If you have pelvic pain, chances are you have trigger points somewhere within or adjacent to your pelvic floor muscles.
Indeed, trigger points are a key factor in many pelvic pain syndromes. For that reason, I’m dedicating this week’s blog post to them. I’ll begin with an overall explanation of what they are. Then, I’ll explore the part they play in pelvic pain syndromes. And lastly, I’ll wrap up with a discussion of how pelvic pain trigger points are diagnosed and treated.
The Trouble with Trigger Points
A muscle is made up of numerous fibers. A trigger point is a small, taut patch of involuntarily contracted muscle fibers within a muscle or muscle fascia. The tightly contracted fibers that form a trigger point effect blood supply to the nearby tissue, which in turn makes the area hyperirritable when compressed.
In addition to the local pain they cause, trigger points often refer pain elsewhere. On top of that, they can pull on tendons and ligaments associated with the muscle they are in, and can even cause pain deep within a joint where there are no muscles.
Once trigger points made it onto the medical map, it became obvious that a handful of different kinds existed. For instance, there are active trigger points, which as their name suggests, actively cause pain and other symptoms. There are latent trigger points, which are dormant, but have the potential to cause trouble. And there are satellite trigger points, which can crop up in another trigger point’s referral zone. For instance, a trigger point in the levator ani muscle can cause a trigger point to occur in the abdomen.
So not only can trigger points refer their pain to other regions, they can actually cause other brand new trigger points to crop up in other places. That’s why it’s important to keep in mind that trigger points can be very misleading, and when dealing with them it’s a mistake to always assume the problem is where the pain is.
For example, in women, trigger points in the obturator internus muscle of the pelvic floor can refer pain/irritability to the urethra. So say Jane Doe has an active trigger point in her obturator internus. As a result, Jane begins to experience urethral burning and urgency. So she visits her doctor believing she has a urinary tract infection. But a battery of tests shows that there’s nothing wrong with Jane’s urinary tract. Jane’s doctor tells her that everything is fine. But Jane is frustrated because everything’s not fine. She’s in pain and feels like she constantly has to urinate.
What both the doctor and Jane are missing is that the cause of her urinary symptoms is a patch of constricted muscle fibers in a small, out-of-the-way muscle in Jane’s pelvic floor.
This is a frustratingly common scenario. Indeed, pretty much everyone will deal with trigger points at some time in their lives. If you have lingering pain, tightness, or muscle restriction, chances are you have trigger points. Plus, trigger points are at the root of many ailments you wouldn’t expect such as dizziness, nausea, tooth pain, restless leg syndrome, painful periods, and irritable bowel syndrome. However, oftentimes issues caused by trigger points are misdiagnosed as arthritis, tendonitis, bursitis, or ligament injury.
The good news is that inroads are being made, new research on trigger points is being undertaken, and the medical community is increasingly starting to recognize them as causes of pain. More good news is that even though there are some 620 potential trigger points possible in human muscle, they show up in pretty much the same places in everyone. So trigger point maps do exist complete with referral patterns, and that goes for the pelvic floor too.
Trigger Points and the Pelvic Floor
Now let’s get to the main reason you’re reading this blog about trigger points: their relationship with the pelvic floor.
Trigger points play a role in the vast majority of pelvic pain syndromes. Indeed, in some cases, they’re the only culprits.
For instance, I recently had a male patient, let’s call him Ben, who had trigger points in his rectus abdominus from doing too many sit ups over a period of years. His main complaints were lower abdominal pain and penile pain. After about eight months of working to release those trigger points, Ben is now symptom-free.
However, while it is possible for trigger points to be the sole cause of pelvic pain, it’s much more common for them to be just one component in a multi-layered problem.
For instance, another patient of mine, Lori, had trigger points in her bulbospongiosus, obturator internus, and piriformis muscles. However, in addition to these trigger points, she had connective tissue dysfunction, an overall hypertonic (or tight) pelvic floor, and urinary urgency and frequency.
