By Stephanie A. Prendergast, MPT, Cofounder, PHRC Los Angeles
Over the last few week’s, we have received various inquiries about Myofascial Trigger Points. Why do they occur? What are they? How can we fix them? This week we do a deep dive and answer our most frequently asked questions!
Q: Never heard of this ! What is this exactly?
A: A myofascial trigger point (MTrP) is defined as a hyperirritable area within a muscle or fascia. Simply put, it is a group of small muscle fibers that remain in a contracted state instead of ‘relaxing’ when the muscle is not at work. Trigger points can develop in any muscle in the body and are associated with several consequences.
When compressed (or examined) MTrPs often hurt, causing local tissue pain. They also refer pain to areas away from the trigger point itself. They can cause central nervous sensitivity, creating situations such as allodynia and hyperalgesia. Allodynia is defined as ‘pain in response to a stimulus that does not normally provoke pain”. Hyperalgesia is defined as an ‘increased sensitivity to feeling pain and an extreme response to a painful stimulus’. Trigger points can also limit normal range of motion and can lead to proprioceptive disturbances that can affect things such as our balance.
Q: How can trigger points be released or massaged?
A: Trigger Point Release is the technical term for treatment of trigger points. Skilled manual therapists are trained in a number of techniques that can effectively eliminate myofascial trigger points. Examples include manual compression, sometimes with contract-relax movements, or strain-counter strain techniques. In some states pelvic floor physical therapists can dry needle trigger points, acupuncturists are sometimes trained to do this too. At home people can learn to treat their trigger points using various devices, such as a theracane or theragun. Foam rolling can also be effective.
Q: I was wondering whether it is possible to have trigger points in the vagina?
A: The vagina itself is not a skeletal muscle, therefore, it does not develop trigger points. The pelvic floor muscles are palpated transvaginally to identify trigger points in the Levator Ani muscles, the muscles of the urogenital diaphragm, the obturator internus, the coccygeus, and/or the external anal sphincter. Many of these muscles can contribute to vaginal pain.
Q: Can I work on these myself? Internally. Is it safe to try to release and massage these trigger points by ourselves or should we visit a doctor?
A: We recommend a combination of pelvic floor physical therapy and a home program tailored to a person’s needs to address their specific areas of impairment. We teach our patients different techniques that they can do themselves at home, both internally and externally. Pain Management doctors generally offer procedures for myofascial pain such as trigger point injections or botox. It is not necessary to see a physician prior to starting physical therapy in most states, therefore we advise seeking out a pelvic floor physical therapist to help with trigger point treatment. If conservative measures fail, medical procedures can help.
Q: Would you be aware of these trigger points or might you just feel aching/pain? And would they be triggered by specific movements or come on when the muscles are tired or tense?
A: This is a great question and it depends on the severity and reactivity of the trigger point. However, studies show that people with trigger points also have upregulated nervous systems and this will also play a role in the amount of discomfort that someone has. In some cases, people may only feel pain when it is provoked on examination, other people may have unprovoked aching or severe pain. Trigger points can be aggravated by stretching and strengthening and may need to be addressed with physical therapy before the muscles involved can be stretched or strengthened.
Q: What would the referral pattern be for piriformis and obturator internus? Also, do ligaments such as the sacrotuberous ligament have trigger points or just muscle?
A: The Obturator Internus can refer to the tailbone and sit bone area, and also cause pain in the buttock region, hip joint, or down the upper back of the leg. The Piriformis can cause buttock pain and also contribute to sciatica. Travel and Simons have mapped out trigger point referral patterns, if you run a google search you will be able to see pictures and their referral patterns!
Q: I would love more information/blogs on this topic
A: Check out this blog we have that explains Pelvic Pain Trigger Points!
Q: I’ve been to 3 PT’s and all have me doing stretching. I have trigger points????
A: Symptomatic trigger points can be provoked by stretching and strengthening, if this is the case for someone we suggest manual therapy techniques first to help reduce the trigger point, and then provide therapeutic exercises if the muscles need to be stretched or strengthened to reduce pain and restore function. It is important to note that not all people with trigger points will feel pain with stretching or strengthening.
