Ending pain by coaching the body of patients to deal with muscle trigger points and resistance to stretching
When muscles develop trigger points, they can misbehave in a variety of uncomfortable, painful, and disruptive ways. Unless practitioners understand that these patterns of dysfunction are commonly caused by trigger points rather than injury or disease, and work on coaching the body with patients, they are likely to pursue inappropriate treatments that make the situation worse.
Strength deficits
Many patients come to our clinic having been assessed by a physical therapist or other medical professional as having a “strength deficit.” In these cases, the patient has failed a strength machine evaluation, and the doctor will assign them strengthening exercises for whichever muscles tested weak. But often, these muscles aren’t truly weak at all; they have developed trigger points that lead to dysfunction. The strengthening exercises, prescribed by a doctor or therapist who doesn’t understand trigger points, can make the pain worse rather than relieving it because trigger points are easily created in situations involving acute overload.
Remember that once a muscle becomes overloaded and develops trigger points, some percentage of its fibers are essentially taken offline and locked in a contracture; they become taut fibers. When a motor signal is sent to the muscle, many of its fibers cannot respond because they are already contracted. These taut fibers send danger signals to the spinal cord, which can cause active pain referral. As a result, when the patient tries to engage the muscle, they are likely to feel pain as the muscle bunches up. In addition, once the CNS (central nervous system) receives those danger signals during a muscular contraction, it can inhibit that muscle and engage its antagonist as a way to provide safety. So inevitably, the muscle isn’t going to look good on a strength test.
When we look at these “strength deficits” through the lens of trigger point therapy, we can see that resistance training for strength is inappropriate in the early phases of treatment. Before we can ask the muscle to take on more work, we have to help the muscle fibers become healthy. Otherwise, if you put additional demands with resistance training on muscles that have trigger points, that’s a formula for more overload, and they are likely to get worse. This happens often and is a primary cause of failed therapy.[1]
Resistance to stretch
Another sign that trigger points are present in a muscle or muscular system is limited or compromised range of motion in the corresponding joint or joints. This phenomenon is often present in so-called frozen shoulder syndrome.
Resistance to stretch is an easy phenomenon to reproduce in a muscle with trigger points. As the muscle lengthens, the taut fibers attempt to lengthen as well, pulling apart the area of the sarcomeres in contracture. This mechanical disturbance of the trigger point will tend to irritate the contracted tissues and stimulate the nociceptive compounds in the trigger point, increasing their signaling to the spinal cord. Discomfort will increase, and the patient may notice pain in the stretching fibers as well as the referral zone of the muscle. The pain may ramp up dramatically, and at that point it becomes too uncomfortable to push farther into the stretch without applying some means of distraction, such as therapeutic vibration. As soon as there is a pain response, the CNS tends to go into protective mode by locking things down with muscular engagement. For the CNS, reduced motion equals increased stability and safety, and taut fibers from trigger points are a useful way to provide additional stability without excessive energy demands.
Stretching a muscle with trigger points is a reliable way to produce its pain referral pattern and assess which muscles are responsible for a pain pattern. It is not, however, a good first step in treatment. In cases where range of motion is limited and the muscles are resistant to stretch, it’s a mistake to try to lengthen muscles before therapeutic and rehabilitative work on the tissues. Stretching must be done incrementally, and there are various hacks that we can use to prevent the CNS from embedding more trigger points to protect against injury, which we’ll go into later.
Grabbing, shaking, twitching
The amount that a muscle can lengthen without distress (its stretch range) is an important criterion, but its quality of motion is equally important. When coaching the body a patient might be able to move their joint into a range that seems normal; hypermobile individuals might be able to move into a range that exceeds normal.
If trigger points are present in the muscle or its antagonist, you may notice that the muscle periodically “grabs,” resisting lengthening or shortening. You must move the joint slowly, paying close attention, or you might miss it. You might also notice a muscle twitching at rest or feeling shaky and unstable when the client attempts to engage it. This is a strong sign that taut fibers are sending disturbing signals to the spinal cord, confusing the system about how to respond.
Muscle spasms may accompany trigger point dysfunction. Some muscles spasm when you try to shorten their fibers if they have embedded taut fibers. You may have experienced this phenomenon in the form of a charley horse in the hamstrings or calves. Once the spasm starts, you basically have to wait until it subsides. They aren’t necessarily painful, but they compromise the muscle’s ability to both lengthen and shorten. We will cover the topic of shortening dysfunction in detail in a later section.
