A Trigger Point (TrP) is a palpable nodule in the taut bands of the skeletal muscles fascia.
It is a hyperirritable spot that can elicit tenderness, local twitch response and referred pain by direct compression or muscle contraction which usually responds with a pain pattern distant from the spot.
In myofascial mainly in the center of a muscle belly, the trigger point usually develops. Those are palpable nodules within the tight muscle at the size of 2-10 mm and can demonstrate at different places in any skeletal muscles of the body. TrPs are directly associated with myofascial pain syndrome, psychological disturbance, and restricted daily activities.
Causes of Myofascial Pain Syndrome:
- Injury due to falls or during birth trauma.
- Lack of exercise – commonly in sedentary persons.
- Bad posture.
- Muscle overuse and respective micro-trauma – weightlifting.
- Chronic stress condition – anxiety, depression, and psychological stress trauma.
- Vitamin deficiencies – vitamin C, D, B; folic acid; iron.
- Joint problems and hypermobility.
- Generalized fatigue.
- Hormonal changes. For example – menopause.
- Lack of activity. For example – Immobilisation for a long time during fracture.
Classification Of TrPs:
TrPs can be divided into several groups:
Primary/central and secondary/satellite trigger points:
Primary or Central trigger points cause pain when the pressure has been applied to the local tender area and radiates to the referred pain map. Usually, are based around the center of a muscle belly
Secondary or Satellite trigger points cause pain in surrounding muscles of existing central trigger points they usually spontaneously withdraw when the central TrP is healed. It can be present in the form of a cluster.
Active and inactive/ latent trigger points:
Active TrP is a point that causes tenderness and referral pain patterns only on palpation. Almost always central TrPs are active and some satellite TrPs. Inactive TrPs can eventually become active if there is a provocative factor.
Latent trigger point usually stays for a longer time and when the muscle gets tighter or stressed due to any of the cause, it activates and presents into pain and other symptoms.
Diffuse trigger points:
Commonly happen in case of severe postural deformity where initially primary TrPs are multiple, so secondary multiple TrPs are the only response of a mechanism called diffuse.
Attachment trigger points:
Arise in tendon-osseous junctions which become very tender. If it is left untreated, the nearby joint gets spring up due to the degenerative process
Ligamentous trigger points:
Even ligaments can develop trigger points. Some pain syndromes are successfully healed when treated surrounding ligaments
Symptoms and Clinical Findings of Myofascial Pain Syndrome:
- Sharp pain while moving the affected part.
- A tender knot in the muscle.
- Difficulty in performing the movement as sometimes the trigger point can aggravate or exacerbate the symptoms.
- Due to altered motor recruitment to muscle, Weakness or imbalance is seen in either the affected or in functionally related muscles
- Difficulty in sleep due to pain.
- Tension headaches, migraines, tinnitus, temporomandibular joint problems
- Postural abnormalities and compensations.
Risk Factors of Myofascial Pain Syndrome:
- Factors which increases the chances of trigger point formation are
- Lack of exercise
- Sedentary lifestyle
- Chronic muscle overuse
- Daily stress
- Medications (and its overuse),
- Sleep disturbances increase the chances of trigger point formation.
How To Diagnose Trigger Points
- In myofascial pain syndrome, Trigger points cannot be diagnosed through any blood test or x-ray. It can be only identified their presence and to what extent by palpating with fingertips by a skilled physiotherapist.
- Usually, there will not be any tightness in a muscle at rest. But during trigger point formation, it gets more pinpoint down even further.
- Trigger points can be palpated in two phases, acute and latent phase.
- Acute trigger points have mostly severe pain which not even present at the point but also seen as a referred pain to other areas. Referred pain is defined as the pain starts at one point but shows or represents at another part of the body. An acute trigger point is mostly due to overstressing the muscle by repeating the movement of the same muscle group during the workout. Poor posture for a long time can also be a factor that presents symptoms while palpation.
- The latent trigger point is the type of tender points mostly not painful. Pain while palpating is because they signal their presence of knot in that area.
- The trigger point is palpated in two ways
- Sliding- fingertip is compressed perpendicularly and transited back and forth at any given time.