Q: Curious to hear about the science behind the stretching/strengthening recommendation. Would you consider posting the source?
A: We recommend the Travell and Simons Trigger Points Manuals.
Q: I’ve had left-sided pain from the front to the back and there is a trigger point at the tailbone area of the coccygeus muscle, she says. Are we not supposed to be stretching that muscle? She goes internal and stretches it and has me doing stretches and this has been going on for three years. Each PT I’ve tried has been stretching that muscle. Please tell me what you think I should do?
A: Unfortunately we cannot advise you without evaluating you. If the pain is persisting and not resolving we suggest working with your PT to best understand why and how your treatment plan can be changed to be more effective. It may make sense to seek a second opinion from another physical therapist and a pain management physician.
Q: What if a hypertonic PF with MTRP identified was an incidental finding for a patient with UI as their primary complaint?
A: A thorough physical therapy evaluation and assessment should help you best understand why you have UI. Multiple impairments are typically associated with pelvic health symptoms rather than it being any one thing alone.
Q: Good to know. My urogyn always tells me to do all the pelvic stretches after telling me I have a short tight floor. Of course she says get pt but when I tell her stretching makes it worse she says you need range of motion. Her answer is Botox. Period.
A: We are sure this is frustrating for you, we are sorry to hear it. If stretching is causing pain it is likely not therapeutic right now, manual therapy may be more relieving.
Q: Why do pretty much all pelvic floor protocols include stretching as part of the therapy alongside trigger point release?
A: We do not recommend ‘protocols’ because all of our patients are unique, even if they have the same symptoms. Stretching may be therapeutic in some situations and provocative in others, it depends on the person.
Q: Could nerves get caught up on myofascial trigger points?
A: Muscle impairments, including trigger points, can sensitize both peripheral nerves they lie close to and the central nervous system.
Did we miss a question you wanted answered? Drop it in the comments for our next Q&A round!
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Are you unable to come see us in person in the Bay Area, Southern California or New England? We offer virtual physical therapy appointments too!
Virtual sessions are available with PHRC pelvic floor physical therapists via our video platform, Zoom, or via phone. For more information and to schedule, please visit our digital healthcare page.
In addition to virtual consultation with our physical therapists, we also offer integrative health services with Jandra Mueller, DPT, MS. Jandra is a pelvic floor physical therapist who also has her Master’s degree in Integrative Health and Nutrition. She offers services such as hormone testing via the DUTCH test, comprehensive stool testing for gastrointestinal health concerns, and integrative health coaching and meal planning. For more information about her services and to schedule, please visit our Integrative Health website page.
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FAQ
What are pelvic floor muscles?
The pelvic floor muscles are a group of muscles that run from the coccyx to the pubic bone. They are part of the core, helping to support our entire body as well as providing support for the bowel, bladder and uterus. These muscles help us maintain bowel and bladder control and are involved in sexual pleasure and orgasm. The technical name of the pelvic floor muscles is the Levator Ani muscle group. The pudendal nerve, the levator ani nerve, and branches from the S2 – S4 nerve roots innervate the pelvic floor muscles. They are under voluntary and autonomic control, which is a unique feature only they possess compared to other muscle groups.
What is pelvic floor physical therapy?
Pelvic floor physical therapy is a specialized area of physical therapy. Currently, physical therapists need advanced post-graduate education to be able to help people with pelvic floor dysfunction because pelvic floor disorders are not yet being taught in standard physical therapy curricula. The Pelvic Health and Rehabilitation Center provides extensive training for our staff because we recognize the limitations of physical therapy education in this unique area.
What happens at pelvic floor therapy?
