, I ordered the books: volumes I and II of Myofascial Pain and Dysfunction: The Trigger Point Manual, by Janet Travell and David Simons. The price of medical books was a shock and I bridled a bit, but I finally had to ask myself: What is this knowledge worth? My shoulder answered the question for me. When the books came, I entered a world I hadn't known existed. As soon as I began to zead, the mystery of my shoulder problem began to clear. In the Trigger Point Manual, 1 found hundreds of beautifully executed illustrations of the muscles of the body. They showed the likely trigger points for every muscle and the patterns of pain they predictably touched off. I found that, although the physiology of a trigger point was extremely complex, a trig- ger point for practical purposes could be viewed as what most people call a “knot”: a wad of muscle fibers staying in a hard contraction, never relaxing. A trigger point in a muscle could be actively painful or it could manifest no pain at all unless touched. More often, though, it would sneakily send its pain somewhere else. I gathered that much of my pain, perhaps all of it, was probably this mysterious displaced pain, this referred pain. I had never been able to figure out why all the rubbing I had been doing had never done any good. Jt was a mis- take to assume the problem was at the place that hurt!8 — The Trigger Point Therapy Workbook The pain in the front of my shoulder was actually coming from behind it, from trigger points in the infraspinatus, a muscle that covered part of the outside of my shoulder blade. The deep aching behind my shoulder was coming from trigger points in the subscapularis, a muscle on the underside of my shoulder blade, sandwiched between the shoulder blade and the ribs. The unrelenting pain at the inner edge of my shoulder blade was being sent by trig- ger points in the scalene muscles, in the front and sides of my neck. It was no wonder nobody knew what to do for me! It was clear to me that all I had was a massive number of trigger points in the muscles in my shoulder—trigger points in over twenty muscles, as it turned out. That first massage therapist, the one I liked so much, had treated me very successfully with ordinary massage techniques and I understood now that it was trigger points she was dealing with. Perhaps I could deal with the trigger points myself using massage. ] began to think that this might be a job for someone with a technician’s mentality—maybe someone who was smart enough to take on the complexities of a piano would be well equipped to fix trigger points. Driven by my misery and by my excitement about these new ideas, I studied Travell and Simons night and day. I found that my trigger points would yield under the touch of my own hands if I persisted. After only about a month of assiduously applying what I was learning chapter by chapter, I had succeeded in fixing my shoulder ... my own shoulder! 1 was astounded. The pain was gone. I could raise my arm. I could sleep through the night. This stuff really worked! Given the innately optimistic cast of my mind, | immediately took a larger view. I saw that I had in my hands the tools to take effective care-of myself, at-least-when-it came-to-any Kind of myofascial pain. I supposed that I might be able to treat any trigger point I could reach and extinguish virtually any pain I might have. I could develop a complete system, a kind of new technology, and maybe other people would be helped by it Mechanical Ingenuity Travell and Simons had done a wonderful thing in giving the science of myofascial pain to the medical community. The illustrations by Barbara Cummings brilliantly clarified every aspect of the subject. Without these dedicated people, the science of trigger points and referred pain would still be an impossible jumble, largely unknown and inaccessible. Unfortunately, Travell and Simons’ two main methods for deactivating trigger points weren't oriented toward self-treatment. They were designed specifically for the doctor's office or the physical therapy clinic: a doctor could inject trigger points with procaine, a local anesthetic; and a physical therapist could presumably stretch trigger points out of existence. It bothered me, however, that the physical therapy protocol, which Travell and Simons called their “workhorse” method, involved. the muscle stretching that I had found so ineffec- tive and even dangerous, in that it had made my shoulder problem dramatically worse. To be sure, Travell and Simons had made stretching safer by using a refrigerant spray on the skin. “Distracting” the nervous system with the spray meant the underlying muscles were less likely to tighten up in defense. Nevertheless, safe or not, I felt that the spray and stretch method was too elaboarte to be practical for self-treatment, and that it would be impossible to use on areas that were hard to reach. Trying to get at the relatively small trigger points by stretching whole groups of recalci- trant muscles seemed unnecessarily indirect and inefficient. The problem was not with the generalized tension in the muscle, but rather with the trigger point, a very specific,Chapter 1—A New Life 9 circumscribed place within the muscle. The trigger points knotted up muscle fibers obvi- ously needed to relax and let go, but why not go straight to the trouble spot and deal with it directly? Massage seemed to me the natural approach, and it obviously worked with trigger points—that good massage therapist had proven that much to me. I wanted to find simple ways to use massage for self-treatment. I wanted to develop a comprehensive method for dealing with trigger points anywhere in the body. I wanted something that a regular person like me could immediately understand and use. I was sure all this could be done. Among the old-time piano men at Steinway, the highest compliment was to be called “a pretty good mechanic.” A good mechanic cared about the details and he stuck with the job until he got it right; he could find the solution to a problem even if it wasn’t in the book. My life up to that point had been built around being a good mechanic, and being able to find the simple solution. That's certainly what I had to do in devising ways to self-treat trigger points. For the purposes of treating trigger points, I felt the body was best thought of as a machine, a mechanical system of levers, fulcrums and forces, especially in regard to the ‘bones and muscles. I could understand such a system. A lifetime of working with my hands was about to begin to pay off in a new and unexpected way. My first challenge was to learn the exact location of each muscle, to visualize how it attached to the bones, and to understand the job the muscle did. Finding the precise massage technique that a trigger point would respond to was where the art would come in. The difficulty here was in figuring out how to reach unreachable places and get effective lever- age in awkward positions without hurting my hands and fingers, which were already being overused in the course of an ordinary workday. The project became an obsession. I studied Travell and Simons the first thing in the morning and the last thing at night. I studied in the parking lot at McDonald’s. Using my own body as the laboratory, I discovered something new every day. I found trigger points everywhere and became aware of pain that I didn’t know I had. I only wanted to talk about trigger points and often greeted family members excitedly with the exclamation, “I found another one! I found another one!” Over a period of three years, I learned how to find and deactivate trigger points in 120 pairs of muscles, which enabled me to cope with every trig- ger point that Travell and Simons dealt with in their books except those inside the pelvis. A World of Pain The misdiagnosis of pain is the most important issue taken up by Travell and Simons. Referred pain from trigger points mimics the symptoms of a very long list of common mala- dies; physicians, in weighing all the possible causes for a given condition, have rarely even conceived of there being a myofascial source. The study of trigger points has not historically been a part of medical education. Travell and Simons hold that most of common everyday pain is caused by myofascial trigger points and that ignorance of that basic concept could inevitably lead to false diagnoses and the ultimate failure to deal effectively with pain. (Travell and Simons 1999: 12-14) From the beginning, I had a sense that for some reason the great work of Janet Travell and David Simons had fallen into a deep pit and was in danger of being buried and forgot- ten. Surely by now Travell’s discoveries about pain should have swept the country and changed the world of health care. The first volume of the Trigger Point Manual had been pub- lished in 1983, but I couldn’t find anything about trigger points in the public library. None of10 The Trigger Point Therapy Workbook the popular family medical guides even mentioned trigger points. Nothing truly informative was to be found. in bookstores. Doctors were still using drugs as the primary treatment for pain. Many were actively hostile to the concept of trigger points, discounting the idea as just more bogus medicine, something purely imaginary. Only massage therapists seemed to be informed about trigger points and referred pain, and only exceptional individuals among them (in my own experience at least) were treating trigger points effectively. What's more, the burgeoning variety of unproven modalities offered by massage therapists gave the profession such an aura of flakiness that the elegant science of myofascial pain treatment got unfairly confused with treatments whose results could easily be attributed to the placebo effect. With such an identity, how could the medical profession or the public at large ever take it seriously? Clearly, there was a world of pain out there in need of the simple and genuine solutions I felt I had in hand. I despaired of doctors ever listening to me about trigger point therapy. Taking the facts about myofascial pain directly to the public seemed the more logical tack. I began to think about leaving the piano business behind. There was something more impor- tant for me to do. The first thing I wanted to do was to write about the self-treatment of pain for all my ailing friends in the Piano Technicians Guild. Previous articles in the Piano Technicians Jour- nal had given me a following. I guessed that my ideas about pain had a better chance of pub- lication in this journal than almost anywhere else. I also conceived of giving seminars and workshops about the self-treatment of pain, and I thought that getting a massage school diploma might give me more credibility-But I had an even better motive for going to massage school. My daughter Amber had had chronic back pain ever since lifting a heavy chair during a scene change while she was work- ing in summer theater. Employing my new knowledge about trigger points, I'd been trying to give her massage, but I just wasn’t very good. I didn’t know the time-tested manual tech- niques used by massage therapists. It would be worth learning to do massage right, if only to help my daughter; and anything I learned that benefited my method of self-treatment would be a plus. I applied to the biggest massage school I could find, one with a busy, well-managed student clinic where I could get a great deal of experience in the shortest time possible. At that moment, I couldn’t imagine becoming a professional therapist, but I definitely wanted the skills. With the help of my son-in-law, who I had trained to take over my piano business, I plowed through a backlog of half a dozen rebuilding jobs. We cleared my calendar in time for me to start a six-month clinical course at the Utah College of Massage Therapy. Massage School There were forty-nine of us in the class: thirty-six women and thirteen men. We were a greatly varied group of all backgrounds, from many states and foreign counties, and ranging in age from. seventeen to sixty. It soon became apparent that, although I was the oldest in the class (and possibly prejudged by most of the others to be a creaking fuddy-duddy), I was the only one who could claim to be free of pain. All the others—young and old, male and female—had some kind of enduring problem with pain. I found that it was almost a cliché that people go to massage school because they have chronic pain and they’re looking for the solution they haven't found elsewhere.Chapter I-A New Life 12 Jt seemed ironic to me that I arrived in Utah having read both volumes of Travell and Simons’ Trigger Point Manual and having gone a long way toward developing my method of self-healing, yet I couldn’t get anyone to listen. I had just left a business where my word was taken as gospel. I had disciples. In the role of student, my accustomed authority was reduced to nil. Nobody wanted to hear what I knew about trigger points. I could only stand and watch as a fellow student would have a pain crisis, usually bad neck pain or a back spasm, and run off to a chiropractor or to the emergency room. I kept offering help and being turned down. Tt was even harder to approach the instructors about do-it-yourself massage, but the anatomy teacher apparently felt less threatened than the others. He was a big, self-confident guy with a great sense of humor, who didn’t fear losing his authority with the students. During a break one day, he heard me talking to a classmate about trigger points and asked if I knew how to fix pain. He said he often had pain that shot diagonally across one side of his chest. He was having it again just that morning. It wasn’t his heart, he said; he'd had it checked. While he explained, I reached up and began pressing on his neck just above his col- larbone. He suddenly stopped talking and winced, then exclaimed, “Hey, that's it! That's my pain! How did you do that?” A trigger point in a scalene muscle was causing the pain in his chest. I showed him how to work the trigger point himself and he told me later that the pain had gone away and hadn’t come back. T couldn't get over it. This man was a registered nurse and a gifted teacher of anatomy, who knew his muscles but didn’t know about his own trigger points. He was a product of the same system that turns out physicians with the same astounding gap in their knowledge. ‘After my classmates saw me go hands-on with our anatomy teacher's trigger points, they began letting me show them some of my tricks. I showed one student how to kill her sinus pain by working on her jaw mwuscles, another how to stop his feet from hurting by massaging his calves, and another how to get rid of her dizzy spells with attention to trigger points in the front of her neck. Several eventually came to me for back pain of various kinds. Near the end of the course, I got to show the whole class my techniques for getting rid of arm and hand pain, something we all experienced working in the clinic. Several classes of budding massage therapists worked in the weekend clinic where it was not unusual for us to give 1200 massages on a Saturday and Sunday. Isaw the same pain patterns in the clinic that I had seen with my fellow students: lots of back trouble, plus a broad selection of every other kind of pain you could think of. I saw pain in every part of the body and every joint: shoulders, elbows, wrists, knuckles, hips, knees, and ankles. Typically, the client had already been the rounds of doctors, chiroprac- tors, physical therapists, and so on, looking for the magician in the white coat: They'd tried yoga, magnets, pain diets, herbal therapies, and acupuncture. Some had had their problem for ten years and more, Many guessed they were just getting arthritis and so were habitually popping pills. They felt older than their years, handicapped by pain. They felt their careers in danger. Depression due to constant pain was a prevailing theme. It was exasperating to hear the same stories repeatedly, to know both how simple theix problems were and just what to do for them, and to know many clients were coming for massage only as a last resort. In my view, massage is the only thing that works for these kinds of pain, and should be the first thing tried, not the last. I consistently found trigger points to be the cause of my clients” problems, and clients nearly always got off my table feeling better. Many left my booth feeling they'd finally found something that worked. I felt more and more that I also had found something that worked. I liked giving massage a great12 The Trigger Point Therapy Workbook deal—I was surprised at how much. I asked for extra shifts