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Learn what trigger points are and the benefits massage therapy can provide for clients in pain.
By Christian Bond, March 2, 2015
Chronic pain is but one of several reasons you might find clients coming to you for massage therapy. Still, as more and more health professionals start valuing the role massage therapy can play in helping people deal with conditions that have pain as a major symptom, you might find an uptick in the number of clients looking to you for some relief.
And knowing ways you can help is going to be key.
Trigger points can be implicated in a wide range of common conditions that involve chronic pain, including sciatica, plantar fasciitis, low back pain, trigger finger and frozen shoulder, to name a few. By learning what trigger points are and the benefits massage therapy can provide, you’re giving yourself one more tool to use with clients who come to you in pain.
Trigger points are defined as “a focus of hyperirritability in a tissue that, when compressed, is locally tender and, if sufficiently hypersensitive, gives rise to referred pain and tenderness.”1 In other words: a trigger point is believed to be a localized spasm or knot in the muscle fiber that may cause pain to be referred to other, more distant parts of the body. “I have seen clients who have been told they have arthritis of the elbow when the problem was actually the bicep muscle being so tight that the arm could not straighten and stress was being placed on the inside elbow joint, causing both pain and an inflammation,” says Julie Donnelly, a licensed massage therapist in Sarasota, Florida.
Related: Learn how AMTA-led advocacy efforts protected the term "trigger point"
According to Steve Jurch, Director of Allied Health Training at the Community College of Baltimore County, trigger points are typically caused by three types of muscle overload: acute, sustained and repetitive. “These types of muscle overload can occur in a variety of settings, including occupational and athletic settings, and can also result from underlying pathologies,” he explains.
Here is how a trigger point forms: Muscle overload causes an abnormal release of acetylcholine (from dysfunction in motor end plates). This release causes an influx of calcium into the sarcomeres in the affected area which, in turn, causes these sarcomeres to contract. “Because of the sarcomere contraction, there is an increase in the tension of the muscle fiber,” Jurch explains. “This tension creates contraction knots in the short sarcomeres, and these knots evolve into a trigger point. The lengthened sarcomeres along with the contraction knots, referred to as the trigger-point complex, constitutes the taut band in several adjacent fibers.”
But for clients who may not be as versed in anatomy and physiology as you, you might consider finding more common ways to talk to them about what’s happening. “I always use an analogy of taking a 12 inch piece of rope and tying knots in it until it’s only 10 inches long,” explains Donnelly. “The client can easily understand what’s happening. The knot is getting tighter and the fibers on either side of the knot are being overstretched.”
Take shoulder and elbow pain as an example. “The two-headed biceps muscle originates at the shoulder at the supraglenoid tubercle and the coracoid process of the scapula and inserts into the tuberosity of the radius and bicipital aponeurosis,” Donnelly says. “When the muscle contracts normally, a person will take their straight arm and touch their shoulder. However, when the muscle is in spasm, they won’t be able to fully straighten the bent arm.” In this case, your client may be feeling shoulder pain that is actually the result of a tight biceps muscle.
Perhaps one of the biggest benefits of massage therapy is that it’s noninvasive and fairly easily tolerated by the client. “Second,” says Jurch, “is that other forms of treatment may not address all of the necessary areas.” Meaning, again, that some of your clients may be feeling pain in one area whose source is actually in another. “A massage therapist can understand the relationship between each of the muscles that have an impact on a joint,” explains Donnelly. “Knowing which muscle needs to be released first in order for subsequent muscles to be effectively treated is immensely helpful.”
That a massage therapist is focused on muscles, tendons and insertion points is also helpful, according to Donnelly. “A massage therapist can use the referral patterns of the trigger points to follow the point of pain described by the client back to the originating muscle, locate the trigger point in that muscle and apply direct pressure to release the spasms,” she explains.
Typically, massage therapists use a type of compression—sometimes referred to as digital pressure—to help relieve trigger points. “The goal of treating trigger points is to remove the spasm and return the sarcomere to its original length,” Jurch explains. “Digital pressure works by applying pressure to a ‘knot’ for anywhere from 30 seconds to 90 seconds, until a change in the tissue is felt.”
However, both Donnelly and Jurch agree that while doing this work, clearly communicating with your clients is imperative, as they may experience some pain and you need to be able to adjust pressure when necessary. “Unlike a relaxing massage, trigger point therapy can be uncomfortable to receive, especially while applying the direct pressure on the trigger point,” Donnelly says. “I always explain to clients that it’s very important for them to tell me immediately if the pain is not tolerable to I can adjust my pressure.”
Jurch shoots for a seven out of 10 on a client’s pain scale, cautioning that massage therapists don’t want to be too aggressive with this work and cause irritation to the tissue. “Once the therapist feels the tissue change,” he says, “they should remove the pressure and perform some general massage strokes to the area.”
So, while you are used to checking in with clients during a massage therapy session, doing so more frequently may be necessary when doing trigger point work. “What may be just fine in one area might be intolerable in another,” Donnelly explains. “I ask my clients over and over ‘Is this pressure OK?’ Sometimes we laugh because I ask so often, but they definitely get the point that it’s vital for me to know how they are doing during the entire massage therapy session.”
Clients who are in chronic pain, no matter what the cause, are looking for one thing: relief. More and more, massage therapy is proving helpful. For your clients who look to you for help managing chronic pain, understanding—and being able to treat—trigger points can sometimes make all the difference.
Steve Jurch, Director of Allied Health Training at the Community College of Baltimore County, had a client who was experiencing numbness and tingling in her arms and hands. “She was in her late 60s and was in otherwise good health,” he says. “She had been to her physicians and was diagnosed with spinal stenosis and told surgery may be required.”
After an initial assessment that revealed the client had a forward-head posture that was likely causing some spasm and shortening of the muscles of the anterior neck, Jurch thought he might be able to help the client find some relief with massage therapy. “Since the major nerves that feed the arm pass through this area, we discussed trying some trigger point and soft tissue techniques along with stretching to see if we could get some relief,” he explains.
Jurch began seeing the client once a week and focused his work on releasing trigger points in the scalene, sternocleidomastoid, and both pectoralis major and minor. “Posteriorly, the trapezius, rhomboids, levator scapulae, splenius captious and the rotator cuff were the focus,” he adds.
The client started seeing results after the third session and was able to postpone surgery. “We use stretching and general soft tissue techniques to maintain the progress that she’s made,” Jurch explains.
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1. Myofascial Pain and Dysfunction. The Trigger Point Manual. Janet G. Travell,
MD and David G. Simons, MD. Williams & Wilkins, Baltimore, MD.