A physician well-known to this corner had a sudden onset of severe low back pain going down both legs. He had been engaged in a vigorous physical program for years, and was in excellent condition. There was no known injury. MRI showed a large disk herniation between the second and third lumbar vertebrae.
The pain persisted over four months, with some relief from chiropractic, but he was still in pain.
Then he went to see a myofascial practitioner. Extremely tender trigger points were identified on both sides, in the buttocks, thighs and even lower legs, which, when pressed, exactly mimicked the lower back pain. These trigger points were pressed deeply and massaged. Specific exercises were directed to apply pressure to these points at home, using a rubber ball and foam roller, after range of motion and heat. Changes were recommended in sitting and sleeping positions.
The pain started to improve immediately, and after six sessions was about 70% resolved, only showing up at the end of the day.
Another individual developed severe rectal pain the day following prostate surgery. He was unable to sit, had to position himself on his side, and walking was impaired. Over the next year he saw numerous urologic and orthopedic specialists, pain specialists, had x-rays and MRIs, multiple injections, physical therapy, even an injection into a nerve plexus deep in the rectum, all without relief.
He went to a myofascial therapist. Severe trigger points were identified in his buttocks and treated. After only the second treatment his pain had improved and he could sit down again.
What is a trigger point?
It is a tender-to-touch spot in a tightened band of muscle. The tightening is due to shortening of the cellular components of muscle called sarcomeres, composed of protein elements called actin and myosin that normally slide over other as the muscle contracts and elongates. There are thousands of sarcomeres within a single band of muscle, the width of a human hair.
An active trigger point consists of a cluster of shortened sarcomeres, usually at the point where the nerve enters the muscle. A trigger point will tighten and weaken the entire muscle it is located in, reducing both flexibility and range of motion. A muscle containing trigger points will be both tighter and weaker. The severe tightening also interferes with blood flow to the involved muscle, causing more weakness due to loss of nutrients, even a separation of muscle filaments.
It is very important to know that trigger points may produce pain in an entirely different location from where they exist. This is called referred pain. For example, low back pain may be coming from a trigger point in the soleus muscle, in the lower leg. Trigger points may cause other symptoms than pain, like tingling, prickling, numbness, weakness, and reduced range of motion. In other words, they are great mimickers of other medical conditions.
Neck pain, back pain, jaw pain, abdominal pain, even pelvic pain, may be caused by trigger points elsewhere in the body. Patients with trigger point pain may be extensively worked up with MRIs and CT scans, ultrasound studies or even colonoscopy. Abnormalities may be found on these studies leading to ineffective therapies such as epidural steroid injections for a bulging disc, when the true cause of pain is an undetected trigger point. If the physician with the ruptured disc mentioned above had gone to an orthopedic surgeon, he might have been advised to have the disc removed, and the pain would not have been relieved. Many individuals subjected to surgery for back pain experience no benefit from the procedure, likely because the real cause of pain was hidden trigger points.
Physical therapy for back pain will be ineffective if the trigger points responsible for causing the pain are not identified and treated. Treating only the location of the pain does not treat the cause of pain, and it will persist. Strengthening exercises will also be ineffective, and may even worsen pain by aggravating the trigger points. Because trigger points cause weakness, the weakness will not resolve until the trigger points are handled.
One of the foremost researchers into myofascial pain and trigger point therapy was Janet Travell, personal physician to President John F. Kennedy. She treated the President for years for ongoing problems with back pain.
Myofascial pain is largely unknown and unappreciated by many doctors and therapists, even those who specialize in musculoskeletal problems. At this time it fits in the realm of “alternative” medicine. Based on personal experience, it is a powerful alternative to unwarranted, last-ditch surgery, ineffective drugs and spinal injections. It is also an answer for unyielding, undiagnosed pain.
Allan Sosin MD