and accumulated twice as many hours as were required. Until I was working regulatly in clinic, I hadn’t seen that giving massage to others was a way of taking care of myself. I'd only been thinking of getting a diploma from a good school so I would have a bit of credibility when I went on to teach self-massage. Unex- pectedly, I got as much from the massages as my clients did, maybe more. I felt myself becoming kinder and more empathic. Knowing how to take care of my own pain had made me more fit for taking care of others, which made me more fit for taking care of myself. My six months at the Utah College of Massage Therapy was transformational. I regretted I hadn’t done it sooner. Recurrent Themes While in massage school I finished writing my series of eight articles on self-applied trigger point massage for the Piano Technicians Journal. Publication began two months after I gradu- ated. When the first article appeared, desperate piano tuners began calling me for advice from all over the United States and Canada. They didn’t want to wait until the article on their particular problem came out. Many were on the verge of quitting piano work because of chronic pain. Some had been in pain for as long as twenty years, repeatedly going the rounds of the health-care community just like I had, with the same frustrating result One tuner from New England had been afflicted with severe recurrent pain in both knees since climbing Mount Katahdin, the highest point in Maine, twelve years earlier. The pain had started as he descended the mountain and his friends had had to carry him most of the way to the bottom. Now he couldn’t even go out and mow his lawn without being crip- pled for days by the effort. Working with me over the phone, he was able to find and mas- sage the horribly painful trigger points in his thigh muscles that were causing the pain in his knees. Before we hung up, the pain was gone. There had been no way for him to know that his trouble was not in his knees but in his thigh muscles, strained by the unaccustomed mountain climbing: his doctors, physical therapists, and chiropractors hadn’t known. At the Piano Technicians Guild National Convention a couple of months later, he happily told me he'd continued working on his trigger points and hadn't had any more trouble with his knees. I was as pleased as he was. Iwas scheduled to give a workshop on the self-treatment of pain at that convention and was worried that nobody would come. From the number of sufferers who had called me on the phone, I should’ve known better. One hundred and ten people showed up, and it was standing room only in the modest-sized meeting room. I knew at least one thing about every petson in the room before we even began: they all hurt. Piano technicians are the most diverse, intelligent, creative group of people I’ve ever had the privilege to know, and at the same time they’re the most assertively independent. Some literally would rather die than ask for help. if I could tell them something about the treatment of pain that they could do themselves, they wanted to hear it. They were all in such need that no one so much as looked away throughout the whole program. I was very’ encouraged. ‘That was the first convention I went to not as a piano tuner, but as a massage therapist. I didn’t go to classes at all that week. I didn’t go to committee meetings. J didn’t even party at night. Thad something better to do. I spent every day, from eight in the morning until ten at night, troubleshooting trigger points and giving massage, only leaving my room to get aChapter 1—A New Life 13 quick meal. They weren't all piano tuners who came to me; spouses needed help too. Although there were some recurrent themes, like shoulder pain, they brought me all kinds of problems—back pain, neck pain, headaches, numb hands—just like in the massage school clinic. People at the convention had come from all over North America, even from several foreign countries. No matter where these people lived, they all had the same story: they'd had trouble getting effective treatment. Nobody seemed to know what caused their pain and nobody could help. Back in Kentucky, as I began my private practice, again I saw all the by now familiar patterns. All the people who came for massage had already been to a physician or a pain clinic. Almost all had experimented with chiropractic. Many had been to the emergency room for their pain. Most had been through physical therapy. They had, tried everything, including various forms of alternative medicine. Some hhad even tried massage but hadn’t been impressed. It had been “feel-good” massage: it had been relaxing but hadn’t put a dent in their pain. Interestingly, almost all the people who came to me had some kind of back pain along with whatever other pain complaint they had. Their previous treatments for back pain had always focused on the spine. I heard about injections of papaya or cortisone. People had usually been told they had arthritis or bad disks, or that their cartilage had been worn away. ‘They'd been shown X-rays that purported to prove it. One woman was on her doctor's schedule to have her vertebrae fused. Some had already had surgery, and frequently had as much pain after surgery as before. Typically, the surgeon’ last word. was always that he was sorry but he’d done all he could. Then he'd renew their prescription for rs and. dump them off on a physical therapist. I heard these stories over and over again. And over and over, I found that trigger point therapy gave them the relief they’d been seeking for so long. Had trigger points been the problem in the first place? Arthritis? Bad disks? In Travell and Simons’ Trigger Point Manual, I had read that you can have herniated disks and arthritis of the spine and still find that myofascial trigger points are the primary cause of your back pain. One client said her doctor confided sympathetically that he had back pain too. He wore magnets under his clothing just like she did. Many of my clients had tried magnets and were often a little embarrassed to say so. Yes, the magnets did seem to help, they said, but the pain always came back, It was the same with TENS units: when you took them off, you still had your problem. (A transcutaneous electrical nerve stimulation {TENS] unit gives you lit- tle shocks that interfere with pain signals, but has no effect on the cause of the pain.) Nearly everyone I treated was on pain medication of some kind, although few had the illusion that painkillers were a real cure. People seem to know intuitively that throwing a doak over the pain only keeps you from seeing the real problem. When you hide the prob- Jem, you never get the opportunity to address it. Looked at in this way, painkillers actually perpetuate pain. People want real solutions; they don’t want to dope the problem away. ‘Another common theme among the people who came to me was numbness and pain in the hands and fingers. I began to get the impression that the computer keyboard was crip- pling the country. I saw wrist braces of all kinds. A doctor had wanted to put one woman’s wrists in casts to heal her numb hands. While many clients feared they had carpal tunnel syndrome or had even been given the diagnosis, massage of trigger point in the forearms, shoulder, and neck always took the pain and numbness away. This outcome was usually a surprise to the client. It soon ceased to be a surprise to me. Good results were so consistent with “carpal tunnel” symptoms that I began to wonder whether true carpal tunnel syn- drome really existed.14 ‘The Trigger Point Therapy Workbook ‘What did all this mean for me? I knew how to help myself and it was clear I could help other people, but what was the best use of my newfound skills? There was indeed a world of pain out there, but I’d started too late as a massage therapist to hope to help very many peo- ple one on one. At my age I wasn’t going to have a Jong career as a healer. What could I do for the world of pain with the time and energy I had left? It became increasingly clear that I had to write a book about trigger point therapy and get this information out to as many peo- ple as possible. Casting a Wider Net A doctor should have written this book. It should’ve been written by a bona fide, credentialed expert in a white coat with years and years of experience and scores of articles published in medical journals. If “M.D.” followed my name on the cover of this book, 1 wouldn’t have had to write this chapter. This chapter is meant to give you some reason to trust what I have to say about pain, some reason to suspend your disbelief long enough to give my methods a fair try. The best evidence of whether my method is a good one for you will come from your own personal experience with it. Trying it is the only way you can truly validate my claims about its success. I don’t claim to be an authority on pain. Travell and Simons are the pain experts. In writing this book, my job has primarily been to put their vast knowledge into more under- standable form and transmit it to you. Having figtired out how to fx my own pain counts for something, though. Being a massage therapist counts too, because I’ve proven to myself and to my clients that I know how to fix pain for other people. I thought you might be interested in my shoulder story. I thought you might be inter- ested in how the wisdom of Janet Travell and David Simons got me through my difficulties and how they truly gave me a new life. From my success in defeating pain, I thought you might gain a smidgen of hope: my new life offering the possibility of a new life for you. My own hope is that this book will be a useful one. It’s you who will prove me right or wrong.CHAPTER 2 All about Trigger Points . In the four introductory chapters of Myofascial Pain and Dysfunction: The Trigger Point Manual, Travell and Simons give a detailed presentation of everything that is known about the sci- ence of trigger points and referred pain. They substantiate their assertions with references to. several hundred scientific articles that pertain to the subject. The personal authority of Janet Travell and David Simons is impressive in itself. Janet G. Travell, M.D. (1901-1997) Among those who recognize the reality and importance of myofascial pain, Janet Travel is generally recognized as the leading pioneer in diagnosis and treatment. Few would deny that she single-handedly created. this branch of medicine. At the time the first volume of her book went to press in 1983, she had been studying and treating trigger points and referred pain for over forty years. She had already published more than forty articles about her research in medical journals, the first appearing in 1942, Her revolutionary concepis about pain have improved the lives of millions of people. Trigger point massage, the most effective modality used by massage therapists for the relief of pain, is based almost entirely on Dr. Travell’s insights. The innovative clinical techniques for the treatment of myofascial pain that are beginning to be used by physicians and physical therapists all over the world wouldn't have existed without Dr. Travell’s dedicated energy and intelligence. Dr. Travell’s personal success with one particular patient had a far-reaching effect on history. Not many people remember that Janet Travell was the White House physician dur- ing the Kennedy and Johnson administrations. President Kennedy honored her with that position in gratitude for her treatment of the debilitating myofascial pain and other ailments that had threatened to prematurely end his political career. It’s a stunning example of how trigger point therapy can change someone’s life and destiny. Although she was in her sixties at the end of her duties at the White House, Dr. Travell had no intention of retiring or even slowing down. She went on developing and teaching her methods with vigor and enthusiasm for the next thirty years. She was past eighty when the first volume of the Trigger Point Manual was published, and past ninety when the second volume appeared. She refused to rush into print: she wanted to get it right.i —SN 16 The Trigger Point Therapy Workbook David G. Simons, M.D. David Simons lends authority to the study of myofascial pain with his long experience as a research scientist. In his early career, Dr. Simons worked as an aerospace physician, develop- ing improved methods of measuring physiological responses to the stress of weightlessness, A fascinating sidelight to his career is the world altitude record for manned balloon flight he set in 1997 as a young Air Force flight surgeon. Dr. Simons’ strict attention to detail and adherence to scientific method helped him bring rigorous objectivity to the documentation of myofascial pain, He was the driving force in getting the Travell and Simons books writ. ten. Well into his seventies now, David Simons is still hard at work promoting further research concerning trigger points. He has just coauthored a new book, Muscle Pain, that seeks to impart a better understanding of the neurophysiology of muscles. The Essentials Considering the sheer mass of scientific detail that Travell and Simons cover in their first four chapters, it’s intimidating for anyone without a scientific education to simply sit and tum the pages. The aim in this chapter is to boil down the essentials of trigger point science and make them accessible to the layman in clear, concise, everyday language. As a conse- quence, many of Travell and Simons’ most carefully reasoned and well-supported assertions can only be summarized here’. If you think you might have the appetite and the capacity to digest the original work of Travell and Simons, by all means go on and do it. You can find their two-volume Trigger Point Manual in most university medical libraries. If you're a health-care professional, think about buying the books and doing a deeper study than is pre- sented here. A physician should certainly consider his or her personal library incomplete without them. The Price of Ignorance Travell and Simons believe that trigger points are the primary cause of pain and that the public suffers pain needlessly because too many doctors are still uninformed about them. For that reason, they believe misdiagnosis of pain and ineffective treatments often character- ize the practice of medicine, resulting in enormous unnecessary cost, both to the pocketbook and to quality of life. (1999: 12, 14, 36) In the Trigger Point Manual, they list twenty-four examples of mistaken diagnoses, from. angina and appendicitis to tennis elbow and tension headache, which are likely to be made when the physician is unaware that myofascial trig- ger points may be to blame. (1999: 37) Too often, they believe, when pain has a myofascial origin, diagnosis entirely eludes the physician, who then is apt to write the problem off as minor or imaginary and categorize it as untreatable. Too many people grimly live with pain that is very real and that could be very easily treated if their doctor or other health-care prac- titioner would simply take the time to acquire the appropriate knowledge. ~ Phe Pages on which these assertations appear are cited in parenthesis, sometimes accompanied by citations of sources ‘Travell acl Simons themselves cited. Due to space considerations, references to Travell and Simons we often listed simply 1 1992 or 1999, depending on which volume of the book is cited.