Trigger points – Untangling those knots once and for all!

Ryan LaCorte Cara Parliament, Publications

What exactly is a trigger point?

What people typically refer to as “knots” in muscles are actually trigger points. These are small fibers of muscle tightly contracting, causing areas of tenderness. When muscles are constantly contracting, they are unable to relax and recover their blood supply, which carries oxygen and glucose (the muscle’s energy source), to the muscles. When muscles are deprived of these recovery elements, fibers within the muscle remain contracted, becoming “angry,” creating trigger points.

Trigger points can be classified as “active” or “latent.” Active trigger points cause pain at rest, are tender to the touch, and cause radiating or referred pain. Latent trigger points do not cause spontaneous pain, but may restrict movement or can be the cause of muscle weakness.

What trigger points can cause:

  • Pain with pressure applied to these tense muscle fibers
  • Referred pain to a location near the trigger point
  • Inability to fully lengthen the muscle, restricting range of motion (aka muscle tightness)
  • Weakness of the muscle where trigger points are located
  • Headaches
  • Neck pain
  • Low back pain
  • Chronic pain

What causes trigger points?

  • Muscle overuse, which is sustained or repetitive muscle contractions, deprive the working muscle of oxygen and glucose preventing the recovery process of the muscles. When the muscles cannot recover properly, parts of the muscle remain contracted, leading to constantly tense fibers of the muscle, aka trigger point formation.
  • Poor posture is a main cause of trigger points in the neck, back, and shoulder area. When someone stands hunched over, with rounded shoulders and a forward-bent head, the muscles responsible for holding the shoulder blades back and keeping the neck up are constantly contracting. These muscles are working extra hard to keep the skeleton erect and in alignment as best as possible. All these muscles constantly contracting, will lack proper recovery, again leading to trigger points.
  • Poor body mechanics, such as bending at the waist instead of at the knees when lifting objects, can also lead to trigger points, among other serious issues (disc issues, muscle strains, tears… so bend at the knees!). By bending over at the waist and coming back up when lifting a heavy object, one is causing the muscles of the back to pull excessive loads in an elongated position (when muscles are weak), leading to prolonged and extreme contractions. These excessive and strenuous contractions again lead to deprivation of oxygen, glucose and recovery to the muscles being used, ultimately predisposing them to those pesky and painful trigger points.
  • Muscle imbalances (some muscles weaker than others)
  • Direct trauma to muscle causes disturbance to the tissue, which can disrupt the blood supply to the muscle, preventing adequate oxygen and glucose to reach the muscle, ultimately leading to trigger points (among other injuries to the muscle).

How to prevent trigger points:

  • Maintain proper posture- keep your chin up, shoulders and head back… no slouching!
  • Gently stretch regularly! Keeping those muscles loose is crucial.
  • Build that core! Strong core muscles help keep proper posture and reduce your tendency to slouch.
  • Proper ergonomics at work! Make sure your desk and computer set up allow your head to look directly forward, hands are at a level that prevents you from hunching over, have a supportive chair with a lumbar roll, have knees bent 90 degrees.
  • Take stretch breaks!
  • Use heat or ice when you need it- They are your friends!

Myofascial pain syndrome vs Fibromyalgia

It is common to have more than one trigger point. However, when someone has many painful or tender trigger points, they may have myofascial pain syndrome (MPS). Fibromyalgia (FM), on the other hand, causes someone to “hurt all over,” having widespread chronic pain accompanied by fatigue, sleep disturbances, mental ‘fogginess’ or confusion, and low pain tolerance. Fibromyalgia is considered more of a neurological disease, whereas MPS is considered a dysfunction of a muscle tissue. Although both diagnoses are very similar, there are a few defining features that help health care professionals differentiate between the two. FM’s painful spots are referred to as “tender points,” which differ from trigger points.

Tender points have 18 specific locations, are usually symmetrical in location on one’s body, do not refer pain, and cause an overall increase in pain sensitivity (hence the low pain tolerance!). So if someone does not have the tender points in 11 of those 18 specific locations, they do not have FM! Trigger points, however, are localized painful spots in any area of the body that typically refer pain and can vary in presence, showing up one day and may be absent a few days later.

Treatments available for trigger points:

  • Spray and Stretch technique, which involves having a therapist gently stretch the muscle while simultaneously applying ethyl chloride spray topically. This spray temporarily decreases skin temperature, causing an anesthetic affect, which allows the muscle to be passively stretched toward normal length. This elongation then helps to inactivate trigger points, relieve muscle spasm, and reduce referred pain.
  • Ischemic compression is a manual technique involving pressure applied to the trigger point, temporarily depriving the area of blood flow. This then allows for resurgence of blood flow to the area upon release of pressure. This revival of blood flow helps supply the formerly restricted area with the needed blood, glucose and oxygen, creating a healing/recovering effect, diminishing trigger point.
  • Trigger point injection, which is indicated for patients who have symptomatic active trigger points that produce a twitch response to pressure and create a pattern of referred pain.
  • At home treatments include trigger point tools, such as the one shown below, that allow you to locate the trigger point and control the amount and direction of pressure.

How physical therapy can help:

Physical therapists can locate, reduce and even eliminate trigger points as well as educate you on how to prevent future issues. Manual techniques physical therapists can perform include soft tissue mobilization and ischemic compression to help break up those pesky and uncomfortable “knots” and help the tense muscle fibers relax and allow the recovery process to occur. PTs can help strengthen core and postural muscles and aid patients in correcting body mechanics and posture. Strong core and postural muscles will help patients reduce the tendency to slouch and help keep their muscles in their optimal length and position, preventing them from getting “angry” or overused and ultimately reducing the likelihood of developing trigger points. Physical therapists can also provide suggestions and guidance for setting up work stations to promote proper posture and body mechanics at the work place, as well as educate you on proper lifting techniques, preventing future trigger point formation, among other potential injuries!


Etiology of myofascial trigger points. Bron, C and Dommerholt J.D. Curr Pain Headache Rep. 2012 Oct; 16(5): 439–444. Published online 2012 Jul 27. doi: 10.1007/s11916-012-0289-4 .

Trigger points and myofascial pain syndrome. Ingraham P & Taylor T, MD. (Nov 2016).

Trigger points: diagnosis and management. Alvarez DJ, DO, Rockwell PG, DO. University of Michigan Medical School, Ann Arbor, Michigan. Am Fam Physician. 2002 Feb 15;65(4):653-661.

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