CEU: Trigger Points - Pathophysiology and Treatment - 204

Hey, this is Sandy. And Randy? And we're here on AT Corner. Being an Athi trainer comes with ups and downs, and we're here to showcase it all. Join us as we share our world in sports medicine. Welcome back to another episode of AT Corner. For this week's episode, we are going to be bringing another Education episode and we will be talking about trigger points. Yes, and this is ACU episode. Thank you so much to athletic training chat and clinically pressed.

So if you are interested in claiming these CE us as category AC US right now, if you're listening to it, it is free. Go to their website. It's also down in the show notes below and you can take the quiz and course evaluation and then there's several others up there for you. Eventually, this will be behind a paid wall, so you can purchase it still very affordable, but there will be several free new ones. Yes. So what are we talking about today, Randy?

So today we're going to talk about the pathophysiology of trigger points. So exactly what they are, how they form will describe the role of trigger points kind of have in muscoskeletal injury and we'll discuss some of the treatment options for trigger points. I think trigger points are one of those things that we come across so often, but how many times have you actually sat down and actually talked about them? I know, right?

I thought it was actually really interesting kind of understanding how they form, what exactly they are 'cause I feel like we talked about it in school, but like, quickly. Yeah. Also, I feel like your capacity at that moment versus like when I talk about this with my students all the time, like when you see something as a student versus when you see something again as a certified, like you see it with a different lens. Yeah, that's a good point.

So trigger points are basically just these hyper irritable spots

within a top band of skeletal muscle. And there are two types. There's latent, which is just kind of like, yeah, it kind of hurts, but it's really just kind of local. It's just the kind of that spot. And then what I think most people think about when they think of trigger points are what would be termed like kind of active. Those kind of create spontaneous pain that can just kind of hurt randomly, but they also create a referred pain, especially like when you palpate them.

So when you touch it, like maybe you touch one in your neck and you're like, oh man, I feel it in my eye, right? Like that. That would be like a trigger point or an active trigger point, I should say. So it it those are kind of big characteristics of like an active compared to a latent trigger point. So are we going to be talking about both? Are we kind of focusing on that active both, OK.

Cool talk about both. A lot of the research kind of did kind of looked at both like depending on treatment pathology and stuff like that. So essentially how they form isn't really completely understood quite yet. There's obviously a good idea, but right, like there's still a

lot that we're learning about trigger points. Essentially there's a disruption of the regulation of neurotransmitters at the neuromuscular junction. So, so right at that kind of motor end point where going back to Physiology one O 1, where those acetylcholine goes in and like it goes to like the motor end play and triggers off the, the continuation of the action potential.

Basically there, that's where you're kind of seeing this and what, what's essentially happening is there's still a release of neurotransmitters or the neurotransmitters are still in that kind of space that's telling the muscle, Oh, I still need to fire. So that section of muscle is basically just getting a stimulus, even though it's not really supposed to be getting a stimulus.

And what this does is it leads to that continued signal that's telling the muscle, oh, I still need to be releasing calcium because the calcium binds to troponin and that's what creates the cross bridging and essentially makes muscle contraction. But are you actually seeing this muscle contraction? You're not seeing yes and no. You're not seeing like the muscle shorten, but you feel the top band. That's what the top band is. It's that shortening of the sarcomeres.

It's literally that section of the muscle contracted. But it's just that one section. It's not like it's like within a piece of the. Muscle, yes. So what happens is with that just continued contraction of that one section of muscle, right, Because it's such sustained, the capillaries that are are surrounding that kind of area of the muscle get compressed, right? So what happens is now there's less blood flow going to that area. Oh my gosh, we need blood flow.

Exactly. ATP decreases, so you're going to start running out of energy in that area AT PS also needed to help release calcium from troponin to stop muscle contraction or to control it. So if you don't have enough of it, nothing's taking calcium away. So now you're actin, Mycin are still just really connected. So this is a great cascade of yes. And then to make things worse, with the lack of blood flow, you start to get ischemia to the cells of that area.

So now that releases pro inflammatory chemicals and this is what can also help kind of increase that pain. So this is all because there's some dysregulation or disruption of the regulation of the neurotransmitters. Do we know like why that happens? If I feel like, not necessarily like there's a like couple reasonings behind it as far as like, oh, well, looking at like fatigue, you know, how does fatigue play a role in that?