‘Chapter 2—All about Trigger Points 17 Pills, Pills, Pills Dr. Sidney Wolfe, in Worst Pills, Best Pills, contends that too many physicians resort to pre- scribing narcotics and other chemical substances for the relief of pain, not necessarily because they don’t know what else to offer, bot -because of the phosmaceusical industry's inordinate influence in the medical community. He believes that the billions of dollars ‘poured into pharmaceutical advertising is one of the Biggest causes of the public’s almost folfe points out pan medications have potential adverse reactions and that some actually kill thousands of people every year. He believes there are at least twenty com- monly prescribed pain medications that are so dangerous they should be taken off the mar ket. He lists thirty-nine others that should have only very limited use. Dr. Wolfe quotes studies suggesting that an appallingly high percentage of physicians are insufficiently aware of just how dangerous some of their favorite drugs can be. He strongly recommends seeking proven nondrug remedies whenever possible before giving in to pharmaceutical solutions. (Wolfe 1999) . Trigger Point Science Although much of the medical community resists having to learn about what they think are new, untested notions about pain, trigger points aren’t really a new concept. Travell and Simons, in an extensive review of the medical literature, found that the knotlike characteris- tics of trigger points have been written about for over 150 years. Their ability to cause dis- placed pain was known as early as 1938. Janet Travel] first used the term “trigger point” in print in 1942. (1999: 15) It’s a good guess that ancient Chinese systems of therapeutic touch, surviving today as acupressure and related modalities, were probably early attempts to explain and deal with what we now know as trigger points. People have probably been coping with trigger points for many thousands of years in the simple acts of rubbing one another's backs and necks. Massage for the relief of pain by dealing with the “knots” in muscles has been a formal pro- fession in this country for almost a hundred years. People have always known about “knots.” It’s only that they haven’t known about all the ways they connect with pain. The Prevalence of Trigger Points Trigger points are remarkably common. Travell and Simons describe them. without exaggeration as the “scourge of mankind.” (1999: 14) No one escapes trigger points, not even children and babies. (1999: 21) Trigger points can develop in any of the 200 pairs of muscles in the body, which gives them a wide territory for creating mischief. (1999: 13) Trigger points can last as long as life and can even survive in muscle tissue after death, detectible until rigor mortis sets in. (1999: 68) The pain inflicted by trigger points may be the biggest cause of disability and loss of time in any workplace or office, in any professional or amateur sport, or simply around home—anywhere people are apt to overdo some activity. Travell and Simons quote studies suggesting that trigger points are a component of up to 93 percent of the pain seen in pain18 The Trigger Point Therapy Workbook clinics, and the sole cause of such pain as much as 85 percent of the time. (1999: 12; Gerwin 121; Fishbain 181-197) An underestimated trait of trigger points is that they can exist indefinitely in a latent state, in which they don’t actively refer pain. Travell and Simons believe that the long-term effects of latent trigger points may be of even greater concern than the pain caused by active ones. They assert that latent trigger points tend to accumulate over a lifetime and appear to be the main cause for the stiff joints and restricted range of motion of old age. The constant muscle tension imposed by latent trigger points tends to overstress muscle attachments even in younger people, which can result in irreversible damage to the joints. You may not sus- pect that you have latent trigger points, but they're very easy to find. They're exquisitely painful when pressed on. Latent trigger points can be activated by very little stress or strain. (1999: 12-21) . Mistaken Identity Many people have the mistaken impression that trigger points are the same thing as acupressure points. Acupressure points are said to be concentrations of energy or blockages on the meridians, the body’s supposed energy pathways. It’s difficult to prove that such meridians exist. Trigger points, on the other hand, are demonstrably physical phenomena. Acupressure points don’t refer pain as trigger points do and aren't painful to touch unless they happen to coincide with a trigger point. Acupressure anid acupuncture both enjoy greater success in relieving pain when a trigger point is present at the same site as an acu- pressure point. (1999: 41-42; Melzack 3-23) People often say “pressure points” when they mean to say “trigger points,” but a pres- sure point is what you press on to stop the flow of blood from. a wound. Pressure is used on a trigger point not to stop blood flow but to increase it. Trigger points are also often mixed up with “tender points,” one of the official criteria for a diagnosis of fibromyalgia. This is a serious mistake when made by a professional, because it can sentence the person unnecessarily to a life without hope of significant improvement or cure. According to Travell and Simons, many who have been diagnosed with fibromyalgia in reality are afflicted only with widespread trigger points. Also, a signifi- cant part of the pain suffered by someone with genuine fibromyalgia can be due to myofascial trigger points. Massage is widely recognized as an effective way to deal with fibromyalgia when the practitioner is able to suit it to the sufferer’s specific condition. (1999: 36-41, 140-142) ‘There are clear guidelines for distinguishing trigger points from tender points: a trigger point needs firm pressure to elicit pain, while a tender point is so painful it can hardly be touched. In addition, tender points cause only local pain; they don’t refer pain to another site as trigger points do. Genuine fibromyalgia sufferers usually have both types of “points.” Their states of pain can be improved markedly when they can bear treatment of their trigger points. Not infrequently, people think that myofascial trigger points cause only pain in the face, teeth, and jaws, getting “fascial” mixed up with “facial.” Trigger points certainly can cause face pain, but myofascial pain can occur anywhere in the body. The prefix “myo” in myofascial (MY oh FAH shul) refers to muscle. Fascia (FAH shuh) is the thin, transhicent membrane that envelopes and separates muscles like shrink-wrap. (A good place to see fas- cia is on a chicken leg.) When you have trigger points in a muscle, the fascia covering it typi- cally gets tight and inflexible and becomes part of the problem.Chapter 2—All about Trigger Points 19 Validation of Trigger Points ‘There has always been skepticism regarding the reality of trigger points, and much remains today among those who are unaware of the evidence unearthed by Dr. Travell in 1957. She discovered that trigger points generate and receive tiny electrical currents. This demonstrated that a trigger point communicates with the nervous system and that signals are sent back, The activity of a trigger point could be quantified by measuring these tiny cur- rents with electromyographic instruments. The precise location of a trigger point could be determined by this same means. Muscle tissue not in a state of contraction is electrically silent. Electrical activity confined to a very small area showed that only a small part of the muscle was in contracture. Interestingly, pressure on a trigger point increases its electrical activity. Stretching the muscle does the same thing, which explains why stretching so often makes pain worse. (1999: 58-69) The most convincing practical demonstration of the existence of trigger points is to just feel them with the fingers. Active and latent trigger points alike give a distinctively painful response to pressure. If a trigger point is near the surface, sensitive fingers can detect that it’s a little warmer than surrounding tissue. This temperature difference, which is due to increased metabolic activity in the trigger point, is measurable. (1999: 29-30) Being soft tissue, trigger points can’t be seen on X-ray. They have been viewed, how- ever, with electron microscopy in fresh human cadavers. In the second edition of volume I of the Trigger Point Manual, Travell and Simons include a very convincing and informative elec- tron microscopic photograph of a trigger point in a dog’s leg muscle. (1999: 68-69) A Clear Definition Ttavell and Simons define a trigger point as “a highly irritable localized spot of exqui- site tenderness in a nodule in a palpable taut band of muscle tissue.” The first part of that definition just means that a trigger point hurts like the devil when you push on it. When a trigger point is active enough, you're likely to startle, wince, and pull away. This is called “giving the jump sign.” The “nodule” in the formal definition is the trigger point itself. To your fingertips, it feels like a knot or a small lump that can range in size from a pinhead to a pea. In the large muscles of the thigh, a trigger point can feel like a knot the size of your thumb. Sometimes a trigger point feels like a short piece of partially cooked macaroni or spaghetti. Your fingers must be sensitive to feel these nodules. Not everyone has that sensitivity. Particularly gifted massage therapists are able to rely entirely on their sense of touch to find trigger points. Luckily, in troubleshooting your own myofascial pain, the trigger point’s exquisite tender- ness to pressure always gives it away. Trigger points always hurt when pressed on—there’s never any question. The “palpable taut band” is a semihard strand of muscle that feels like a cord or cable and is easily mistaken for a tendon. Taut means it’s tightly stretched. Palpable means you can feel it with your fingers. Plucking a taut band in some muscles elicits a localized twitch response, which is a brief spontaneous contraction. Taut bands tend to restrict range of motion by limiting a muscle’s ability to lengthen. They can exist painlessly in muscles with- out the presence of trigger points. ‘A trigger point is not the same thing as a muscle spasm. A spasm involves a violent contraction of the entire muscle. A trigger point is a contraction in only a small part. A20 ‘The Trigger Point Therapy Workbook spasm can usually be relaxed in a matter of minutes. For physiological reasons, trigger points don’t give up that easily. The Physiology of a Trigger Point The place where contraction actually occurs in muscle fiber is a microscopic unit called a sarcomere. Millions of sarcomeres have to contract in your muscles to make even the small- est movement. A trigger point exists when overstimulated sarcomeres become unable to release their contracted state. (1999: 45-47) Figure 2.1 is a representation of several muscle fibers within a trigger point. Letter A is a muscle fiber in a normal resting state, neither stretched nor contracted. The distance between the short crossways lines within the fiber defines the length of the individual sarcomeres. The sarcomeres run lengthwise in the fiber. Letter B is a knot in a muscle fiber consisting of a mass of sarcomeres in the state of maximum continuous contraction that characterizes a trigger point. The bulbous appearance of the contraction knot indicates how that segment of the muscle fiber has drawn up and become shorter and wider. Letter C is the part of the muscle fiber that extends from the contraction knot to the muscle’s attachment (to the breastbone in this case). Note the greater distance between the crossways lines, which displays how the sarcomeres are being stretched by tension within the contraction knot. These stretched segments of muscle fiber are what give tightness and rigidity to the taut band. Therapy should equalize sarcomere length in the fiber. Normally, sarcomeres act like tiny pumps, contracting and releasing to circulate blood through the capillaries that supply their metabolic needs. When sarcomeres in a trigger point hold their contraction, blood flow essentially stops in the immediate area. The resulting oxy- gen starvation and accumulation of the waste products of metabolism irritate the trigger point. The trigger point responds to this emergency by sending out pain signals until the brain institutes a policy of rest for the muscle. You stop using the muscle, which then begins to shorten and tighten up. (1999: 69-78) To learn more about sarcomeres and the complex chemistry of muscle contraction, consult any good biology or anatomy textbook. Figure 2.1. Magnified contraction knots (trigger points) in muscle fibersChapter 2—All about Trigger Points. 21 Points Solving the problem of myofascial pain hinges on iAld locating central trigger points, or those which occur in the (4 | H| center of a muscle. Trigger points always originate at Central Trigger t the midpoint of a muscle’s fibers. This is where the motor nerve enters, bring- ing the signals which tell A B c D the muscle to contract. This Figure 2.2 Orientation of muscle fibers: (A) parallel; (B) parallel with also happens to be just the _tendinous inscriptions; (C) bipennate; (D) unipennate place where sarcomeres get» into trouble, locking up and forming a trigger point. Knowing how to find the belly (the enlarged, fleshy part) of a mus- cle often brings you right to the trigger points that are causing the pain. (1999: 47-49) The problem gets more complex when the fibers don’t run from end to end in a muscle. The orientation of the fibers in muscles varies, depending on the job they’re designed to do (Figure 2.2). In a musclé made for speed, the fibers are parallel (A), running straight from end to end, and its trigger points are easily found, just as expected, halfway along it. How- ever, a muscle made for power will have fibers running diagonally at some angle to its length. A diagram of such fiber arrangements looks like a feather (C) or sometimes a feather bisected down the middle (D). Since trigger points may be found in the center of each indi- vidual fiber, they may be situated anywhere along the muscle. (1999: 49-53) ‘Another variation is when a muscle divides into several heads, like the biceps, triceps, ot quadriceps. Trigger points may exist in only one head or they may be present in all. In other muscles like the rectus abdominis of the stomach, the muscle may be divided by lateral bands of connective tissue (B), giving several potential sites for trigger points along its length. There are several instances of a muscle being divided lengthwise into two or more bellies. If you don’t know where all the muscle bellies are, you can easily overlook critical trigger points. (1999: 49-53) Attachment Trigger Points Exquisitely painfull places are often found at or near where the muscle attaches to bone. ‘Travell and Simons believe these attachment trigger points are created secondary to central trigger points in the muscle belly. Rather than being true trigger points, they may be only highly sensitized connective tissue that has been abused by the stress of continuous muscle tension. Attachment trigger points are always under the control of centrally located trigger points, which should be the primary target of treatment. Attachment trigger points generally cease to be tender when central trigger points have been deactivated. In chronic conditions where trigger points have been in place for months or years, stresses at the site of muscle attachment are thought to cause degenerative changes in the joint. (1999: 72, 76; Fassbender 355-374)22 The Trigger Point Therapy Workbook The Mystery of Referred Pain The reality of referred pain can be convincingly demonstrated by simply pressing on a trigger point that is bad enough to reproduce its referred pain pattern. It’s a little harder to explain why pain is referred at all. Research on pain referral is difficult because the mecha- nisms of the human nervous system are so unimaginably small. The tiny electrochemical impulses in the nerves can be detected and measured to some extent, but not with accuracy or gteat discrimination. In addition, there are ethical limits on how far you can go in pain experiments, whether with animals or humans. Nevertheless, scientists have made a number of suppositions about how pain can be displaced from its cause. The easiest theory to accept regarding referred pain is that the signals simply get mixed in your wiring. Sensory inputs from several sources are known to converge into single nerve cells at the spinal level, where they are integrated and modified before being transmitted to the brain. Under these circumstances, it may be possible for one electrical signal to influence another, resulting in mistaken impressions about where the signals are coming from. (1999: 56) On the surface, this looks like bad design, but the displacement of pain seems too consis- tent to be accidental. Janet Travell’s great discovery was that referred pain occurs in very predictable patterns in everyone, with only small variations. This predictability implies that there may be some evolutionary advantage to the referral of pain. It’s notable that referred pain occurs very often in or near a joint, where pain is most likely to make you modify the activities or conditions that have created the problem. (1999: 96) Fortunately, it’s not necessary to understand why trigger points send their pain else- where. All you need to know is that they do. After you've worked with referred pain for a while, you develop an intuition about it. After gaining some experience, people often find that their fingers inexplicably begin going right to the trigger point that’s causing the pain, even though it may be some