Hey, this is Sandy. And Randy?
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Join us as we share our world in sports medicine.
Welcome back to another episode of AT Corner.
For this week's episode, we are going to be bringing another
Education episode and we will be talking about trigger points.
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So what are we talking about today, Randy?
So today we're going to talk about the pathophysiology of
trigger points. So exactly what they are, how
they form will describe the role of trigger points kind of have
in muscoskeletal injury and we'll discuss some of the
treatment options for trigger points.
I think trigger points are one of those things that we come
across so often, but how many times have you actually sat down
and actually talked about them? I know, right?
I thought it was actually really interesting kind of
understanding how they form, what exactly they are 'cause I
feel like we talked about it in school, but like, quickly.
Yeah. Also, I feel like your capacity
at that moment versus like when I talk about this with my
students all the time, like when you see something as a student
versus when you see something again as a certified, like you
see it with a different lens. Yeah, that's a good point.
So trigger points are basically just these hyper irritable spots
within a top band of skeletal muscle.
And there are two types. There's latent, which is just
kind of like, yeah, it kind of hurts, but it's really just kind
of local. It's just the kind of that spot.
And then what I think most people think about when they
think of trigger points are what would be termed like kind of
active. Those kind of create spontaneous
pain that can just kind of hurt randomly, but they also create a
referred pain, especially like when you palpate them.
So when you touch it, like maybe you touch one in your neck and
you're like, oh man, I feel it in my eye, right?
Like that. That would be like a trigger
point or an active trigger point, I should say.
So it it those are kind of big characteristics of like an
active compared to a latent trigger point.
So are we going to be talking about both?
Are we kind of focusing on that active both, OK.
Cool talk about both. A lot of the research kind of
did kind of looked at both like depending on treatment pathology
and stuff like that. So essentially how they form
isn't really completely understood quite yet.
There's obviously a good idea, but right, like there's still a
lot that we're learning about trigger points.
Essentially there's a disruption of the regulation of
neurotransmitters at the neuromuscular junction.
So, so right at that kind of motor end point where going back
to Physiology one O 1, where those acetylcholine goes in and
like it goes to like the motor end play and triggers off the,
the continuation of the action potential.
Basically there, that's where you're kind of seeing this and
what, what's essentially happening is there's still a
release of neurotransmitters or the neurotransmitters are still
in that kind of space that's telling the muscle, Oh, I still
need to fire. So that section of muscle is
basically just getting a stimulus, even though it's not
really supposed to be getting a stimulus.
And what this does is it leads to that continued signal that's
telling the muscle, oh, I still need to be releasing calcium
because the calcium binds to troponin and that's what creates
the cross bridging and essentially makes muscle
contraction. But are you actually seeing this
muscle contraction? You're not seeing yes and no.
You're not seeing like the muscle shorten, but you feel the
top band. That's what the top band is.
It's that shortening of the sarcomeres.
It's literally that section of the muscle contracted.
But it's just that one section. It's not like it's like within a
piece of the. Muscle, yes.
So what happens is with that just continued contraction of
that one section of muscle, right, Because it's such
sustained, the capillaries that are are surrounding that kind of
area of the muscle get compressed, right?
So what happens is now there's less blood flow going to that
area. Oh my gosh, we need blood flow.
Exactly. ATP decreases, so you're going
to start running out of energy in that area AT PS also needed
to help release calcium from troponin to stop muscle
contraction or to control it. So if you don't have enough of
it, nothing's taking calcium away.
So now you're actin, Mycin are still just really connected.
So this is a great cascade of yes.
And then to make things worse, with the lack of blood flow, you
start to get ischemia to the cells of that area.
So now that releases pro inflammatory chemicals and this
is what can also help kind of increase that pain.
So this is all because there's some dysregulation or disruption
of the regulation of the neurotransmitters.
Do we know like why that happens?
If I feel like, not necessarily like there's a like couple
reasonings behind it as far as like, oh, well, looking at like
fatigue, you know, how does fatigue play a role in that?
And the body's ability to actually kind of help kind of
shuttle that stuff back into where they're supposed to be?
Like there's stuff like that, but there's not like a, oh, This
is why this is how you kind of fix it.
So it's not 100% understood, but it's just that regulation just
is breaking down. The feedback to the body isn't
necessarily there because of like say like fatigue or like
damage. So I assume you don't talk to
your athletes about these neurotransmitters and ATP and
all that stuff. How do you explain this to your
athletes? I, I, I just say basically those
kind of knots are just one area of the muscle that's just like
staying contracted that I just boil it down to that instead of
giving them the full now, if they're interested, I'll give
them the full full background. Be like, hey guys, this is
pretty cool. Fun fact.