And the body's ability to actually kind of help kind of shuttle that stuff back into where they're supposed to be? Like there's stuff like that, but there's not like a, oh, This is why this is how you kind of fix it. So it's not 100% understood, but it's just that regulation just is breaking down. The feedback to the body isn't necessarily there because of like say like fatigue or like damage. So I assume you don't talk to your athletes about these neurotransmitters and ATP and

all that stuff. How do you explain this to your athletes? I, I, I just say basically those kind of knots are just one area of the muscle that's just like staying contracted that I just boil it down to that instead of giving them the full now, if they're interested, I'll give them the full full background. Be like, hey guys, this is pretty cool. Fun fact. So overall, just that kind of environment does cause further damage to the muscle, cause sustained calcium release can

actually be very damaging. So obviously not a good situation. We want to try to alleviate it as soon as we can, which also like if you have latent trigger points like, it's better to take care of them sooner because they can turn into active over time. It's like a volcano. It's. Like a volcano. You know, it's taken this long to get to a soundtrack for this episode. I'm kind of surprised, yeah. Though obviously there can be a relationship between trigger

points and and injury themselves, but there's really not like a great link between do trigger points cause injuries? Do injuries cause trigger points? It's almost just like they're related. Correlations, not causation, yes. Exactly, right. So it's they're there at the same time, but we don't know which one got there first necessarily. The chicken or the egg? Exactly. It's a chicken or the egg problem to just kind of show just kind of how they're related. There's been a few studies that

have kind of looked at this. Those with the anterior knee pain have been shown to have higher amounts of trigger points in their vastus lateralis and vastus medialis compared to just someone who doesn't have anterior knee pain. Same thing with neck pain or, and shoulder pain too. Those patients tended to have a higher number of trigger points in their upper trapezius and then different spine conditions.

Again, they tend to have a few more active trigger points than someone who doesn't have a spine condition. So there's definitely a link like they're, they're, they're, they go hand in hand or they can. We just don't necessarily know. OK. Is it because the injury and then you 'cause it or is it because of this and then it caused that breakdown?

I never really thought about that I guess, but I when you said about the neck pain, I feel like everyone with neck pain you can find a trigger point in the in the upper trap really easily. Oh, for sure. But I think that what's important to know is, I mean, obviously if they're there, we're going to treat them. So whether it came first or not, right? But also to know that like trigger points can cause some issues for the muscle itself.

The muscles with trigger points in them are fatigue a lot, lot faster. I think, I think one study said like 4 times faster. Yeah, because you got to think like that section of muscle is taking up like it's just sustained contraction, right? No energies getting there to like help. So it's going to deplete its energy, it's going to get fatigue. So if you have multiple trigger points within a muscle, right, your, your muscles only running at a portion of its full

capacity. There's also an increased resting muscle tone. And so just at rest, you have a little bit higher tone to the muscle than just a muscle who did that didn't have trigger points. So again, could kind of go to the that fatigue ability aspect. If you talk about resting muscle tone, how much is this affecting like the antagonist of that muscle? Oh, I didn't see anything that said that.

That's a good point. I didn't see anything that actually talked about like, OK, how does that affect the antagonist muscle? But you could technically say by reciprocal inhibition that it could be inhibiting the antagonist more, right? That's what I was wondering. Like if there's because they have a equal and opposite reaction. Yeah. Is that the right term? But the, I mean, if you think about one side, like there's got to be an effect on somewhere else in the body. Yeah, for sure.

Yeah. I didn't see anything that specifically addressed that. But using reciprocal inhibition, that would be the case. I mean, there are some support for stuff like that too, like a tight hip flexor, like a tight Ileocoas has been shown to decrease the activity of glute Max, right? So I think you could say that probably there's probably an effect on the antagonist.

I just wonder though, 'cause I mean, we're talking about a shortened section of the muscle, but this increases the resting muscle tone of the entire muscle. That's what you're saying. At least where the surface electrode was. They did try to keep it close to where the point is, but it's not exactly. Something to think about. And then also they can lead to altered bio mechanics. They've shown that it's actually affected scapular kinematics with trigger points.

In particular there was less posterior tilting with trigger points in the upper trapezius, so now closing more space in that shoulder. So it can affect kinematics as well. So they are trigger points aren't just like it's just a knot. No, they can't actually cause a lot of issues for the muscle and just human movement in general. Sweets What can we do about them? So for treatment, there's a lot

of different ways and it's kind of expanded a lot lately. We're going to talk like there's some that are more invasive, like dry needling and stuff. We're not really going to talk about that. We're going to talk about kind of the less invasive ones just because not, not everyone has access to dry needling or not. Maybe some people can't actually

do dry needling. So I figured it would be better just to talk about at least what's more accessible and less invasive, as that might be a little bit more accessible for everyone. The most commonly applied kind of topic or even treatment would be ischemic compression. So this is literally just compressing that nodule, right? That little top band of muscle from 60 to 90 seconds. Now I've heard like it's supposed to be 90 seconds or until the you actually feel the knot, kind of.