distance away from the pain. It takes time to acquire this facility. Trigger Point Symptoms The sensory symptoms created by myofascial trigger points take a variety of forms and they aren’t limited to the sense of pain. Symptoms of dysfunction—such as muscle stiffness, weakness, edema, nausea, dizziness, and postural distortions, to name a few—are even more diverse and include a number of surprises. Referred Pain The defining symptom of a trigger point is referred pain. Characteristically, referred pain is felt most often as an oppressive deep ache, although movement can sharpen the pain. Referred myofascial pain can be as intense and intolerable as pain from any other cause. Some common examples of referred pain are tension headaches, migraine, sinus pain, and the kind of pain in the neck that won’t let you turn your head. Jaw pain, earache, and sore throat can be expressions of referred pain. Another is the incapacitating stitch in the side that comes from running too hard. ____ Soze legs, sore feet, and painful ankles are examples of referred pain. Stiffness and pain in a joint should always make you think first of possible trigger points in associated muscles,Chapter 2—All about Trigger Points 23 Pain in such joints as the knuckles, wrists, elbows, shoulders, knees, and hips are classic trig- ger point symptoms. If you don’t count headaches and backaches, pain referred to the joints is the most usual manifestation of myofascial pain syndrome. Back pain always has a myofascial component, no matter the official diagnosis. Although arthritis, bad disks, and displaced vertebrae come quickly to mind when your back hurts, back pain very often is nothing but referred pain from myofascial trigger points. Pain in your low back can come from trigger points in surprising places, such as your but- tocks, your stomach muscles, or even knotted-up muscles in your calves. Treatment for back pain often fails when myofascial trigger points are not considered as a possible cause. (1999: 804-809; Rosomoff 114-118) . Unexplained intrapelvic pain and pain connected with sexual function can be referred from trigger points in the inner thighs, the low abdomen, or inside the pelvis itself. It’s not unusual for trigger points in these places to refer pain to the ovaries, cervix, uterus, testes, prostate, rectum, or bladder. A woman’s vaginal pain during intercourse in the missionary position, with the legs up and spread, can be referred pain from a certain mean-spirited myofascial trigger point high in the overstretched adductor magnus muscle of the inner thigh. Janet Travel believed that even a large part of menstrual pain is due to trigger points in abdominal muscles and could be prevented to a great extent by regular self-applied mas- sage between menstrual periods. ‘Travell and Simons tell us that many symptoms that seem to be internal may actually be coming from. trigger points in external muscles. Stomachaches, heartbum, or pain that feels like an ulcer can be referred from trigger points in the stomach muscles. Referred pain from a trigger point in the rectus abdominis can simulate acute appendicitis. The pain of colic in a baby can have the same source. Other referred symptoms from abdominal trigger points take some interesting forms, like heart arrhythmia, nausea, diarrhea, loss of appetite, projectile vomiting, and urinary incontinence. Older children and adults who wet the bed should know their problem might be only a referred weakening of the urinary sphincters by trigger points low on the abdomen. (1999: 941) Compression of Vessels and Nerves Muscles that have been shortened and enlarged by trigger points frequently squeeze nearby nerves. Nerves that pass through a muscle are even more vulnerable. Compression of a nerve can distort the electrical signals that travel along it, resulting in abnormal sensations such as numbness, tingling, burning, and hypersensitivity in the areas served by the nerve. This is a very common occurrence in the arms and hands. It happens occasionally in the legs and feet. Trigger points can also cause a muscle to clamp down on the blood flow in an artery, making a distant body part feel cold. Trigger points in a calf muscle (soleus) can impede the retum of blood in a vein, resulting in a swollen ankle or foot. The same effect in a neck mus- cle (anterior scalene) can cause a swollen wrist and hand. (1999: 448, 516-523) Autonomic Effects The referral effects of myofascial trigger points on the autonomic nervous system can be surprising, The autonomic system controls the glands and the smooth muscles of the diges- tive system, the blood vessels, the heart, the respiratory system, and the skin. Some of the24 ‘The Trigger Point Therapy Workbook effects of trigger points on these systems may be as yet unknown. Travell and Simons list some of the known effects as reddening of the eyes, excessive tearing, blurred vision, a droopy eyelid, excessive salivation, persistent nasal secretion, and goose bumps. Trigger points ina pectoral muscle can cause an erect, hypersensitive nipple. Trigger points can distort your perception when gauging the weight of things. They can affect the inner ear, causing dizziness and imbalance. Their weakening effect on muscles adds to problems with coordination, causing you to stumble and lurch and unexpectedly drop things. (1999: 21) Problems with Movement Movement requires some muscles to contract and others to lengthen. Trigger points can make a muscle reluctant to do either. Stretching or contracting irritates trigger points and increases pain, making you less and less inclined to move. If your neck hurts, you stop turn- ing your head. If your back hurts, you stop trying to lean over. If your shoulder hurts, you stop reaching for things. This is called “splinting” or “guarding,” a natural protective response that keeps the muscle from suffering further abuse. Splinting calls other muscles into action to take up the burden. That may sound like a good idea until you realize that the helper muscles are bound to get stressed from doing the awkward, unaccustomed work. Very soon, they develop trigger points too and an entire limb, or one whole side of the body, can become involved. The muscles stiffen and your range of motion becomes progressively limited. Your reluctance to move turns into an inabil- ity to move. Depending on the focus of the trouble, you end up unable to bend your knee, raise your arm, turn your head, or reach down to tie your shoelaces. Unnatural twists or curves in the neck, spine, or hips can also result from this kind of wholesale myofascial trigger point activity. The familiar and much dreaded dowager’s hump may begin this way, from the pull of bound-up chest and anterior neck muscles. Trigger points should be one of the first things investigated when scoliosis or any other abnormal spinal curve is being addressed. Chronically bad posture, especially with the head or hips thrust forward, may not be correctable until certain trigger points are attended to. An apparent short leg is sometimes simply a collection of long-standing trigger points drawing up that side of the body. (1992: 32, 42) Problems with Mood Unireated myofascial symptoms that go on for months or years can really drag your spirits down. Chronic pain is a well-known cause of depression, especially if you've been told it’s untreatable. Therapy for depression should include treatment of trigger points when. they’re the source of your depressing chronic pain. It can become a deadly cycle when a sense of hopelessness keeps you from taking positive action to combat your trigger points. Sleeplessness and chronic fatigue are other very common symptoms of myofascial trig- ger points. Muscles tend to overcontract and be slow to relax when afflicted with trigger points. The constant tension causes you to tire too easily. Pain from trigger points disturbs your sleep and keeps your muscles from resting. The resulting chronic fatigue should not be a surprise. (1999; 110) eeChapter 2—All about Trigger Points 25 Dyslexia, Too? Travell and Simons don’t mention dyslexia in their long list of proven myofascial symp- toms. But trigger points provoke such an unbelievable variety of symptoms in the head, neck, and face that it’s worth wondering whether dyslexia should be counted among them. Conventional beliefs about dyslexia blame it on a dysfunction within the brain, but there are other theories. Harold N. Levinson, M.D., in Sinart but Feeling Dumb, expresses the belief that dyslexia basically stems from an inner ear dysfunction. His reasoning is that the inner ear, mediated by the cerebellum, is vital to the ability of the eyes to track, sort out and make sense of what they see, including the printed word. Dr. Levinson tells of numerous successes in treating dyslexia with finely controlled doses of seasickness medicine and other substances meant for fighting dizziness. (Levinson 1994) Travell and Simons note that trig- ger points are a known cause of dizziness, indicating that they may affect the inner ear. (1999: 314, 334) In dyslexia, a number of other problems appear to accompany reading difficulty, including headaches, blurred or double vision, balance and coordination problems, speech disorders, poor memory, messy writing, impaired concentration, hyperactivity, and confu- sion about telling time and direction. Some of these problems are oddly coincident with symptoms of myofascial trigger points. Trigger points affecting the ear can cause discoordination, dizziness, loss of balance, ear pain, ringing in the ears, and occasionally a unilateral loss of hearing. We know that children have trigger points, even from birth. Tense, overstressed. chil- dren, just like adults, are particularly apt to have trigger points in the jaws, neck, and face. Are these kids prone to be dyslexic because of a myofascial effect on the innex ear? It would seem worth checking out. Hopefully, someone in the business of treating dyslexia will be motivated to investigate this question. All the trigger points that might be involved could be treated with the techniques presented in this book. Trigger Point Causes Some of the activities and events that create trigger points are obvious, like accidents, falls, strains, and overwork. The onetime episode of overdoing, for example, is notorious for end- ing in debilitating pain that long outlasts the event. Everyone occasionally lifts or carries unreasonable loads, ambitiously exercises when out of condition, or hammers away too long and too hard at some unaccustomed work. All these things constitute abuse of muscles. It would pay to examine the varieties of abuse more closely. Avoidable Muscle Abuse The chronic overloading of muscles in work situations is so common nowadays that it has earned a number of fancy labels. We call it overuse syndrome, repetitive motion injury, tepetitive strain, cumulative trauma disorder, and occupational myalgia. All these terms look good on an insurance claim, but none of them mean anything other than that you've worked a group of muscles beyond their endurance and now they’re making you pay for it. It’s important to look critically at a work situation that causes the overuse of muscles and results in myofascial pain. Trigger points are usually easy enough to deal with, but they26 ‘The Trigger Point Therapy Workbook tend to come right back if you don’t change the conditions that bring them on. On the job, thoughtless positioning of the body is clearly hazardous when it causes strain, inefficient movement, and poor body mechanics. Maintaining an awkward position too long, habitual muscle tension, disregard of efficient methods, and reluctance to take rest breaks are some of the things you need to work on if you hope to end the pain that comes from overwork, Lack of commitment to making improvements may be the biggest obstacle of all. Along with flagrant, mindless overwork, there are other less obvious ways to abuse muscles and create trigger points. Being overweight and out of shape can set you up for overstressed muscles. Carrying an overloaded purse or backpack just invites trouble. Carrying a fat billfold in the back pocket is famous as a cause of sciatica, which is pain from the sciatic nerve itself and from trigger points in buttock muscles, both created by pressure from the billfold. (1999: 139, 147, 175, 182) Muscles of the back, neck, and hips can be severely stressed by the postures dictated by car seats, chairs, and other furniture that are designed for appearance instead of good support. Unavoidable Muscle Abuse Trigger points are created in muscles when they suffer direct impact in accidents such as falls and auto collisions. The sudden wrenching movements that occux during these events, when muscles are either overcontracted or overstretched, can also be expected to result in trigger points. Trigger points are the major source of the pain of whiplash, though they often go unsuspected and unaddressed. They generally accompany fractures, muscle tears, sprains, and dislocations. Failure to recognize and treat trigger points as an inevitable part of any physical injury causes needless pain and can defer complete recovery indefi- nitely. (1999: 437-439) Unsuspected Muscle Abuse According to Travell and Simons, many kinds of medical treatment can be unrecog- nized causes of trigger points and myofascial pain. Trigger points are sure to be provoked by the immobility imposed by braces, slings, and casts. When surgery leaves long-term residual pain, trigger points should be suspected in muscles that have been cut, stretched, or other- ‘wise traumatized. Physicians may persist in trying to treat the site of the pain, not recogniz- ing it as referred myofascial pain, and consequently overlook and fail to attend to the cause. An ordinary injection in the gluteal muscles can set up trigger points, particularly in the gluteus minimus, leaving a patient with a mysterious agonizing case of sciatica that can last for months. Steroids injected into painful joints, though seeming to bring relief, may not be an appropriate treatment when the pain is of myofascial origin. The trouble is that the patient, thinking he has been cured, goes unmindfully on with the stressful activity that caused the trouble in the first place. The critical trigger points go untreated and continue to pull inces- santly on the bones of the joint, ultimately making the problem worse. Steroids themselves, if overused, can seriously degrade the connective tissue of bones, muscles, ligaments, and tendons. Surgery may even be called for to repair the damage. Pain medications continue to be the treatment of choice because they work so well in reducing the awareness of pain. But pain must always be viewed as a warning that some- thing is wrong and needs correction: it’s not enough to murder the messenger and ignore the see ——“(eChapter 2—All about Trigger Points 27 message. Many people, concerned about unknown side effects, are becoming leery of all medications or foreign substances put into or taken into the body. Medical history is full of tragic examples of the truth about a prescription drug coming out too late. It’s not unreason- able to wonder whether your prescription for pain, depression, anxiety, or such conditions as high blood pressure may cause more illness than it cures. As an example, Travell and Simons tell about research indicating that calcium channel blockers for hypertension appear to irritate and perpetuate trigger points. In other words, your high blood pressure medicine may be worsening your pain. (1999: 75) Sidney Wolfe, in Worst Pills, Best Pills, lists scores of drugs that are known to have the potential for causing muscle pain as a side effect. (Wolfe 1999) If you take prescription drugs for any reason, it would be worth your while to get this valuable book and study it thoroughly. Fibromyalgia ‘There’s some question as to whether trigger points cause fibromyalgia or whether it’s the other way around. Maybe the two conditions aren’t connected at all. One thing is certain, however: you can have widespread trigger points (myofascial pain syndrome) and fibromyalgia at the same time. Myofascial pain syndrome and fibromyalgia are both charac- terized by hypersensitive spots in various parts of the body. With fibromyalgia, these spots are called “tender points” rather than “trigger points.” Either condition is easily mistaken for the other if you’re unaware of critical differences. Myofascial pain is usually localized and its cause is very’ specific, in the form of trigger points that can be clearly felt in the muscles. People with fibromyalgia ordinarily hurt all over and often can hardly bear the