During an evaluation for pelvic floor dysfunction the physical therapist will take a detailed history. Following the history the physical therapist will leave the room to allow the patient to change and drape themselves. The physical therapist will return to the room and using gloved hands will perform an external and internal manual assessment of the pelvic floor and girdle muscles. The physical therapist will once again leave the room and allow the patient to dress. Following the manual examination there may also be an examination of strength, motor control, and overall biomechanics and neuromuscular control. The physical therapist will then communicate the findings to the patient and together with their patient they establish an assessment, short term and long term goals and a treatment plan. Typically people with pelvic floor dysfunction are seen one time per week for one hour for varying amounts of time based on the severity and chronicity of the disease. A home exercise program will be established and the physical therapist will help coordinate other providers on the treatment team. Typically patients are seen for 3 months to a year.
What is pudendal neuralgia and how is it treated?
Pudendal Neuralgia is a clinical diagnosis that means pain in the sensory distribution of the pudendal nerve. The pudendal nerve is a mixed nerve that exits the S2 – S4 sacral nerve roots, we have a right and left pudendal nerve and each side has three main trunks: the dorsal branch, the perineal branch, and the inferior rectal branch. The branches supply sensation to the clitoris/penis, labia/scrotum, perineum, anus, the distal ⅓ of the urethra and rectum, and the vulva and vestibule. The nerve branches also control the pelvic floor muscles. The pudendal nerve follows a tortuous path through the pelvic floor and girdle, leaving it vulnerable to compression and tension injuries at various points along its path.
Pudendal Neuralgia occurs when the nerve is unable to slide, glide and move normally and as a result, people experience pain in some or all of the above-mentioned areas. Pelvic floor physical therapy plays a crucial role in identifying the mechanical impairments that are affecting the nerve. The physical therapy treatment plan is designed to restore normal neural function. Patients with pudendal neuralgia require pelvic floor physical therapy and may also benefit from medical management that includes pharmaceuticals and procedures such as pudendal nerve blocks or botox injections.
What is interstitial cystitis and how is it treated?
Interstitial Cystitis is a clinical diagnosis characterized by irritative bladder symptoms such as urinary urgency, frequency, and hesitancy in the absence of infection. Research has shown the majority of patients who meet the clinical definition have pelvic floor dysfunction and myalgia. Therefore, the American Urologic Association recommends pelvic floor physical therapy as first-line treatment for Interstitial Cystitis. Patients will benefit from pelvic floor physical therapy and may also benefit from pharmacologic management or medical procedures such as bladder instillations.
Who is the Pelvic Health and Rehabilitation Team?
The Pelvic Health and Rehabilitation Center was founded by Elizabeth Akincilar and Stephanie Prendergast in 2006, they have been treating people with pelvic floor disorders since 2001. They were trained and mentored by a medical doctor and quickly became experts in treating pelvic floor disorders. They began creating courses and sharing their knowledge around the world. They expanded to 11 locations in the United States and developed a residency style training program for their employees with ongoing weekly mentoring. The physical therapists who work at PHRC have undergone more training than the majority of pelvic floor physical therapists and as a result offer efficient and high quality care.
How many years of experience do we have?
Stephanie and Liz have 24 years of experience and help each and every team member become an expert in the field through their training and mentoring program.
Why PHRC versus anyone else?
PHRC is unique because of the specific focus on pelvic floor disorders and the leadership at our company. We are constantly lecturing, teaching, and staying ahead of the curve with our connections to medical experts and emerging experts. As a result, we are able to efficiently and effectively help our patients restore their pelvic health.
Do we treat men for pelvic floor therapy?
The Pelvic Health and Rehabilitation Center is unique in that the Cofounders have always treated people of all genders and therefore have trained the team members and staff the same way. Many pelvic floor physical therapists focus solely on people with vulvas, this is not the case here.
Do I need pelvic floor therapy forever?
The majority of people with pelvic floor dysfunction will undergo pelvic floor physical therapy for a set amount of time based on their goals. Every 6 -8 weeks goals will be re-established based on the physical improvements and remaining physical impairments. Most patients will achieve their goals in 3 – 6 months. If there are complicating medical or untreated comorbidities some patients will be in therapy longer.