So overall, just that kind of environment does cause further
damage to the muscle, cause sustained calcium release can
actually be very damaging. So obviously not a good
situation. We want to try to alleviate it
as soon as we can, which also like if you have latent trigger
points like, it's better to take care of them sooner because they
can turn into active over time. It's like a volcano.
It's. Like a volcano.
You know, it's taken this long to get to a soundtrack for this
episode. I'm kind of surprised, yeah.
Though obviously there can be a relationship between trigger
points and and injury themselves, but there's really
not like a great link between do trigger points cause injuries?
Do injuries cause trigger points?
It's almost just like they're related.
Correlations, not causation, yes.
Exactly, right. So it's they're there at the
same time, but we don't know which one got there first
necessarily. The chicken or the egg?
Exactly. It's a chicken or the egg
problem to just kind of show just kind of how they're
related. There's been a few studies that
have kind of looked at this. Those with the anterior knee
pain have been shown to have higher amounts of trigger points
in their vastus lateralis and vastus medialis compared to just
someone who doesn't have anterior knee pain.
Same thing with neck pain or, and shoulder pain too.
Those patients tended to have a higher number of trigger points
in their upper trapezius and then different spine conditions.
Again, they tend to have a few more active trigger points than
someone who doesn't have a spine condition.
So there's definitely a link like they're, they're, they're,
they go hand in hand or they can.
We just don't necessarily know. OK.
Is it because the injury and then you 'cause it or is it
because of this and then it caused that breakdown?
I never really thought about that I guess, but I when you
said about the neck pain, I feel like everyone with neck pain you
can find a trigger point in the in the upper trap really easily.
Oh, for sure. But I think that what's
important to know is, I mean, obviously if they're there,
we're going to treat them. So whether it came first or not,
right? But also to know that like
trigger points can cause some issues for the muscle itself.
The muscles with trigger points in them are fatigue a lot, lot
faster. I think, I think one study said
like 4 times faster. Yeah, because you got to think
like that section of muscle is taking up like it's just
sustained contraction, right? No energies getting there to
like help. So it's going to deplete its
energy, it's going to get fatigue.
So if you have multiple trigger points within a muscle, right,
your, your muscles only running at a portion of its full
capacity. There's also an increased
resting muscle tone. And so just at rest, you have a
little bit higher tone to the muscle than just a muscle who
did that didn't have trigger points.
So again, could kind of go to the that fatigue ability aspect.
If you talk about resting muscle tone, how much is this affecting
like the antagonist of that muscle?
Oh, I didn't see anything that said that.
That's a good point. I didn't see anything that
actually talked about like, OK, how does that affect the
antagonist muscle? But you could technically say by
reciprocal inhibition that it could be inhibiting the
antagonist more, right? That's what I was wondering.
Like if there's because they have a equal and opposite
reaction. Yeah.
Is that the right term? But the, I mean, if you think
about one side, like there's got to be an effect on somewhere
else in the body. Yeah, for sure.
Yeah. I didn't see anything that
specifically addressed that. But using reciprocal inhibition,
that would be the case. I mean, there are some support
for stuff like that too, like a tight hip flexor, like a tight
Ileocoas has been shown to decrease the activity of glute
Max, right? So I think you could say that
probably there's probably an effect on the antagonist.
I just wonder though, 'cause I mean, we're talking about a
shortened section of the muscle, but this increases the resting
muscle tone of the entire muscle.
That's what you're saying. At least where the surface
electrode was. They did try to keep it close to
where the point is, but it's not exactly.
Something to think about. And then also they can lead to
altered bio mechanics. They've shown that it's actually
affected scapular kinematics with trigger points.
In particular there was less posterior tilting with trigger
points in the upper trapezius, so now closing more space in
that shoulder. So it can affect kinematics as
well. So they are trigger points
aren't just like it's just a knot.
No, they can't actually cause a lot of issues for the muscle and
just human movement in general. Sweets What can we do about
them? So for treatment, there's a lot
of different ways and it's kind of expanded a lot lately.
We're going to talk like there's some that are more invasive,
like dry needling and stuff. We're not really going to talk
about that. We're going to talk about kind
of the less invasive ones just because not, not everyone has
access to dry needling or not. Maybe some people can't actually
do dry needling. So I figured it would be better
just to talk about at least what's more accessible and less
invasive, as that might be a little bit more accessible for
everyone. The most commonly applied kind
of topic or even treatment would be ischemic compression.
So this is literally just compressing that nodule, right?
That little top band of muscle from 60 to 90 seconds.
Now I've heard like it's supposed to be 90 seconds or
until the you actually feel the knot, kind of.
Yeah, the way that I have always done it is hold it for 90
seconds unless you or until it releases, whichever comes first.
Yeah. So which was interesting 'cause
like, like the research I was looking at didn't like
specifically say, has to be 90, right?