lightest touch. Tender points are typically present almost everywhere and aren't limited to muscles. Fibromyalgia is believed to have a systemic cause, instead of something specific to the muscles, and the entire body is usually involved. There are other ways to differentiate between myofascial pain syndrome and fibromyalgia. Muscles with trigger points feel firm; muscles of the fibromyalgia sufferer are soft and doughy. Muscles with trigger points stiffen the joints and inhibit your range of motion. In fibromyalgia, the joints are loose, or even hypermobile, although the person may have an overall subjective sense of stiffness and may be hesitant to move because of ongoing pain. Depression can come with both conditions, but people with myofascial pain can gener- ally go on with life. People with fibromyalgia are frequently overwhelmed by deep fatigue and sometimes can hardly move at all without agonizing pain. None of the self-treatment techniques in this book will have a direct effect on fibromyalgia itself. However, massage can benefit any myofascial trigger points that may be present among the tender points and significantly reduce the level of pain. (1999: 36-40) Trigger Point Persistence Trigger points can sometimes be very difficult to get rid of. You may find that after you've successfully deactivated them, they seem to come right back. The influence of perpetuating factors on myofascial pain is seriously underestimated, not only by the sufferer, but also by many therapists. Management of perpetuating factors often makes the difference in whether treatment will succeed and whether its benefits will last. A perpetuating factor is sometimes so important that its removal can allow a trigger point to deactivate on its own. Some28 ‘The Trigger Point Therapy Workbook systemic factors, such as vitamin deficiency, ate so strong that they can be the initiating cir- cumstance in the cteation of trigger points. (1999: 179) Physical Factors Congenital irregularities in bone structure, postural stress, poor work habits, repetitive strain, and lack of exercise can all contribute to the difficulty in getting rid of trigger points. Abnormal Bone Structure A short leg, an asymmetric pelvis, short upper arms, and a long second metatarsal bone in the foot are conditions that make it necessary for the body to continuously compensate, resulting in perpetual strain on certain groups of muscles. Unequal leg length may create and maintain trigger points in the legs, buttocks, back, and neck. Unless corrected by a heel lift or other means, a short leg may cause persistent or recurrent pain in these areas: a proper heel lift has even been known to stop intractable headaches. Unfortunately, leg length is dif- ficult to measure accurately. Chronically tight muscles can add to the difficulty by drawing up one side of the body and causing the appearance of a short leg. Sometimes, one entire side of the body is smaller than the other. In such a case, one side of the pelvis is likely to be smaller too, which makes your pelvis tilt while you're sitting, When this happens, the spine curves abnormally, placing an extra load on the quadratus Iumborum and other back muscles. The effect can be transmitted as far away as the scalene and sternocleidomastoid muscles of the neck. Crossing your legs with the same leg over all the time may indicate that you're compensating for an asymmetric pelvis. Sitting on a pad or thin cushion under the smaller side of the pelvis can help remedy this condition. Be aware that keeping a thick wallet in your back pocket tilts the pelvis in the same manner and can cause the same kind of perpetual strains. Short upper arms are more common than you might think and aren’t usually recog- nized as a potential cause for lingering myofascial pain. You should always have elbow sup- port while sitting, and when you have short upper arms, you need higher arms on the chairs you sit in. Lack of support for your elbows causes continual strain on the trapezius and levator scapula muscles, whose trigger points cause headaches and neck pain. (1999: 183) Morton's foot, an easily corrected disparity in the length of the first and second metatar- sal bones of the foot, is known to be the origin of a variety of aches and pains. This condition causes instability in the foot and ankle that can affect virtually the entire body. Morton’s foot is discussed in detail in Chapter 10. (1999: 179-184) Postural Stress Trigger points can be caused and maintained by postural factors such as couches, chairs, and. the bucket seats in cars that strain muscles by failing to properly support the body. You may be so accustomed to these strains that you don’t notice them. Badly con- ceived seating is the source of much chronic back and neck pain. Strained or awkward positions in your work situation can perpetuate trigger points. The apparent comfort and familiarity of a longtime habit can make you unaware of its effects on your muscles. It’s wise to examine how you sit, stand, and work to find the ways in which you may be subjecting certain muscles to continuing tension and strain. See if you're keeping an arm or a leg locked in a cramped position while you work. ObserveChapter 2—ANl about Trigger Points 29 whether you're keeping your head turned or cocked at an angle for long periods of time. Develop an awareness of unusual tightness in muscles that would indicate postural imbalance. Keeping muscles immobile or inactive encourages them to stiffen and grow weak. A sedentary lifestyle is a great perpetuator of trigger points. Muscles need to work in order to stay healthy. (1999: 184-185) Repetitive Movement Repetitive movement overloads muscles, even when it requires only minimal effort. Repetitive movement that is strenuous can actually be healthier because you're more apt to be aware when the muscles are growing tired. The seeming effortlessness of office work can have an insidious effect on large and. small muscles alike, Working at a computer keyboard is particularly stressful. The small muscles of the forearms and hands have to slave away for hours at a time, contracting hundreds if not thousands of times in a single session. At the same time, larger muscles of the shoulders, upper back, and neck remain static and immo- bile but under continuous contraction to hold your head and arms in position. The static posture and unrelieved. subtle strain of computer work can perpetuate trigger points in any part of the upper body. Many jobs in industry, because of their repetitious nature, make it impossible to deal effectively with myofascial problems. If the health of the workers is worth anything, it would be much. more cost-efficient and productive to allow people to vary their tasks a number of times during the day. Janet Travell’s advice to homemakers was always to “scramble” their housework, instead of working all day at one thing. Think of ways to scramble your work, no matter what it is. (1999: 185-186) Vitamins and Minerals ‘Travel and Simons state that nearly half the patients they treat for chronic pain are found +o be lacking certain vitamins or minerals that are necessary for lasting relief. These critical nutrients include B vitamins 1, 6, and 12, vitamin C, and folic acid. The minerals calcium, iron, magnesium, and potassium are also critically important. Groups of people who are especially likely to be deficient in these items are the elderly, pregnant women, dieters, the economically disadvantaged, the emotionally depressed, and people who are seriously ill. The problem in many cases is not an inadequate ingestion of vitamins and minerals, but the intake of other substances that cause their elimination. Smoking destroys vitamin C. Taking in excessive amounts of water can wash B vitamins out of your system. Alcohol, ant- acids, and the tannin in tea impair absorption of B1. Antacids can also affect absorption of folic acid. Oral contraceptives leave you short of B6, as do antitubercular drugs and corticosteroids. Overdosing on vitamin C or folic acid can deplete your B12. Levels of the minerals calcium, iron, magnesium, and potassium must be adequate for normal muscle function. The exchange of calcium ions is directly involved in the contraction and relaxation of muscle fibers. Iron enables muscle tissue to use the nutrients and oxygen that are delivered by the blood. Iron also has a role in regulating body temperature. People with inadequate iron feel cold all the time. Too much iron, however, is as bad as too litile, sometimes leading to discoloration of the skin, heart disease, and slow recovery from stroke. Potassium deficiency affects heart and other smooth muscle function. Magnesium is needed.30 The Trigger Point Therapy Workbook in conjunction with the body’s use of calcium. Low levels of magnesium are associated with muscle hyperexcitability and weakness. Despite their concem for the balance of the vitamins and minerals in your body and their specific levels, Doctors Travell and Simons find that a good multivitamin with minerals should ordinarily meet your needs. They add the caution not to exceed maximum limits of folic acid, iron, vitamin A, and vitamin B6. (1999: 186-213) Metabolic Disorders You’re likely to have trouble getting rid of your trigger points when any chemical or glandular imbalance interferes with metabolism in the muscles. Some conditions to watch out for are thyroid inadequacy, hypoglycemia, anemia, and high levels of uric acid in the blood (uricemia). Nicotine, caffeine, and alcohol cause enough irregularity in the metabolism, to make it difficult to keep trigger points deactivated. (1999: 213-220) Low output from the thyroid. gland can increase the irritability of muscles, predisposing them to development of trigger points. Thyroid insufficiency is likely to make relief from trigger point therapy very short-lived. Typical signs of hypothyroidism include muscle cramps, weakness, stiffness, and pain. Other symptoms are chronic fatigue, cold intolerance, dry skin, and disturbed menstruation. Some people have trouble losing weight. Thyroid inadequacy may play a role in fibromyalgia. Lithium appears to lower thyroid secretion, while estrogen replacement increases it. Indirectly, lithium may make your trigger points worse; estrogen may make them betier. (1999: 214-218; Sonkin 45-60; Bochetta 193-198) Recurrent bouts with hypoglycemia (low blood sugar) tend to aggravate your trigger points and decrease the effectiveness of trigger point therapy. Symptoms of hypoglycemia are a fast heartbeat, sweating, shaking, and increased anxiety. A more severe spell can bring visual disturbances, restlessness, trouble with thinking and speaking, and even fainting. Emotional distress makes you more susceptible to hypoglycemia. Caffeine and nicotine both accentuate the secretion of adrenaline, which can worsen this condition. Alcohol should also be avoided. (1999: 219-220; Foster 1758-1762) Uricemia can make your trigger points more troublesome. Gout, the deposit of urate crystals in the joints, is the extreme manifestation of this problem. A diet of too much meat and too little water is likely to promote uricemia. Vitamin C helps combat the problem (1999: 220; Kelley 479-486). Psychological Factors Tension, anxiety, and everyday nervousness can make trigger point therapy ineffective. Habitually holding your muscles tight never gives them a chance to rest, not even at night when you're sleeping. A tight muscle is working continuously, and the tightness should be considered a form of overuse. You may not be aware of just how much muscle tension you're holding on to. Relaxing your muscles won't get rid of their trigger points, but it will allow therapy to work better. Cultivate an awareness of when you're holding rigid postures. Going around with hunched shoulders is a classic sign of excessive tension. You may be breathing shallowly when things aren’t going well; you may even be holding your breath at times. If you tune in to your body during tense moments, you'll detect the tightness in your chest and stomach.Chapter 2—All about Trigger Points 31 There are several excellent books in the catalog of New Harbinger Publications, the pub- lisher of this book, that can help you learn to deal better with your tensions. Other Factors A number of other influences may affect your success with trigger point therapy. Chronic infections, including sinusitis, can keep trigger points going. An allergy to airborne irritants that causes respiratory distress can make it very difficult to keep up with tigger points in the neck, chest, and abdomen. Food allergies can make all the muscles of the body more vulnerable to stress. Infestation of the intestinal tract can perpetuate trigger points indirectly through depletion of essential nutrients. Infestations can be insidious and are more common than you may think. (1999: 220-226) You can’t depend on your control of perpetuating factors alone to get rid of trigger points and myofascial pain. You may even find it hard to judge whether your control of per- petuating factors is having an effect. But keep an open mind and keep exploring. You may happen onto the one factor that makes all the difference. Therapeutic Methods Almost any intervention will affect a trigger point, according to Travell and Simons, as long as it’s a physical intervention. Nothing subtle will do. Trigger points don’t respond to posi- tive thinking, biofeedback, meditation, and progressive relaxation. Even physical methods can fail if they're too broadly applied. Conventional stretching exercises, for example, are not sufficiently specific to affect trigger points in a dependable way. When overdone, stretching can actually make trigger points worse. Other therapeutic methods can yield disappointing resulis. Applications of heat or cold may temporarily reduce pain but they won't deactivate your trigger points. Likewise, electrical stimulation can give temporary relief of pain but not affect a trigger point specifically. Most systems of therapeutic touch, like acupressure, shiatsu, craniosacral therapy, myofascial release, Swedish massage, and even deep tissue bodywork—despite their good uses—are also too nonspecific to guarantee success with tig- ger points. For dependable results, therapy needs to be applied directly to the trigger point. (1999: 126-147) In the Trigger Point Manual, Travell and Simons discuss numerous ways to cope with trigger points, including a few ideas for self-applied massage. They cover only two methods in comprehensive detail: trigger point injection and spray and stretch. These therapies are designed for use in a doctor's office or a physical therapy clinic. Trigger points will release when injected with a local anesthetic. They will sometimes do the same when stuck with a dry needle, as in acupuncture. Injection of trigger points requires a high degree of skill. Spray and stretch is safer and easier to use than injection and is the method favored by Travell and Simons for general use in a professional setting. Spray and stretch is fundamentally different from conventional stretching in that it directly addresses the trigger point before the affected muscle is stretched. (1999: 126-147)32 The Trigger Point Therapy Workbook Trigger Point Injection ‘The most exacting method of attacking trigger points is to inject them with a mild dose of procaine, a local anesthetic that wears off quickly. The therapeutic effect is in the mechani- cal disruption of the trigger point’s contracted muscle fibers by the needle. The anesthetic keeps it from hurting. The trigger point nodule is hardly ever larger than a pea, and often is no bigger than the head of a pin. It takes exceptional skill to accurately stick one with a hypodermic needle. As Travell and Simons describe it, it’s like trying to impale a tiny ball of hard rubber: the needle tends to bounce off the nodule or push it aside rather than penetrate. If you try to hold a trigger point between your fingers, it tends to slip out like a wet noodle. It reacts the same way to a needle. ‘Trigger point therapy by injection has other drawbacks. The needle usually leaves some postinjection soreness, which can take several days to subside. As with any invasive proce- dute, injections also risk inadvertent damage to nerves, blood vessels, and vital organs. In addition, your body has to get rid of the anesthetic that has been injected, which limits the number of trigger points that can be injected at any one time. By comparison, a massage therapist in a single session can give attention to every trigger point you may have, with no risk in the worst case beyond low-grade soreness for a day or two. Trigger points can be