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Myofascial trigger points

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Clarifying and standardizing nomenclature

It is imperative to have an operational understanding of medical conditions by standardizing nomenclature when possible. Myogenic dysfunction has been poorly defined due to the numerous names for the same conditions. While most of the medical community still refers to Myofascial Pain Syndromes by various names, which usually refer to the area or structure that was affected, we prefer to use Myofascial Pain Syndrome instead of Myofasciitis or Myositis. Unfortunately, there appears to be a revising of nomenclature in definition from the first edition to the second edition of Travell & Simons' Trigger Point Manuals. Therefore, we will present you with versions from each in an attempt to clarify.

 

Compare and contrast trigger point glossary of terms

VOLUME 1 FIRST EDITION
MYOFASCIAL PAIN AND DYSFUNCTION
THE TRIGGER POINT MANUAL

By: Janet G. Travell, M.D.
David G. Simons, M.D.
VOLUME 1 SECOND EDITION
MYOFASCIAL PAIN AND DYSFUNCTION
THE TRIGGER POINT MANUAL

By: David G. Simons, M.D.
Janet G. Travell, M.D.
Lois S. Simons, P.T.
TRIGGER POINT: A focus of hyperirritability in tissue that, when compressed, is locally tender and, if sufficiently hypersensitive, gives rise to referred pain and tenderness, and sometimes to referred autonomic phenomena and distortion of proprioception. Types include myofascial, cutaneous, fascial, ligamentous and periosteal trigger points. TRIGGER POINT: See Myofascial Trigger Point
MYOFASCIAL TRIGGER POINT: A hyperirritable spot, usually within a taut band of skeletal muscle or in the muscle's fascia that is painful on compression and that can give rise to characteristic referred pain, tenderness, and autonomic phenomena. A myofascial trigger point is to be distinguished from cutaneous, ligamentous, periosteal and non- muscular fascial trigger points. Types include active, latent, primary, associated, satellite and secondary. MYOFASCIAL TRIGGER POINT (Clinical definition of a central trigger point) A hyperirritable spot in skeletal muscle that is associated with a hypersensitive palpable nodule in a taut band. The spot is painful on compression and can give rise to characteristic referred pain, referred tenderness, motor dysfunction, and autonomic phenomena. Types of myofascial trigger points include: active, associated, attachment, central, key, latent, primary and satellite. (Note especially the distinction between central and attachment myofascial trigger points). Any myofascial trigger point is to be distinguished from a cutaneous, ligamentous, periosteal, or any other non-muscular trigger point.
  MYOFASCIAL TRIGGER POINT (Etiological definition of a central trigger point): A cluster of electrically active loci each of which is associated with a contraction knot and a dysfunctional motor endplate in skeletal muscle.
SECONDARY MYOFASCIAL TRIGGER POINT: A hyperirritable spot in a muscle or its fascia that became active because its muscle was overloaded as a synergist substituting for, or as an antagonist countering the tautness of, the muscle that contained the primary trigger point, to be distinguished from a satellite trigger point. SECONDARY TRIGGER POINT: Term previously used, but rarely in this edition. Trigger points previously identified as secondary trigger points are now classified as satellite trigger points. A secondary trigger point was previously identified as one that developed in a synergist or an antagonist of the muscle harboring the key trigger point.
SATELLITE MYOFASCIAL TRIGGER POINT: A focus of hyperirritability in a muscle or its fascia that became active because the muscle was located within the zone of reference of another trigger point, to be distinguished from a secondary trigger point. SATELLITE MYOFASCIAL TRIGGER POINT: A central myofascial trigger point that was induced neurogenically or mechanically by the activity of a key trigger point. Distinguishing the mechanism responsible for the key-satellite relationship can rarely be resolved by examination alone. The relationship usually is confirmed by simultaneous inactivation of the satellite when the key trigger point is inactivated. A satellite trigger point may develop in the zone of reference of the key trigger point, in an overloaded synergist that is substituting for the muscle harboring the key trigger point (key muscle), in an antagonist countering the increased tension of the key muscle, or in a muscle linked apparently only neurogenically to the key trigger point. Previously, only a trigger point that developed in the referred pain zone of another trigger point was identified as a satellite trigger point.