Some use like 60 seconds, some use 90.
So around that ballpark or until you feel it.
Relax. I mean 90 seconds if you think
about it is a long time. So usually like when I'm doing
it with my athletes, like I'll hold it and I'll say just let me
know when you stop feeling it. Refer to wherever it's.
Nice. That's a good idea.
It is not a comfortable experience because obviously
it's a hyper irritable band. And I think a lot of the studies
that were doing it basically kind of just said take it to
like a 7 out of 10 pain. Yeah.
So it's not super comfortable. And most of the time you're
doing this to like multiple spots too.
It's not just like you're like, oh, I'm just doing this one and
then we're done. Yeah.
So the reason this works is because it just content like it
almost like further progresses that ischemia to the area.
So you're shutting off blood flow and then when you let go,
the body has a just a reactive just what's referred to as
reactive hyperemia where just blood flow just rushes in.
All right. So the idea is like, yo, you're
increasing blood flow rapidly, so it's bringing nutrients and
it's flushing the waste products.
And that's what is supposed to be helping in this case.
It's like leaning into the deficit or like making the
problem worse so that it could get better.
Yeah, exactly. And there there's a lot of
literature that supports ischemic compression.
There's a reason why this is pretty common and why it's kind
of like stayed the test of time. It's really good at decreasing
pain. It's really good at improving
function and alleviating the trigger point as a whole.
And what I thought was interesting too is this, this
can be done with a foam roller so the patient can apply this
technique on their own. Like obviously like it for like
foam roller reachable places. Like specifically foam roller or
like anything that can like a lacrosse ball or like like one
of those hook like technically. Anything but like the study, you
used a foam roller. Got it.
But it's the sustained compression, right?
So you have to like, find the knot, sit on it and like, sit on
it for like 90 seconds and then it could help.
Which how many of our athletes do that on the foam roller?
Half the time I look and it's just like, I'm done.
Like, OK, that's great. It's better than nothing, I
guess. Or they grab the foam roller
that has like all the knobs and like what?
What are you going to do with that?
Yeah, or the PVC. Oh yeah, PVC pipe.
There's a study that looked at instrument assisted as well.
And again, it, it can have similar effects to ischemic
compression, right? It's leading to that increased
blood flow. I would say that there's more of
a neurological component in this one too, just because right,
you're adding kind of stress against like the, the connective
tissue. So I think there's going to be
more pain relief by activating those mechanoreceptors and
getting more feedback to the central nervous system to
hopefully promote relaxation. So I think it it kind of works
the same, but also slightly different than ischemia
compression. But it it's been shown too to be
almost just as effective as ischemia compression, at least
for decreasing the pain and improving function.
I mean, I feel like as long as you're getting blood flow to the
area, that's really what it needs.
That's and that's kind of the the basis of what everything
that I saw is like just getting blood basically what we're doing
to try to get blood flow there. And that's why like ultrasound
can be helpful. KT tape was actually debatable
on how helpful it might actually be.
I know. But when man, when you look this
up, there's like a lot of studies that pop up with KT
tape. It's interesting.
Some say, hey, it may decrease the pain, Some say it just, hey,
it just kind of prevents the pain from rising.
And then others just say it does nothing.
I feel like with all of the sensory effects of KT tape, I
feel like I could see where they're coming from of helping
like decrease that pain. But as far as like actually
making a difference on bringing that blood flow or actually
treating the trigger point, I see where it's kind of like
debatable. Yeah, I think it's a little
iffy, but again, I think it it's we're never just going to do one
thing right. OK, that's it, right.
We're not just going to put KT tape on that.
All right, get the get out of here if.
You have someone who's who's dealing with some pain on top of
it, like maybe this could work. For your author exactly right.
So most things we're not just going to be a one and done just
all right, get out of here. I'm done.
All right. So a lot of times we are going
to pair these and exercise has been shown to be very effective
when it's paired with like manual therapy or something,
right? So it's shown to exercise and
manual therapy has been shown to be a little bit more beneficial
than just doing the manual therapy, All right.
So actually doing exercises like rehab exercises, mobility
exercises have been shown to be beneficial.
Even adding muscle energy technique has been shown to have
added benefit when paired with manual therapy.
So definitely treatable and it definitely kind of aligns with
what we got going on normally, right?
We're going to pair things together so.
I mean, that all makes sense. I feel like when you have
someone who is dealing with like a trigger point you, honestly,
I'm trying to like most of the time when I'm thinking about
this, I feel like it's in the neck.
I mean, that's a very common area for it to be in the neck.
Right. Like like I've had, like, I
mean, I've had some people with like obviously knots, which
would probably be more like latent trigger points like in
their calf or like honestly like kind of there or like you said
in the neck sometimes in the rotator cuff.