Yeah, the way that I have always done it is hold it for 90 seconds unless you or until it releases, whichever comes first. Yeah. So which was interesting 'cause like, like the research I was looking at didn't like specifically say, has to be 90, right? Some use like 60 seconds, some use 90. So around that ballpark or until you feel it. Relax. I mean 90 seconds if you think

about it is a long time. So usually like when I'm doing it with my athletes, like I'll hold it and I'll say just let me know when you stop feeling it. Refer to wherever it's. Nice. That's a good idea. It is not a comfortable experience because obviously it's a hyper irritable band. And I think a lot of the studies that were doing it basically kind of just said take it to like a 7 out of 10 pain. Yeah.

So it's not super comfortable. And most of the time you're doing this to like multiple spots too. It's not just like you're like, oh, I'm just doing this one and then we're done. Yeah. So the reason this works is because it just content like it almost like further progresses that ischemia to the area. So you're shutting off blood flow and then when you let go, the body has a just a reactive just what's referred to as reactive hyperemia where just blood flow just rushes in.

All right. So the idea is like, yo, you're increasing blood flow rapidly, so it's bringing nutrients and it's flushing the waste products. And that's what is supposed to be helping in this case. It's like leaning into the deficit or like making the problem worse so that it could get better. Yeah, exactly. And there there's a lot of literature that supports ischemic compression. There's a reason why this is pretty common and why it's kind

of like stayed the test of time. It's really good at decreasing pain. It's really good at improving function and alleviating the trigger point as a whole. And what I thought was interesting too is this, this can be done with a foam roller so the patient can apply this technique on their own. Like obviously like it for like foam roller reachable places. Like specifically foam roller or like anything that can like a lacrosse ball or like like one

of those hook like technically. Anything but like the study, you used a foam roller. Got it. But it's the sustained compression, right? So you have to like, find the knot, sit on it and like, sit on it for like 90 seconds and then it could help. Which how many of our athletes do that on the foam roller? Half the time I look and it's just like, I'm done. Like, OK, that's great. It's better than nothing, I guess. Or they grab the foam roller that has like all the knobs and like what?

What are you going to do with that? Yeah, or the PVC. Oh yeah, PVC pipe. There's a study that looked at instrument assisted as well. And again, it, it can have similar effects to ischemic compression, right? It's leading to that increased blood flow. I would say that there's more of a neurological component in this one too, just because right, you're adding kind of stress against like the, the connective

tissue. So I think there's going to be more pain relief by activating those mechanoreceptors and getting more feedback to the central nervous system to hopefully promote relaxation. So I think it it kind of works the same, but also slightly different than ischemia compression. But it it's been shown too to be almost just as effective as ischemia compression, at least for decreasing the pain and improving function.

I mean, I feel like as long as you're getting blood flow to the area, that's really what it needs. That's and that's kind of the the basis of what everything that I saw is like just getting blood basically what we're doing to try to get blood flow there. And that's why like ultrasound can be helpful. KT tape was actually debatable on how helpful it might actually be. I know. But when man, when you look this up, there's like a lot of studies that pop up with KT tape. It's interesting.

Some say, hey, it may decrease the pain, Some say it just, hey, it just kind of prevents the pain from rising. And then others just say it does nothing. I feel like with all of the sensory effects of KT tape, I feel like I could see where they're coming from of helping like decrease that pain. But as far as like actually making a difference on bringing that blood flow or actually treating the trigger point, I see where it's kind of like

debatable. Yeah, I think it's a little iffy, but again, I think it it's we're never just going to do one thing right. OK, that's it, right. We're not just going to put KT tape on that. All right, get the get out of here if. You have someone who's who's dealing with some pain on top of it, like maybe this could work. For your author exactly right. So most things we're not just going to be a one and done just all right, get out of here. I'm done.

All right. So a lot of times we are going to pair these and exercise has been shown to be very effective when it's paired with like manual therapy or something, right? So it's shown to exercise and manual therapy has been shown to be a little bit more beneficial than just doing the manual therapy, All right. So actually doing exercises like rehab exercises, mobility exercises have been shown to be beneficial.

Even adding muscle energy technique has been shown to have added benefit when paired with manual therapy. So definitely treatable and it definitely kind of aligns with what we got going on normally, right? We're going to pair things together so. I mean, that all makes sense. I feel like when you have someone who is dealing with like a trigger point you, honestly, I'm trying to like most of the time when I'm thinking about this, I feel like it's in the neck.