difficult to locate precisely enough to inject. They can’t always be felt clearly with the fingers, especially if theyre buried deep in a muscle. Trigger points are usually quite easy to find on yourself because of the immediate feedback provided by their - sensitivity to pressure. It’s impossible to have this connection with the trigger points on someone else. ‘All other considerations aside, injection may be the quickest treatment for myofascial pain if the trigger points haven't been in place too long. Chronic pain from long-standing trigger points may require multiple treatments, as with any other therapy. It’s important to accept the fact that trigger points do come back, as life goes on with all its stresses and strains. If you depend on injection therapy, you'll be seeing your doctor a lot. (1999: 150-166) Spray and Stretch Releasing a trigger point by spraying the skin with a refrigerant, then stretching the affected muscle, is the procedure Travell and Simons call their “workhorse method.” Spray and stretch requires less skill than injection does, but there are several stringent require- ments to meet so that it can be done safely. First, you must be certain that you're stretching the muscle containing the trigger point that is referring the pain. If you're entirely focused on the place that hurts, you may apply the method to the wrong muscles. Second, before you even think about stretching, it’s imperative that you chill the skin that overlies the trigger point and its area of referred pain with ice or a refrigerant spray. Trigger points are inclined to react to stretching with a defensive tightening, Chilling the skin prevents this by “distracting” the nervous system and temporarily suppressing the pain. In chilling the skin, it’s vital to work quickly so that the cooling agent doesn’t cool the underlying muscle. Cooling the muscle will inhibit the stretch rather than facilitating it, and more pain will be the likely result. After stretching, a third requirement is that you immedi- ately rewarm the cooled skin with moist hot packs to keep it from drawing heat out of the muscle.Chapter 2—All about Trigger Points 33 If movement was limited by the trigger point before treatment, a fourth step calls for gentle movement several times through the complete range of motion to let the body know that it is possible to move now. Even with these safeguards, stretching remains hazardous for many people. Travell and Simons specifically warn that the stretch must not be forced. They advise merely “taking up the slack” and not trying to make the muscle lengthen beyond the onset of resistance. The danger in attempting to stretch a muscle whose trigger points resist release is the chance you may strain the muscle’s attachments. This is because the taut bands of muscle on either side of the trigger point are already stretched to their limit. Because of the limits they put on stretching, these taut bands in muscles may be a critical factor in ligament and tendon inju- ries. (1999: 127-135) Deep Stroking Massage The safest and most effective method of trigger point therapy, according to Travell and Simons, is deep stroking massage applied directly to the trigger point. It has a more specific effect on the trigger point than spray and stretch and carries much less risk to muscle attach- ments. Its directness makes deep stroking massage nearly as effective as injection, and actu- ally superior around blood vessels and nerves where injection can be too dangerous to use. Deep stroking massage is also obviously the method most adaptable for self-treatment. (1999: 141-142; Danneskiold-Samsoe 1986: 174-178)CHAPTER 3 Massage Guidelines Although professional massage is unquestionably the best method of trigger point therapy, there are many advantages in doing it yourself. With self-treatment, you don’t have to wait for an appointment, you can get help whenever you need it, and you don’t pay a cent. Best of all, you-don’t have to depend on someone else knowing what's causing your pain and Knowing what to do about it. You can be the expert. No one can ever have the connection with your pain that you have. You know exactly where it hurts and how much it hurts. You know better than anyone else when a treatment feels right and when it doesn’t. With self-applied trigger point therapy, you'll have direct control over treatment. Most people feel a satisfying sense of empowerment when they dis- cover they know how to get rid of their own pain. It’s important to realize that self-treatment won't all be smooth going. There will be some difficulties to surmount. You’ll find that you can make some kinds of pain go away very quickly but that a long-established chronic problem can take a while to clear up. This is because trigger points that have been in place for a long time have made pathways in the nervous system that tend to reinforce and perpetuate them. (Travell and Simons 1999: 56-57; Yaksh 116-121) Another reality is that trigger point massage hurts, though if done correctly it will “hurt good.” Trigger point massage may not be pleasant at first if you're a person who reactively avoids all pain. If you believe that all pain is bad and that it’s a dumb idea to make yourself hurt, you may not be willing to do enough massage on yourself to do any good. On the other hand, if you try too hard to make massage work and do too much of it, your body will react against it and make your pain worse for a day or two. Overenthusiastic use of hard tools for massage can result in bruising not only of the skin, but possibly also of deeper tis- sues, such as muscles and nerves. When you have a lot of very active trigger points and work too long on yourself, you can come out of it feeling woozy or nauseous. If you have widespread pain, don’t try to take care of everything at once. Work on your worst problems first and try to be patient with the method and with yourself. Also, recognize that some of the trigger points related to your greatest stresses will tend to be recurrent. It’s not reasonable to expect that you'll never have pain again. Nevertheless, with your skills at trigger point massage therapy, you'll be better equipped to cope with pain than ever before. Plan to be good at it.36 ‘The Trigger Point Therapy Workbook Troubleshooting Success with trigger point massage depends ultimately on your ability to recognize when your pain is referred pain and to trace it back to the trigger point that is causing it. It’s too easy to get caught up in attacking the pain itself and remaining blind to its cause. Although some trigger points cause local pain, myofascial pain will defeat you if you assume that the problem is at the place that hurts. Winning over pain requires giving considerable attention to the referred pain patterns. Only by cultivating a methodical approach to troubleshooting can you become good at finding and deactivating trigger points. ‘The Trigger Point Guides at the beginning of each of the following chapters give lists of muscles that are known to send pain to a given site. To treat your pain, search for trigger points in the muscles on the list one at a time. The muscles are listed in order of greatest probability of being involved. The page number in parentheses after the muscle name is the beginning of the section where that muscle is discussed. The Trigger Point Guides are adapted from Travell and Simons’ Trigger Point Manual (1992; 1999). Each Trigger Point Guide also contains an illustration or two that shows the parts of the body that will be cov- ered in the chapter. New Words It’s useful to know the right names for the muscles. The search for a trigger point is nar-- rowed considerably when you can name the muscle it’s in. Knowing the name of the muscle helps clarify your conception of where it is, and you certainly have to be able to find the muscle before you can find its trigger points. There is no other name for most of the muscles except the latinized scientific name. A simplified key to pronunciation is given when the muscle is introduced. With a little prac- tice, you'll find that the words aren’t as much a foreign language as they may seem. A great number of the English words you use every day have their roots in Latin and Greek. The classical strains in the English language have enriched it and knowing the right words for your muscles will enrich you too. When you learn these beautiful new words and start throwing them around, your friends and family will think you’re brilliant. The people at work will think you're a snob, but only until you show them how to get rid of that headache or sore back. Body Mechanics In the muscle chapters, you'll learn about the job each muscle does. Understanding a muscle’s function helps you find the trigger points that are causing your problem. Insight into body mechanics also lets you see what you can do to prevent the problem. from recur- ring. Simply getting rid of the pain is never enough. More than anything else, you need to know how you can keep it from coming back. Knowledge of body mechanics also fosters an intuition about trigger points. When you know your muscles and have gained some experience finding their trigger points, you'll find your hands going right to them without having to consult the charts. Understanding how the muscles work also increases your awareness of problems when. they‘re just starting up. This helps you nip trigger points in the bud. cereChapter 3—Massage Guidelines 37 Finding Trigger Points False assumptions about the source of your pain can defeat your every effort to get rid of it. Trigger points are not usually found at the place that huris. Pain referral is the essential fact about trigger points. Massage in the wrong place can feel good and yet do no good at all for healing your pain. You won’t conquer referred pain unless you get good at tracking it to its source. The illustrations of the referred pain patterns for each muscle are the key to finding trigger points. Go back to these drawings every time you set out to deal with a pain prob- lem. A referred pain pattern can be such a crazy quilt of disconnected locations that if you try to rely on reason or memory, you'll overlook details that may be crucial to a successful search. You'll notice a tendency for trigger points to send their pain away from the center of the body, but the reverse is true too often to infer a perfectly reliable guiding principle. Also, you'll often find that several different muscles send pain to exactly the same spot. Your pain. may be coming from only one of them, or each may be contributing. The illustrations are absolutely vital for keeping it all sorted out. Figure 3.1 shows how muscles, trigger points, and referred pain are indicated in the illustrations. An area of referred pain is portrayed by a group of parallel lines running diagonally from lower left to upper right. Parallel lines also represent a muscle, but the lines are always enclosed within the outline of the muscle. A black dot approximates the location of a trigger point and may stand for several trigger points in the area. Sometimes an illustration will put you exactly on target and sometimes it will only get you in the ballpark. Ultimately you have to zero in on trigger points by feel. The aim is t0 get to the right area—usually a circle of a couple of inches diameter—then search for that spot of exquisite tenderness. Don’t be discouraged if you can’t feel the little nodules in the muscles. Some people never acquire that skill. Very experienced massage therapists are able to feel every little bump in muscles. Some can find trigger points with their fingertips with- out even being told where it hurts, but when you work on yourself you don’t have to find them that way. The most reliable criterion for detecting a trigger point is its extreme tender- ness. Just seek the little place that hurts : the most when you press on it. Obvi- ously, many medical conditions cause tenderness in muscles and other soft tissue. If you're in doubt, check with a physician, preferably one who is referred pain informed about trigger points and myofascial pain. trigger point Massage Technique muscle When it comes to doing massage the right way, there are two overriding issues: safety and effectiveness. You have to be able to do massage without straining and exhausting the muscles in your forearms and hands and you have to do it in a way that will actually have Figure 8.1 Key to pictorial devices38 The Trigger Point Therapy Workbook an effect on a trigger point, Table 3.1 lists nine principles of safe, effective trigger point massage. Table 3.1 Massage Guidelines at a Glance Use a tool if possible and save your hands. Use deep stroking massage, not static pressure. Massage with short, repeated strokes. Do the massage stroke in one direction only. Do the massage stroke slowly. Aim at a pain level of seven on a scale of one to ten. Limit massage to one minute per trigger point. Work a trigger point six to twelve times per day: If you get no relief, you may be working the wrong spot. Deep Stroking Massage The conventional practice regarding trigger points dictates that you must press and hold them until they release, or at least hold them for a specified number of seconds, depending on the book you've read or the massage school you've attended. This is called ischemic compression, which means that you're squeezing the blood out of the trigger point. The trouble with pressing and holding a trigger point is that it requires the sustained con- traction of your shoulders, arms, and hands, which can become extremely tiring in a' very short time. Massage therapists who use ischemic compression as trigger point therapy very often have constant pain in their arms and hands. This is one of the serious ergonomic haz~ ards that are causing such a large turnover in the profession. The burnout time for massage therapists averages about three years. As you can see, you must do massage safely or you'll end up with more trouble than you started with. Fortunately, there’s a much safer and more effective way to deactivate trigger points. Instead of the static pressure of ischemic compression, it’s altogether better to make a series of deep strokes across the trigger point nodule. This gets results quicker and with less irritation to the trigger point, less damage to your hands, and less risk of bruising the skin and muscle. In addition, a moving stroke, frequently repeated, elicits a greater change in a trigger point than static compression. ‘Compressing the trigger point is the right idea, but a repeated “milking” action moves the blood and lymph fluid out more efficiently. The lymph contains the accumulated waste that has been generated by the continuously contracted muscle fibers. 