Trigger points are discrete, focal, hyperirritable spots in a taut band of skeletal muscle.
According to studies, about 23 million persons, or 10 percent of the U.S. population, have one or more chronic disorders of the musculoskeletal system. Musculoskeletal disorders are the main cause of disability in the working-age population and are among the leading causes of disability in other age groups. Myofascial pain syndrome is a common painful muscle disorder caused by myofascial trigger points. This is different fibromyalgia syndrome, which involves multiple, typically bilateral, tender points. These pain syndromes are often concomitant and may interact with one another.
Recommended course: Trigger Point Therapy
What are trigger points?
Trigger points are discrete, focal, hyperirritable spots in a taut band of skeletal muscle. The spots are painful on compression and can produce referred pain, referred tenderness, and even motor dysfunction. Trigger points are classified as active or latent. Active trigger points cause pain during rest. A latent trigger point does not cause spontaneous pain but may restrict movement or cause muscle weakness. Patient’s only feel a latent trigger point when you press on it.
Many patients have pain around their hips and glutes. These patients often have low back pain as well. Clinically it can be difficult to determine where this pain is coming from. The lumbar spine and hip joint can refer pain into the buttocks and into hip region and many different trigger points can refer pain into overlapping areas.
Trigger point massage therapy in the hip and glutes
Trigger points in the hip and gluteal area are usually the result of one of two mechanisms.
- Fatigue: These trigger points develop for example when patients have been working out with heavier weights for a longer than normal time. Or maybe it’s someone who hasn’t been very physically active in a while and decided to pull weeds in the yard for a few hours, constantly bending forward.
- Sudden spasm: Think of a patient experiencing sudden pain when lifting something heavy, catching themselves from falling, or making a sudden movement while playing sports.
Types and locations of trigger points
Typically, trigger points in the Gluteus Maximus only refer pain in the buttock region and not into the low back or the hips. Trigger points in the Quadratus Lumborum (QL) can refer pain to the lumbar region, the gluteal region, and into the hip area. Trigger points in the Gluteus Medius also refer pain to both the lumbar and gluteal areas.
In the Gluteus Minimus, trigger points can refer pain into gluteal region and to the hip area. Trigger points in the Piriformis also refer to both the hip and the gluteal areas. Trigger points in the Tensor Fascia Latae (TFL) typically only refers pain to the hip area.
Evaluating trigger point pain patterns
During your examination, assess if the pain is referred by lumbar spine, the hip joint(s), or is the pain due to trigger points in one or more muscle groups. You need to try to reproduce their pain symptoms.
If you palpate the Quadratus Lumborum (QL) and this causes their specific pain pattern, you may think that the QL is responsible for their pain. But you must take this step further: Why is the Quadratus Lumborum so tender to palpation (TTP)?
Consider also asking:
- Is the QL working too hard trying to stabilize the lumbar spine?
- Are other core muscles not effective enough, so the QL must compensate?
- Is there a hip problem present that causes an antalgic gait and the Quadratus Lumborum becomes overactive?
- Is there weakness in the opposite Gluteus Medius and this lack of hip strength requires the Quadratus Lumborum to work harder lifting the pelvis during swing phase of gait?
Just because the Quadratus Lumborum has TTP does not automatically mean that the QL is the primary cause of the patient’s pain.
Pain that is referred by the lumbar spine can often be reproduced by lumbar movements. Ask your patient to bend forward and backward and see if this reproduces their symptoms. Often side-bending can trigger their pain patterns as well.
Pain mainly caused by the hip can be present in the groin, the lateral hip area and the posterior-lateral gluteal region. Again, this pain can usually be reproduced by passive range of motion (PROM) of the hip. Or you can trigger their pain by doing some isometric strength testing of the hip flexors, abductors, or the rotators.
Isolating pain in hip and gluteal areas
But it remains difficult to isolate the source of pain in the lumbar, gluteal, and hip areas. If pain has been chronic, there might be several sources of pain. This might be most common: different tissues that are causing the pain at the same time. Therapists need to address these tissues to relieve their symptoms.
Pain factors
Pain is complex, and nociception is only a part of the patient’s pain experience. Many factors influence the patient’s pain: biomechanical factors, but also psychosocial factors can increase the patient’s pain intensity. Lifestyle choices, and health behaviors also influence pain sensitivity: think of lack of proper sleep, not sufficient physical activity, stress, and diet.
Trigger point massage therapy treatment techniques
There are lots of different techniques to treat trigger points. Acupressure is just one of several Asian bodywork therapies (ABT) with roots in traditional Chinese medicine (TCM) that has been used to treat trigger points.
Traditional Chinese medical theory describes special acupoints, or acupressure points, that lie along meridians, or channels, in your body. According to this theory, when one of these meridians is blocked or out of balance, illness can occur. Acupressure and acupuncture are among the types of TCM that are thought to help restore balance. As the balance is restored, trigger points are no longer painful.
Instrument Assisted Soft Tissue Mobilization (IASTM) and Cupping can also be used to treat trigger points. IASTM is a skilled myofascial intervention used for soft-tissue treatment. It’s based on the principles of James Cyriax cross-friction massage and is commonly used by Massage Therapists and Physical Therapists to treat trigger points.
Cupping is a practice in which the therapist puts special cups on the skin to create suction. This causes the tissue beneath the cup to be drawn up and swell causing an increase in blood flow to the affected area, which can help reduce pain from trigger points.
Conclusion
Trigger points in different muscles may refer pain to the very same area. It's important to do a comprehensive evaluation to determine where the pain is coming from. Pain is complex. When practicing trigger point massage therapy, don't just focus on treating the muscles, but help patients make better lifestyle choices. Many different treatment methods exist for trigger point pain and often more than one technique is needed to help patients resolve their pain.