While not eluded to above, acupuncture points and tender points are not the same as trigger points.  However, trigger points may form in the same sights of acupuncture points and/or tender points.

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Other sites for trigger points

1. Skin

2. Scar tissue

3. Ligament

4. Periosteum

Motor points are not trigger points. Motor points are located in close approximation to the middle of the muscle. Trigger points are randomly dispersed.

 

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Eight differential criteria and characteristics for identifying myofascial trigger points

1. Acute, chronic or persistent overloading of a muscle.

2. Distinct patterns of pain referral inherent to that muscle.

3. Diminished strength and lengthening ability of that muscle.

4. Taut, palpable band or nodule within muscle.

5. Extreme tenderness of palpable band or nodule within fibers.

6. Elicited twitch response when taut band is either stimulated or snapped transversely.

7. Replication of pain pattern when trigger point is stimulated.

8. Asymptomatic relief results when treatment has been performed.

 

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Four phases of trigger points

Phase 4: Muscle tissue that does not exhibit a palpable ropy or button like nodular mass, which is characteristic of a trigger point (TrP). However, the tissue may be hypertonic, indurated, effecting range of motion, structural deviation, and hypersensitive to tactile pressure.

Phase 3: Latent Trigger Point - Palpable button like or nodular mass within muscles, fascia, scar tissue, ligaments, and periosteum which have characteristics of a trigger point. When snapped transversely it may replicate a referral pattern as if it were active. However, without direct pressure, it does not produce a subjective referred pain complaint or autonomic phenomena during either activity or rest.

Phase 2: Active Trigger Point - Palpable button like or nodular mass within muscles, fascia, scar tissue, ligaments, and periosteum which have characteristics of a trigger point. Produces a subjective referred pain complaint or autonomic phenomena during activity but reduced or eliminated through rest.

Phase 1: Active Trigger Point - Palpable button like nodular mass within muscles, fascia, scar tissue, ligaments, and periosteum which have characteristics of a trigger point. Produces a subjective referred pain complaint or autonomic phenomena, which is present constantly regardless of activity or rest.

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Myofascial trigger point perpetuating factors

There are several forms of neuropathy, myopathy, arthropathy or circulatory diseases, which can cause myofascial triggers as a secondary effect of the disease.  When this occurs usually more than one region is affected and there are other symptoms and signs associated with these complaints. 

However, these other symptoms are frequently overlooked or not referenced due to the individual considering them as clinically insignificant or dismissing them due to fatigue, activity or aging process.  It is the comprehensive examination that will identify the obscure signs and symptoms, which frequently provide the insight and understanding of a condition. 

Usually muscle pain is described as deep, aching or boring.  Although there are a few triggers, which cause sharp, lancinating or electrical pain, such as the quadratus lumborum.  However, normally this sharp knife-like pain or loss of sensation along a dermatomal pathway is due to neurologic involvement.

Throbbing or pulsating pain usually is vascular in nature. Metabolic or endocrine conditions, toxicity or an infection may also generate triggers but is usually diffuse.  Focal inflammation is localized, such as a tendonitis or bursitis, just as a localized infection usually is point specific and well defined.  Malignant tumors or neoplasms are usually asymptomatic in the initial onset.

However, as the disease progresses it is not uncommon for the individual to point to a specific region for pain.  This may also be the case if the disease has metastasized, with the generalized characteristic pain associated with metastatic cancer, only occurring in the final stages of the disease process. Depending upon the form of cancer, the practitioner may be initially presented with only the pain complaint and triggers that would support that complaint.  Should there be excessive rebound tenderness either in amount or duration, or a recent regeneration of the original pain complaint following the treatment, the practitioner should immediately refer for detailed diagnostics.

The somatic practitioner normally sees individuals whose trigger points are perpetuated by sudden cooling of fatigued muscles, repetitive usage, post exercise stiffness, mechanical overload, ergonomic factors or tension related conditions. These psychological and/or physiological stressors that perpetuate or activate triggers are very responsive to care providing the predisposing issues are identified and significantly reduced.

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According to Travell & Simons, the stimulus for trigger points may be divided into direct and in-direct forms of activation.  Direct stimuli are:

Indirect stimuli are:

Below are links to detailed information about specific perpetuating and activating factors for trigger points.  

 

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Muscle Attachments Trigger Point Referrals muscle test



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