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 until the water wrings out of it clear. A similar process works best with a trigger point. Work deeply and slowly, using very short strokes, and no more than one stroke per sec- ond. The massage stroke doesn’t need to be a long one. It only needs to move from one sideChapter 3—Massage Guidelines 39 of the trigger point to the other. Rather than sliding your finger across the skin, move the skin with the fingers. Work deeply, mashing the trigger point against the underlying bone. Release at the end of the stroke, then go back to where you started, reset your fingers, 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 you'll hear that you should always move the fluid toward the heart, it’s not a critical issue. You can depend on the system to carry the junk away once you get it squeezed out of the trigger point, Stroke in whatever direction feels best. If you don’t make trigger point therapy as easy as you can, it will wipe you out and you won't want to do it. Another benefit of the 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 with the grain of the fibers or across them. Think of this as a microstretch, as opposed to the macrostretch of the whole muscle that you do with conventional stretching exercises. The microstretch is applied directly to the trigger point, right where it’s needed. Done this way, there’s little chance of overstretching the taut band of muscle fibers that lead from each side of the trigger point to the muscle’s attachments at the bone. Abuse of this taut band risks irritating the trigger point and making it hold on tighter. Hurting Good ‘Trigger points hurt when compressed, and you may be very reluctant to work them for fear of doing yourself harm or making your pain worse. You have to realize that pain cre- ated by massage is beneficial. The electrical impulses of moderate amounts of self-inflicted pain are therapeutic in that they disrupt the neurological feedback loop that maintains the trigger point. Rest assured that self-administered pain is usually self-limiting. Your natural defense mechanisms won't allow you to inflict more pain on yourself than you can stand. It’s very unlikely you'll do yourself real harm unless you try to massage too deeply with hard tools. (1999: 140-141) The level of pain caused by massage is useful as a measure of effectiveness. To gain maximum benefits, you should exert enough pressure to make it “hurt good.” Don’t let yourself off too easy, though. Light pressure won't do the job. Aim at a pain level of seven or eight on a scale of one to ten, where number one is no pain and number ten is intolerable. Another positive effect of pain from massage is that it immediately brings a flood of painkilling endorphins. For this reason, you'll find that the longer you work on yourself, the more pressure you will be able to use. If you have a really bad trigger point that you abso- Iutely hate to work on, try giving it a good initial shot of pain, then back off and wait ten seconds before going on. This gives the endorphins time to kick in and deaden your sensitiv- ity. You'll then be able to work deeper with far less discomfort. Endorphins are related chemically to morphine but have many times the power. Using the number scale, continue treating a trigger point until your pressure on it elicits a pain level of only a two or three. Don’t expect to reach this goal in a single session. Never try to force the trigger point to release. Normally, you should expect to continue massage for several more sessions after the trigger point has stopped actively referring pain.40 The Trigger Point Therapy Workbook Saving Your Hands and Fingers Considering the risks inherent in overworking your hands and fingers, it’s smart to avoid using them if there’s any other way. You may not have thought of using your knuckles, knees, heels, or elbows as massage tools, but it can be done. There are also a number of commercially available massage tools ergonomically designed to maximize safety and effi- ciency. Tools aren’t appropriate, however, in sensitive areas such as the front of the neck, the inside of the mouth, or under the arms. When there’s no choice but to use your fingers, you must do all you can to avoid injuring them. ‘The basic principle is to. apply the most force with the least effort and the Jeast strain. When a thumb is used as a massage tool, back it up with the fingers (Figure 3.2). This is called the supported thumb. Don’t use the thumb in opposition 4 Figure 3.2 Supported thumb to the fingers unless there is simply no other way to do it. Gripping or kneading would seem the most natural thing to do, but it is actually quite will do. exhausting. Hands used in this way won't last any time at all. Save the grip for places where absolutely nothing else When using your hands as massage tools, pair them if you can, using the opposite hand to back up the fingers that are doing the massage (Figure 3.3). This tool is called supported fingers. Using the illustrations in Figures 3.3 and 34 as a Starting point, move the edge of the supporting hand even closer to the ends of the fingers, actually cover ing the nails, for maximum support. Rather than using the hand to pinch, squeeze, and Knead, use the thumb or fingers like the end of a stick to push into the flesh. For the greatest mechanical advantage, Figure 3.3 Supported fingers the fingers or thumbs need to be held nearly perpendicu- lar to the surface of the body (Figure 3.4). This allows the force to be directed in a straight line from the elbow down through the arm, wrist, and hand and out the ends of the fingers or thumbs. You'll see right away that if you have fingernails of even moderate length, you will be prevented from using your hands in this way. Massage done with the flats or pads of the fingers is ergonomically so poor that you'll find your hands and fin- gers getting tired before you've gained any benefit. In some lines of work, the inefficiency imposed by long nails contributes significantly to formation of trigger points in the forearms and hands, because the muscles have to work so much harder to overcome the awkwardness. Profes- sional massage therapists keep their nails filed to the quick. You might consider doing the same, at least until Figure 3.4 Supported fingers nearly perpendicular to skin your pain is gone.Chapter 3—Massage Guidelines 41 A great variety of mechanical devices are being sold for massage. The two most versatile and well-designed tools are the Thera Cane (Figure 3.5) and the Knobble (Figure 3.6). Both items are available through any massage therapist, massage school, or wellness center. You can also find them online. Addresses and phone numbers of distributors can be found at the end of the book. In most illustrations in this book, you'll see the Thera Cane being applied to bare skin. This was done for the sake of clar- ity: you won't like it on bare skin. For com- ; fort, hard tools like the Thera Cane and the Figure 3.5 Thera Figure 3.6 The Knobble Knobble should be used through a layer of | °*"* imaeesge-tool clothing, ‘The best massage tool of all—for a surprising number of muscles—may simply be a ball pressed between the body and a wall. You can use a tennis ball or a hard rubber ball of the same size; smaller rubber balls can be used if you need to go deeper. Putting a tennis ball in a sock lets you hang the ball down behind your back without risk of dropping it and having to chase it all over the room. “High bounce” or “super bounce” rubber balls often come in several sizes in one package and can be found in sports, discount, and variety stores. They're very hard without being too hard, and they make excellent massage tools. Kmart is a good place to look for them. Cheap rubber balls made for children usually develop cracks after a While. Don't be unduly concemed, though: it doesn’t destroy their usefulness. Someone should go into the business of making therapeutic balls of pure gum rubber, which is moze durable. Making the Method Work Even though trigger point massage works well for getting rid of trigger points and referred pain, don’t be surprised if you encounter some snags. Worrisome Results Deep massage may occasionally cause bruising in tender areas. This is usually nothing to worry about, but you might want to let up a little on the pressure you're using. Bruising should be taken as a sign that you're trying too hard. It may also be a sign you're working the wrong place, particularly if you're working a lot and getting little improvement. Trigger points ordinarily respond well to massage and it doesn’t take long to feel an improvement. Most treatment failures are the result of working the wrong spot. Always use the Trigger Point Guides at the beginning of the chapters to help find the trigger points you need to treat, and remember that most pain has several possible sites of origin. On the other hand, don’t expect too much from half-hearted efforts. If you're not get- ting the results you think you should be getting, consider whether you're doing enough mas- sage. Your really bad trigger points should have six to eight one-minute sessions a day. You42 The Trigger Point Therapy Workbook will be disappointed in the outcome if you do less. You only need to do a dozen deep strokes per session on any given trigger point to have a beneficial effect. In addition to multi- ple treatments during the day, be sure to massage your really difficult trigger points just before going to bed and again when you get up in the morning, If pain wakes you up in the night, get up and have a session. As a general rule, massaging offer is much better than mas- saging too hard or too long. Some people have difficulty getting the hang of trigger point massage. You may have trouble finding trigger points, or you may feel clumsy and unsure with the tools and tech- niques. In such a case, you may benefit from a few sessions with a professional massage therapist who knows trigger points well. Be upfront tell him or her that you want to learn how to take care of your trigger points yourself. ‘Trigger point massage works extremely well for myofascial pain. Done correctly, it usu- ally shows clear resulis well within a week, often in just a day or two. Keep in mind that pain that persists could have an organic or systemic cause. If your pain began with an acci- Font or a fall, you may have bone or tissue injuries that need medical attention. If you burt Sll over and massage is doing no good at all or seems to make the pain worse, you may be dealing with fibromyalgia or some other systemic problem and will have to seek other remedies. Health Factors If you're successful in deactivating your trigger points but your pain seems to come back after a short time, there may be health factors that are predisposing your muscles to the development and perpetuation of trigger points. These things are discussed in more detail in Chapter 2. Consider whether you may be lacking B and C vitamins or calcium, magnesium, izon, and potassium. Smoking, excess alcohol, birth control pills, and certain other drugs are all known to deplete these nutrients. You may have a thyroid inadequacy. Hypoglycemia can aggravate trigger points. Question whether you're drinking enough water, Hyperurecemia, a cendition where you're not getting enough water or your kidneys aren’t doing their job, can keep your trigger points going. Chronic infections or allergies may perpetuate trigger points. Be care thet food allergies can play a role in both myofascial pain syndrome and fibromyalgia. Expectations You may wonder what you should expect of trigger point massage. You may want to kmow how many massage sessions will be needed to make your pain go away. Will your trigger points come back? Can you really expect to be truly pain free? All of these things depend to a great degree on how much intelligence and commitment go into your efforts. Be realistic regarding expectations of success with trigger point therapy. Although you may occasionally experience the much-desired one-shot fix with trigger point massage, it’s ‘wise not to plan on it. Quick fixes are often illusory and can amount to nothing more than having simply swept the problem under the rug. Sometimes, a one-session triumph is genu- ine: the body can be very good about healing itself with the right stimulus. This happens most often with new pain. Long-standing trigger points requixe considerable attention; this will be true whether you do the massage yourself or seek help from a professional.Chapter 3—Massage Guidelines 43 People tend to quit too soon whether they’re working on themselves or going to a pro- fessional. You will be tempted to stop doing your massage the minute the trigger point stops actively referring pain. Remember that if the trigger point still hurts when you press on it, you've only soothed it into a latent state. Leaving a trigger point in the latent state allows it to be quickly reactivated by almost anything. Massage must continue until the trigger point no longer hurts when you work it. Massage works miracles with trigger points, but only when done correctly and completely. The Learning Curve . You'll be surprised at how quickly you can forget even your most useful discoveries about myofascial pain, It’s useful to keep a pain diary about what you learn from day to day, making notes about the tricks and tools that work best. Then, when a problem comes up again, you'll find the solution all worked out in your pain diary and you won't have to rein- vent the wheel. To succeed in making this method work for you, the old rule applies: just keep trying. For difficult problems, read and reread and then read again any passage in this book that may apply. Underline and make notes in the margins. Take time to think. All the anatomical detail and all the ramifications regarding myofascial pain are so new that you're bound to feel mystified and. overwhelmed sometimes. However, self-treatment of pain is much sim- pler than it seems at first and it will eventually all come together. Don’t give up! Keep ing! There's a long learning curve to mastering everything in this book, but you can expect to see positive results from the very beginning. If you study this book on an. ongoing basis and keep searching for solutions, you'll learn something useful almost daily. Work on know- ing the muscles and bones. It’s important that you understand what’s beneath the surface of your skin. The muscles and bones in there are you. To augment what you see in this book, you may want to get Frank Netier’s Atlas of Human Anatomy and study his magnificent illus- trations. If you've got the stomach to learn from dissected bodies, the six-part Video Atlas of. Human Anatomy by Robert Acland will give you some unique insights. Dr. Acland uses a moving camera technique to create a three-dimensional view, which you can’t get from a book, and which can be very revealing of the structure of things. In whatever way you can, keep exploring and keep leaming. You deserve to be pain-free. Give yourself this gift.CHAPTER 4 Head and Neck Pain46 The Trigger Point Therapy Workbook Trigger Point Guide: Head and Neck Pain Crown Headache sternocleidomastoid (49) splenius capitis (60) Frontal Headache sternocleidomastoid (49) semispinalis capitis (61) zygomaticus (67) frontalis (69) Temple Headache trapezius (52) sternocleidomastoid (49) temporalis (69) splenius cervicis (60) suboccipitals (59) semispinalis capitis (61) Eye Pain stemocleidomastoid (49) temporalis (69) splenius cervicis (60) masseter (63) suboccipitals (59) coccipitalis (69) orbicularis oculi (66) trapezius (52) Sinus Pain sternocleidomastoid (49) masseter (63) lateral pterygoid (65) orbicularis oculi (66) zygomaticus (67) levator labii (67) Ear and Jaw Pain lateral pterygoid (65) medial pterygoid (65) masseter (63) sternocleidomastoid (49) trapezius (62) Tongue Pain sternodleidomastoid (49) medial pterygoid (65) mylohyoid (68) Toothache temporalis (69) masseter (63) digastric (68) ‘buccinator (66) Throat Pain sternocleidomastoid (49) medial pterygoid (65) digastric (68) longus colli (68) buccinator (66) platysma (68) Side of Neck Pain medial pterygoid (65) sternocleidomastoid (49) levator scapulae (67) Back of Head Pain trapezius (62) sternocleidomastoid (49) semispinalis capitis (61) splenius cervicis (60) suboccipitals (69) digastric (68) temporalis (69) Back of Neck Pain trapezius (52) levator scapulae (57) multifidi (62) rotatores (62) infraspinatus (86) digastric (68)Chapter 4—Head and Neck Pain 47 Trigger Point Guide: Head and Neck Pain Frontal headache Crown headache Eye pain Temple headache Ear and jaw pain Side of neck pain Throat pain Tongue pain Back of head pain Back of neck pain48 The Trigger Point Therapy Workbook Trigger points cause an astonishing variety of symptoms in the head and neck region. Some of the effects they can have may contradict a lot of what you've always believed. Trigger points are known to cause pain and hypersensitivity in your teeth, pain and stuffiness in your ears, pain and redness in your eyes, sinus pain and drainage, stiff neck, chronic cough, and sore throat. Trigger points can cause dizziness and balance problems. They can blur your vision and make the words dance around on the page when you're trying to read. They can make your lips numb, your tongue hurt, or an eyelid droop. (Travell and Simons 1999: 308-316). Furthermore, trigger points are responsible for much of the pain. associated with temporomandibular joint (TMJ) syndrome and are involved in important ways with the other symptoms of this disturbing condition, including popping and clicking in the jaw, dis- location of the jaw, restriction of jaw opening, and faulty closure of the teeth. (1999: 379-384) If this isn’t enough, Travell and Simons’ work has shown that trigger points are often the hidden and unsuspected cause of most headaches, no matter what name they’re given: tension headaches, cervicogenic headaches, cluster headaches, vascular headaches or migzaines. (1999: 240-256, 308-314) Many recognized “headache triggers” actually have their effect by cranking up your latent trigger points. A bad cough can do it; so can a viral infec- tion, a hangover, overexertion, analgesic rebound, and too much consumption of sugar. Trig- ger points are the operational element in headaches set off by allergic reactions, chemical withdrawal, physical trauma, and emotional tension. Even the frustrating, unexplainable headaches that come with fibromyalgia can be shown to be due largely to the presence of trigger points. (1999: 242) The paradox about headaches is that the cause is rarely in the affected parts of the head itself. Most headaches come from trigger points in jaw, neck, and upper back muscles. This physical distance between cause and effect is why headaches can be so mysterious and hard to deal with. Obviously, pain and other symptoms in the head and neck area can have other causes than myofascial trigger points, but trigger points should always be one of the first things to be considered, because they can be so quickly checked out. You only need to know where to look. The Trigger Point Guide at the beginning of this chapter will provide the guidance you need in that regard. When trigger points are the cause of your symptoms, self-applied mas- sage will give a degree of relief that even the strongest narcotic medicines don’t provide, and it will last longer. With certain muscles, such as the sternocleidomastoid, relief comes so quickly that the connection between trigger points and your symptoms is hard to deny. Three Special Muscles of the Neck The trapezius, levator scapulae, and sternocleidomastoid muscles are difficult to classify according to location. The trapézius is so large that it covers the upper back, the back of the neck, and part of both shoulders. The levator scapulae starts in the upper back but wraps around to become part of the side of the neck, The sternocleidomastoid also wraps around the neck and could be seen as part of either the side or the front of the neck. Further, the unique multiple functions of these three muscles puts each in a class by itself.Sternocleidomastoid The name sternocleidomastoid (STUR-no- KLY-do-MAS-toid) is made up of the ana- tomical names for the bones it attaches to (Figure. 