I mean, that's a very common area for it to be in the neck. Right. Like like I've had, like, I mean, I've had some people with like obviously knots, which would probably be more like latent trigger points like in their calf or like honestly like kind of there or like you said in the neck sometimes in the rotator cuff. I I have had some like they're infraspinatus, like you can feel the the knot in there. Distal gracilis. That is a section of muscle. No, I've never had that before.

Yeah, that's a good one. All those groin strains. That's interesting. I've never had someone with because I'm trying to think like I don't even think I've really had someone with a knot in their thigh. I mean maybe the quad somewhere within the quad, but like I've never really had someone with a knot in the hamstring. Oh, obviously glutes like piriformis, like you can feel sometimes the nodule or glutamide. I've had a lot of glutamide, especially with like low back

pain. Glutamide, like if you're doing like a like where you put your elbow and then glute and then you're taking their knee and moving their hip into internal and external rotation, Yeah. Yeah, I see. Glute mead's always so tender. Yes, and I've seen that very consistently with low back pain and someone who has low back

pain I've seen, I've found that. I've also noticed that oh man you have quite a few like trigger points and your glute Mead. I have no, I have no idea where this is from, but like right under my mouth to the left side, if I press on it like that is a very active trigger point like all the way up the side of my face. Well, that's crazy. I know sometimes like if I put my hand like I'm just like sitting and I put my hand, it literally just like travels straight up. Oh, that's. Interesting.

And then I hold it and then it goes away. 90 seconds. Until it releases. But yeah, no, I trigger points are interesting. What's your action item for this? Blood flow. Yeah, seriously, it's got to get blood. Flow to it, increasing blood flow, and take advantage of the nervous system too, like reciprocal inhibition, right?

Like so when you get a chance to like you've worked on this trigger point, like activate that antagonist muscle, try to get that neurologic, less neurological input to the other side. So I know we just did the action point, but now that just created a question for me. Since we're bringing blood flow to the area, did you see anything about cupping? Nothing readily popped up. I know it's used commonly but I was surprised that I didn't.

I mean, I didn't specifically look trigger points and cupping, but like my initial search of like trigger points and stuff, cupping wasn't the first. Like there weren't a lot of studies that popped up and I didn't really catch any but that. Is you are making blood. Flow. And that's cupping, what cupping is supposed to be used for too, right? A lot of times are for trigger points. Or even like scanning with the cups. Yeah, no, I didn't say anything with that.

I know for like trigger points, a lot of times I just rest them. I do the scanning more for like connective tissue mobility, like scarring. If I think usually if I'm just doing the just the trigger point kind of idea, I'm just trying to focus on the non. A lot of times I just rest them for that. I'm trying to think. I mean, also something that we used to say in a lot of our episodes, but I think we've kind of not really focused on it a

lot lately. But something just a good point overall is that anything that we talk about is also not 100% effective for every single person in the population. And so I think it's so important. This is where the whole idea of like individualizing your treatment comes in. So like, if you find someone who does really benefit from cupping, like obviously it doesn't matter what the research says if the research doesn't support that cupping as much, if you found that for your person,

it does. I mean, you're never going to find a study that says it's 100% effective for everyone. And so the. So. So following the literature, you can only follow it so far. Yeah, and I mean the literature is supposed to give you an idea of what you should like, what best practices could be or what what the best kind of interventions would be. Right, supposed to guide you. Yeah, it's supposed to guide you, not dictate. I mean, evidence based practice

is 3 pillars, right? Literature is part of it, but also patient values and clinical experience does play a role. I think that's one thing that I tell students all the time is 1. I remind them about that 'cause it seems like we get so caught up on evidence based practice, just meaning research, research, research. And it's a big component for sure, but it's not the only component because again, you're going to find someone who just loves KG tape makes them feel

great, right? And are you going to be that person that tells you, tells them I don't want you to feel better? So no, I'm not going to do that because it quote UN quote doesn't work, right? I don't think anyone wants to do that. I think another thing to remember is like when we look at research, like research is trying to explain what can happen, what should be happening at a population level, right? But he does it by using sample sizes and it's taking a group

mean. So it's taking the average of the group and it's comparing the average to another group, right? So within that average, you're, you're going to have someone who just somehow really responded well. And then you're also going to have someone in that group who did not respond at all, but yet they were still in the group that showed an effect, right, 'cause that's what averages are, right? So I like to remind the students that we treat people, not means. I really like that.

Yeah, right. So yes, if research says, hey, maybe this doesn't work, yeah, that's not going to be my first thought to do. But like, it's still in the still in the toolbox. Right. Maybe they like it. Maybe they respond well. How many references are we out for this? We used about 20. Nice. If you want to find those references, they are on our website. And if you guys are new, we do every episode as either an education episode like this, a

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