In Lori’s case, her pain began after a urinary tract infection followed by a stubborn yeast infection. The pain from the infections kicked off a so-called “guarding” reflex within her pelvic floor. (Guarding occurs when muscles contract rigidly around a painful area to protect it from further damage. But, guarding causes further damage because it restricts blood flow, which in turn causes more guarding and more pain.)
With Lori, it’s impossible to know exactly what part trigger points played in the creation of her pain cycle. An ongoing guarding reflex in and of itself is sufficient enough to overload pelvic floor muscles and cause the development of trigger points. But the overall muscle tightening that followed the guarding could also have caused them to develop, not to mention Lori’s new habit of holding her bladder because of her urgency/frequency issues.
Aside from an overuse/repetitive strain situation as with Ben or pain from infection or guarding as with Lori, trigger points in the pelvic floor can develop for a slew of different reasons. For example, local trauma can cause them to crop up, such as infertility treatments, rectal/vaginal ultrasound, a colonoscopy, a tailbone fall, a bartholin’s abscess, or childbirth. Mechanical and physical stressors, like a hip tear or endometriosis, can also cause the development of trigger points.
Whatever the reason for their development, trigger points are famous for complicating already painful situations, and in many instances, they stick around long after the original problem clears up.
Trigger Point Diagnosis and Treatment
Physical Therapists treating pelvic pain should know how to identify and treat trigger points in pelvic floor and pelvic girdle muscles. In addition, he or she MUST be knowledgeable about the mapped out regions where trigger points typically occur within the pelvic floor as well as the dozens of referral patterns.
For instance, trigger points in the piriformis muscle can refer pain down the back of the leg or into the hip or a trigger point in the levator ani muscle can create the feeling of having a golf ball in the rectum. Having this level of knowledge is an important part of putting the pieces of the puzzle of a patient’s pelvic pain symptoms together and forming a proper treatment plan.
When it comes to diagnosing and treating trigger points, it’s important that a PT evaluate all of the muscles and muscle fascia, both internal and external from the navel to the knees, front and back.
Liz does a great job of explaining what happens when she finds a trigger point, so I’m going to defer to her here. Take it away Liz.
“While going perpendicular along the muscle’s direction, when you come across a trigger point, you will feel a very noticeable change. To me, it feels sort of like a lentil. Plus, when I find a trigger point, I always get a reaction from my patient, so I’m always tuned into him or her for feedback.”
In addition, sometimes a twitch can be felt when a trigger point is compressed, and sometimes that twitch response will cause the entire muscle to contract. Lastly, the trigger point may feel hotter to the touch than the area around it.
A handful of strategies exist for treating trigger points including:
- Manual release techniques: A good PT has a handful of trigger point release techniques in her toolbox.
- Dry needling: Almost all states, but not all, allow PTs to administer dry needling. California, where we practice, does not.
- Trigger point injections: These are administered by physicians and typically contain anesthetic; however, it’s the actual injection that will successfully release the trigger point, not the anesthetic. The anesthetic is simply on board to soothe and numb the tissue.
I hope I’ve answered all of your questions about pelvic pain trigger points in this post! If not, please don’t hesitate to ask any additional questions you might have in the comments section below or email me at firstname.lastname@example.org.
If you would like to do some further reading on trigger points, below are some resources that I recommend:
- “Myofascial Pain Syndromes–Trigger Points” by David Simons and Jan Domerholt, Journal of Musculoskeletal Pain, Vol. 13(1) 2005
- “Myofascial Pelvic Pain” by Rhonda Kotarinos
- “Myofascial Trigger Points and Myofascial Pain Syndromes: A Critical Review of Recent Literature” by David Simons and Jan Domerholt
- The Trigger Point Manual by Drs. David Simons and Janet Travell
- Myofascial Trigger Points: Pathophysiology and Evidence-Informed Diagnosis and Management by Jan Domerholt and Peter Huijbregts
All my best,