4.1). Sterno refers fo the sternum, or breastbone. Cleido refers to the clavicle, or collarbone. Mastoid is the mastoid bone, the knob behind the ear. Don’t be intimidated by this long, wonderful word. It has an infectious rhythm that you'll learn to love: say it four times in a row and you'll be on your feet dancing. You'd best make friends with your sternocleidomastoid muscles, because they make more trouble than you can imagine. Since the stemocleidomastoids are in Chapter 4—Hend and Neck Pain 49 Stemocleidomastoid muscles Figure 4.1 the front of your neck, you've probably never thought about them or even noticed them. You don’t usually get pain in the front of your neck. You get it in the back of your neck. Trigger points in the sternocleidomastoid muscles actually cause an incredible amount of pain, but it’s all sent elsewhere, The sternocleidomastoids themselves rarely hurt, no matter how much trouble they're in or how much trouble they’re causing, Tightness or stiffness in these muscles, however, can indicate the presence of trigger points. (1999: 308-311) Kate, age fifty-one, was a case that illustrates the unexpected effects that sternocleidomastoid trigger points can have and the dramatic and swift relief that can occur with appropriate treatment. She'd lived with TMY pain in both jaws since the age of nine, when she'd had several teeth removed to compensate for a small jmo, She also had frequent headaches and pain deep in her left ear. One day, whilé reading an article about myofascial pain that suggested neck muscles as the source of many mysterious symptoms, she began feeling her neck muscles with her hand. She was startled to find a big knot in the side of her neck that she hadn’t realized was there—she said it felt just like an egg. While she was massaging the muscle, she experienced a release in her left jaw that was so sudden and intense that it frightened her. The side of her neck felt like it was expanding like a balloon. She ran to look at it in the bathroom mirror but could see no swelling or anything else wrong. Then she noticed the pain in her ear and jaws was gone and her bite felt different. Her jaw felt like it had shifted position. Her dentist, after inspecting the change, told Kate that her TM] dysfunction had somehow resolved itself and she now had a proper bite. From a myofascial viewpoint, massive chronic trigger points in Kate's sternocleidomastoids were directly to blame for her headaches and ear pain. They had also maintained secondary trigger points in the jaw muscles that were the cause of her jaw pain and the misalignment of her temporomandibular joints. She has learned that a few minutes of massage to her sternocleidomastoid muscles gets rid of her symptoms when she feels them coming back.50 The Trigger Point Therapy Workbook Symptoms : People are rarely aware of sterno- cleidomastoid trigger points, though their effects can be amazingly widespread. Their influence on other muscles extends their effects significantly. Symptoms created by sternocleidomastoid trigger points fall into four groups: referred pain, balance prob- lems, visual disturbances, and systemic symptoms Referred Pain There are important differ- ences in the referred pain patterns for the two branches of the stemocleidomastoid Figure 4.2 Stemnocleidomastoid, stemal branch: muscle: the sternal branch and the clavicular ‘rigger points and referred pain pattem branch (Figures 4.2 and 4.3). Pain can be sent to the top, sides, back, or front of the head. A frontal headache is practically a signature of sternocleidomastoid trigger points. Not shown is an occasional spillover of pain in the sides of the face, which mimics a disorder characterized by brief attacks of pain caused by irritation of the trigeminal nerve. Pain is also sometimes sent to the back of the neck. (1999: 308-309, 318) Sternocleidomastoid trigger points can send pain deep into the ear and to the-eye-and the sinuses. They can make the back teeth and the root of the tongue hurt. Sometimes a chronic cough or a sore throat is from trigger points in the lower end of one of the sternocleidomastoids. They can be the source of a painless neck stiffness that keeps your head pulled over to one side. Balance Problems Trigger points in the clavicular branch of the sternocleidomastoid muscle are apt to make you dizzy and prone to lurching or falling unexpectedly. They can also be the cause of unexplained fainting. You can experience a degree of reversible hearing loss on the side where these trigger points exist. (1999: 308-314) Dizziness from trigger points can last for minutes, hours, or days. In some cases, it persists for years, defying all treatments and medical explanations. The myofascial expla- nation is that differences in tension in the sternocleidomastoid muscles help with your spatial orientation. If their tensions are unbalanced, you will be unbalanced too. Sternocleidomastoid trigger points are thought to have a direct effect on the inner ear, thereby affecting your balance. Dr. Travell believed that the distorted percep- tion caused by trigger points in sterno- cleidomastoid muscles were a hidden cause of falls and motor vehicle accidents. (1999: 314) Figure 4.3 Stemocleidomastoid, clavicular branch: trigger points and referred pain pattemChapter 4—Head and Neck Pain 51 Visual Disturbances The inner ear functions as guidance system for the focusing and track- ing of the eyes. For this reason, the influence of sternocleidomastoid trigger points on the inner ear can be the indirect cause of blurred or double vision. They can make things appear to be jumping around in front of your eyes. Though not related to the inner ear, a droopy eyelid, excessive tearing or reddening of the eyes can also often be traced to sternocleidomastoid trigger points. (1999: 313-314) Systemic Symptoms A fourth group of symptoms of sternocleidomastoid trigger points is even stranger, involving the generation of excess mucus in the sinuses, nasal cavities, and throat. They can be the simple explanation for your sinus congestion, sinus drainage, glop in the throat, chronic cough, rhinitis, and persistent hay fever or cold symptoms. A persistent dry cough can often be stopped with massage to the sternal branch near its attachment to the breastbone. (1999: 313) Causes An important function of a sternocleidomastoid muscle is to turn the head, Contraction turns the head to the opposite side by pulling the mastoid bone around toward the sternum. ‘Together, the sternocleidomastoids help maintain a stable position of the head during move- ments of the body. ‘Trigger points can be created by postures that keep the-sternocleidomastoids contracted to hold the head in position. Holding your head back to work overhead is particularly bad. Keeping your head turned to one side for any reason is sure to cause trouble. Trigger points in the lower half of the body often distort the posture to such an extent that the neck muscles must exhaust themselves in a constant attempt to compensate. (1999: 314-316) A single incident of heavy lifting can strain the sternocleidomastoids. Falls and whip- lash accidents cause severe overstretching and overcontraction in all the muscles of the neck, including the sternocleidomastoids. Myofascial symptoms from whiplash in an auto accident can persist for years. Other conditions that encourage trigger points are a tight collar, a short leg, a curvature of the spine, a chronic cough, hyperventilation, emotional stress, and habit- ual muscle tension. An auxiliary function of the sternocleidomastoids is to raise the breast- bone when you breathe in. Chest breathing can overwork them. To avoid unnecessary stress to the sternocleidomastoids, don’t sit for long periods with your head turned to one side, don’t read in bed, and don’t sleep on your stomach. Don’t slouch when sitting on a couch or in a chair. Don’t hold the telephone to your ear with your shoulder. Lear to breathe with your diaphragm, not with your chest. During normal breathing, your stomach should go in and out; your upper chest should not expand and con- tract much at all. Treatment The good news about the confusing conglomeration of symptoms generated by stemnocleidomastoid trigger points is that you can fix them yourself in the simplest way. To massage the sternocleidomastoid, take all the soft tissue that you can between your fingers and thumb and knead firmly (Figures 4.4, 4.5, and 4.6). Try to discriminate between the two parts of the muscle; for help see Figures 4.2 and 4.3. One is in front of the other, each52 The Trigger Point Therapy Workbook Figure 4.4 Figure 4.5 Figure 4.6 Sterocleidomastoid massage between fingers and thumb about as big around as a finger. If you pay close attention, you should be able to feel them separately. Search for trigger points from your collarbone to behind your earlobe. If your sternocleidomastoid muscles hurt when: squeezed, they're almost certain-to-be involved in that chronic headache or whatever other symptom you may be having in. your head, face, or jaws. When sternocleidomastoid trigger points are bad enough, a little squeeze will actually reproduce or accentuate a headache, giving you a very convincing demonstra- tion of what trigger points do. Don’t be afraid of these muscles. They may hurt like the devil to massage, but you can’t do them any harm. To the contrary, every squeeze you give them will be of benefit. Your symptoms may disappear in a very short time, but continue working the trigger points repeatedly and patiently over several days, until you can no longer find a place that hurts. A single session of sternocleidomastoid massage shouldn't last longer than a minute or two per side. Sternocleidomastoid massage often makes a headache better almost immediately. The same is true for dizziness and many other sternocleidomastoid symptoms. Trapezius The word trapezius (truh-PEE-zee-us) comes from the Greek word for a small table, a reflection of the muscle’s relative flatness and four-cornered shape. Although the trapezius is located on the upper back and functions mainly to move the shoulder, it appears in this chapter because its trigger points are a primary source of headaches and neck pains. A typical case of unsuspected trapezius trouble was Alison, age thirty. Her symptoms didn’t seem to have anything to do with her trapezius muscles, although they were the very muscles she had over exercised with her weights. She had awakened the next day with the worst headache she'd ever had. The pain was worst in the back of her head, her forehead, and her right temple. She had a terrible ache behind her right eye. She was also dizzy and nauseous and had been vomiting in the night.Head and Neck Pain 53 Figure 4.7 Trapezius number 1 trigger point Figure 4.8 Trapezius number 1 trigger ‘and referred pain pattern: front view point and referred pain pattem: side view Alison found trigger points in her sternocleidomastoid muscles and the muscles in the back of her neck. Squeezing a trigger point in her right trapezius muscle accentuated the pain in her temple and behind her eye. Several sessions of self applied massage over the course of a single day got rid of all her symptoms. Symptoms The first trapezius trigger point, or “trapezius number 1 trigger point,” is located in the very topmost fibers of the thick roll of muscle on top of the shoulder. It causes pain in the temple, at the back corner of the jaw, down the side of the neck behind the ear, and even © behind the eye (Figures 4.7 and 4.8). Occasionally, pain occurs in the back of the head (not shown). Most people have trapezius number 1 trigger points at one time or another. Their effects are most often identified as a tension headache. (1999: 278-287) Trapezius trigger point number 1 is also a frequent cause of dizziness that is indistinguishable from that caused by a trigger point in the, sterno- cleidomastoid. Moreover, it’s capable of inducing secondary trigger points in muscles in the temple and jaw, making it an indirect cause of jaw pain and toothache. (1999: 279) Trapezius trigger point number 2 is deeper in the upper trapezius and sends pain to the base of the skull (Figure 4.9). This referred pain predictably induces secondary trigger points in the muscles of the back of the neck. When neck massage feels good but doesn’t get rid of the pain, the problem may be in the trapezius muscles, not the neck. Figure 4,9 Trapezius number 2 trigger point and referred pain patter54 The Trigger Point Therapy Workbook Trapezius trigger point number 3 also refers pain to the base of the skull and to a small place on top of the shoulder (Figure Y, 4.10). This extremely common trigger point % is located in the lower fibers of the trapezius lac at the lower inner edge of the shoulder = blade, and is very easily missed. It’s respon- sible for the burning pain between your x shoulder blades that comes after a long spell. We at the computer without elbow support. Such aches are very familiar to piano play- ers, who also hold their arms out in front of them for long periods of time unsupported. Although this trigger point is a long way from the neck, it’s one of the many causes of a stiff neck. When trigger points weaken the lower trapezius muscles, they may cause the shoulder blades to stick out in back, a condi- tion called “winging.” (1999: 280) Trapezius trigger point number 4 occurs next to the inner border of the shoulder ( blade in the broad middle part of the a Figure 4.10 Trapezius number 3 trigger points and referred pain pattem trapezius (Figure 4.11). It causes a burning Kind of pain nearby, alongside the spine. Superficial trigger points in this area can cause goosebumps on the back of the uppet arm and sometimes, oddly, on the thighs. (1999: 281-282) The symptoms generated by trapezius trigger points are widely misinterpreted, producing a whole catalog of misdiagnoses and misdirected treatments. You may be told you have spinal disk compression, spinal stenosis, bursitis of the shoulder, or neuralgia. Headaches caused by trapezius trigger points may be labeled as cervogenic, vascular, chus- ter, or migraine when their true cause is not understood. Although there are serious medical causes of headaches, an examination for trigger points should be near the top of any doctor’s list. (1999: 291-293) Figure 4.11 Trapezius number 4 trigger points and referred pain pattern Causes The trapezius covers most of the upper half of the back, extending upward to cover the central part of the back of the neck. This uppermost part of the trapezius is what gives the back of the neck its shape. The muscle attaches to the base of the skull, the spine, the collar- bone, and the shoulder blades. The trapezius supports the weight of the shoulders and must contract strongly to rotate the shoulder blade every time you raise your arm. Another pri- mary function is to hold the shoulder blade solidly in place as a base for the finer operations of the arm and hand.