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.
Melissa Patrick is a certified yoga instructor and meditation teacher and is also available virtually to help, for more information please visit our therapeutic yoga page.
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