I I have had some like they're infraspinatus, like you can feel
the the knot in there. Distal gracilis.
That is a section of muscle. No, I've never had that before.
Yeah, that's a good one. All those groin strains.
That's interesting. I've never had someone with
because I'm trying to think like I don't even think I've really
had someone with a knot in their thigh.
I mean maybe the quad somewhere within the quad, but like I've
never really had someone with a knot in the hamstring.
Oh, obviously glutes like piriformis, like you can feel
sometimes the nodule or glutamide.
I've had a lot of glutamide, especially with like low back
pain. Glutamide, like if you're doing
like a like where you put your elbow and then glute and then
you're taking their knee and moving their hip into internal
and external rotation, Yeah. Yeah, I see.
Glute mead's always so tender. Yes, and I've seen that very
consistently with low back pain and someone who has low back
pain I've seen, I've found that. I've also noticed that oh man
you have quite a few like trigger points and your glute
Mead. I have no, I have no idea where
this is from, but like right under my mouth to the left side,
if I press on it like that is a very active trigger point like
all the way up the side of my face.
Well, that's crazy. I know sometimes like if I put
my hand like I'm just like sitting and I put my hand, it
literally just like travels straight up.
Oh, that's. Interesting.
And then I hold it and then it goes away. 90 seconds.
Until it releases. But yeah, no, I trigger points
are interesting. What's your action item for
this? Blood flow.
Yeah, seriously, it's got to get blood.
Flow to it, increasing blood flow, and take advantage of the
nervous system too, like reciprocal inhibition, right?
Like so when you get a chance to like you've worked on this
trigger point, like activate that antagonist muscle, try to
get that neurologic, less neurological input to the other
side. So I know we just did the action
point, but now that just created a question for me.
Since we're bringing blood flow to the area, did you see
anything about cupping? Nothing readily popped up.
I know it's used commonly but I was surprised that I didn't.
I mean, I didn't specifically look trigger points and cupping,
but like my initial search of like trigger points and stuff,
cupping wasn't the first. Like there weren't a lot of
studies that popped up and I didn't really catch any but
that. Is you are making blood.
Flow. And that's cupping, what cupping
is supposed to be used for too, right?
A lot of times are for trigger points.
Or even like scanning with the cups.
Yeah, no, I didn't say anything with that.
I know for like trigger points, a lot of times I just rest them.
I do the scanning more for like connective tissue mobility, like
scarring. If I think usually if I'm just
doing the just the trigger point kind of idea, I'm just trying to
focus on the non. A lot of times I just rest them
for that. I'm trying to think.
I mean, also something that we used to say in a lot of our
episodes, but I think we've kind of not really focused on it a
lot lately. But something just a good point
overall is that anything that we talk about is also not 100%
effective for every single person in the population.
And so I think it's so important.
This is where the whole idea of like individualizing your
treatment comes in. So like, if you find someone who
does really benefit from cupping, like obviously it
doesn't matter what the research says if the research doesn't
support that cupping as much, if you found that for your person,
it does. I mean, you're never going to
find a study that says it's 100% effective for everyone.
And so the. So.
So following the literature, you can only follow it so far.
Yeah, and I mean the literature is supposed to give you an idea
of what you should like, what best practices could be or what
what the best kind of interventions would be.
Right, supposed to guide you. Yeah, it's supposed to guide
you, not dictate. I mean, evidence based practice
is 3 pillars, right? Literature is part of it, but
also patient values and clinical experience does play a role.
I think that's one thing that I tell students all the time is 1.
I remind them about that 'cause it seems like we get so caught
up on evidence based practice, just meaning research, research,
research. And it's a big component for
sure, but it's not the only component because again, you're
going to find someone who just loves KG tape makes them feel
great, right? And are you going to be that
person that tells you, tells them I don't want you to feel
better? So no, I'm not going to do that
because it quote UN quote doesn't work, right?
I don't think anyone wants to do that.
I think another thing to remember is like when we look at
research, like research is trying to explain what can
happen, what should be happening at a population level, right?
But he does it by using sample sizes and it's taking a group
mean. So it's taking the average of
the group and it's comparing the average to another group, right?
So within that average, you're, you're going to have someone who
just somehow really responded well.
And then you're also going to have someone in that group who
did not respond at all, but yet they were still in the group
that showed an effect, right, 'cause that's what averages are,
right? So I like to remind the students
that we treat people, not means. I really like that.
Yeah, right. So yes, if research says, hey,
maybe this doesn't work, yeah, that's not going to be my first
thought to do. But like, it's still in the
still in the toolbox. Right.
Maybe they like it. Maybe they respond well.
How many references are we out for this?
We used about 20. Nice.
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