- The pick up-affected part is picked up and moved up and down.
- There can be a more than one trigger point in a single muscle. Pain while any of these two ways differentiate trigger point pain from other condition.
- Medications to relax the muscle and to reduce the pain.
- Trigger point injection may help sometimes.
- Everyday life factors that arouse TrPs must be eliminated or reduced.
- Training and education about postures and lifestyle.
- Passive stretching
- Foam Roller techniques.
- Deep Stroking Massage techniques.
- Strengthening to specific muscles
- Kinesio taping
- Proprioceptive Neuromuscular Techniques
- Muscle energy Techniques
- Ultrasound therapy, laser therapy, and Iontophoresis therapy help release the trigger points
- Advanced painless Dry needling technique is used to release the trigger point.
- Warm water fermentation or a moist heat pack for at least 10-15 minutes.
Complications of Myofascial Pain Syndrome:
Complications related to myofascial pain syndrome are
- It affects the quality of life.
- It can lead to depression and isolation as the physical activity gets reduce.
- It impacts the mobility of the overall muscle.
- Stiffness of joints.
- Prolong presence of trigger points leads to degenerative conditions like osteoarthritis.
- Weakness and lack of muscle strength
- Sleep disturbances – the person with myofascial pain syndrome have difficulty to sleep at night. As they move from one position to another, they hit a trigger point and get awake. They find trouble in adjusting their sleep position.
- Fibromyalgia- myofascial pain syndrome may lead to fibromyalgia, where the pain is widespread and more sensitive to signals over time.
Effect Of Dry Needling On Myofascial Trigger Point Of Shoulder – Case Report
This case report describes 50 years old male patient with primary symptoms of left shoulder pain and stiffness since 2 months. He was well 2 months ago but started suffering from pain which got worsed slowly. He was taking some pain relief medications and referred to a progressive rehabilitation center for physiotherapy management.
There was no history of any trauma to the neck and shoulder. An overall observation of the patient was done. Assessment of posture is observed, which showed that there is mild depression of right shoulder and no other postural abnormalities are seen. On palpation, there was tenderness in the upper trapezius, levator scapulae, and posterior scapular region, specifically over teres minor region and mild spasm on the trapezius and teres minor muscle.
The patient felt the pain as burning or throbbing type of sensation with insidious onset in right shoulder joint, which got aggravated with shoulder activities requiring to lift his hand above the head and relieved with rest and pain relief medications.
On the very first visit to our center, he rated his pain as 8/10 in the Numerical pain rating outcome measure scale. Clinical examination revealed that he has a restriction of shoulder movements which has reduced his daily functional activities, specifically performing overhead activities and combing the backside of hair. Assessment of shoulder joint and neck range of motion was taken and found that there is no restriction and pain in moving the neck and left shoulder, but there is a restriction of movement and severe pain in end ranges, mainly in performing abduction and external rotation movements. The strength of the left shoulder has also reduced.
Special tests of the shoulder joint were performed to rule out the musculoskeletal origin, which revealed that there is no pathology starting from the joint. Other sensory examinations are done and ruled out there are no neurological abnormalities. He has not undergone any further investigations to rule out the condition. His main goal was to reduce pain and improve his daily activity.
Initially, a few sessions of pain management were given which include modalities like interferential and ultrasound therapy followed by myofascial release to painful tender points, mild stretches to tightened muscle and the moist heat pack to relax the muscles.
The patient found relieve of pain and increase in shoulder range but there was still localized tender pain over some areas of the right scapular region. Further assessment and palpation revealed that there are some tight knots like bands on the right side of the upper trapezius, levator scapulae and teres minor muscle which revealed that there is some underlying pathology suspecting as myofascial trigger points. This made us decide to use an advanced painless dry needling technique on trigger points. Two sessions of dry needling technique are done in the gap of 3 days in between.
The result showed that after dry needling session, the patient felt the reduction of pain to 1/10 in outcome measure scale and increased of right shoulder movements above the overhead and able to perform all his daily function with the same hand. Thus, this case report showed that the use of dry needling technique on myofascial trigger points results in relieving pain, increasing the movement and improving his daily life activity performance.