When an aircraft is gaining speed for takeoff, the pilots are paying close attention to how the engines are responding so they can catch any issues before pushing the throttle and leaving the ground. Similarly, the CNS receives constant feedback from both sides of the joint as we move. If disturbing signals are coming in as you move a joint, the CNS may quickly vacillate between engagement and release, and smooth motion may be impossible.
Poor balance and coordination
Poor balance might also be an indicator that trigger points have developed in the body. Good balance, as in standing on one foot, requires a constant, fluid interplay between muscles on both sides of a joint. Balance poses such as tree pose in yoga aren’t static experiences — the muscles controlling the ankle and foot must perform continual micro-corrections to maintain stability. If these movements become too large, the person will wobble and shake.
Trigger points can negatively affect one’s balance and coordination by sending erroneous signals to the CNS regarding muscle tension and length. This process can disturb the coordination between agonist and antagonist muscles, resulting in poor balance. Related signs include dropping things, poor fine motor control, reduced ability to play musical instruments, poor performance in sports, and similar problems.
Muscle inhibition
The manual therapy field has a concept called muscle inhibition that is based on the observation that muscles sometimes don’t engage when or as fully as they should. It can also describe a situation when muscles that should contract simultaneously fire in succession, causing imbalance in the joints and even in the position of bones. While the concept is well established, there has been no suitable explanation for why it occurs.
To better understand this phenomenon, let’s look at a prime example. A muscle that commonly becomes inhibited is vastus medialis, the medial short quadricep head. Proper coordination of the four heads of the quadriceps muscles is critical to ensuring that the kneecap (patella) moves in the proper direction and doesn’t rub against its track, potentially causing a condition known as chondromalacia patella. Chondromalacia describes damage to the patella that can occur if it consistently rubs against a side wall of its track.
The quadriceps have oblique attachments to the tendon that controls the kneecap. The branch on the outside of the leg (vastus lateralis) is a larger, more powerful muscle than the inside quadricep (vastus medialis). Each muscle can pull the patella toward itself; ideally, both pulling at once will keep the patella centered as the knee extends.
When a patient develops pain and swelling around the knee, it is common to observe that the vastus medialis doesn’t contract right away as the patient tries to extend their knee, causing the patella to immediately divert in a lateral direction. This is sometimes called inhibition of the vastus medialis, or it may be identified as a “firing order problem.” Because the vastus lateralis contracts first, it pulls the patella more strongly in the lateral direction, causing the patella to rub on the outside of its track and generating inflammation, possibly even damaging the bone surface.
In the case of an inhibited vastus medialis and coaching the body, the patient will likely feel pain around their knee, but the root cause is often trigger points in other, more distant muscles. In some cases, the body seems to let one side of a functional antagonist relationship dominate when dysfunction develops. We have had great success eliminating the inhibition phenomenon by applying our CTB protocols, which consider muscles on both sides of the joint as well as all satellite referral sources.
Coaching the body: shortening dysfunction and how it blocks stretch
Healthy muscles can be stretched or shortened without causing pain or other discomfort. Most people are familiar with stretching and know that certain muscles will feel uncomfortable if you attempt to stretch them beyond a certain point. Very few people realize, and here is where coaching the body with patients is valuable, that muscles can become dysfunctional when shortened. In fact, shortening dysfunction is an even more significant issue than stretching dysfunction and can occur with either passive or active shortening.
Active shortening occurs when you engage a muscle. If you use your biceps and brachialis to bend your elbow, those muscles are contracting actively, and the overall length of the fibers becomes shorter than they were with the elbow straight. If you rest your arm in a bent position, such as during sleep, you are no longer actively contracting those muscles. At that point we say that biceps and brachialis are being passively shortened.
Normally, muscles become softer when in passive shortening, so a telltale sign of shortening dysfunction is the muscle hardening as it is shortened. This indicates that a type of automatic spasm or contraction is happening within the muscle without a motor signal from the spine telling the fibers to engage. This condition can sometimes be painful, and even if not, it can stop the joint from bending any further, meaning that it inhibits the stretch of the muscle’s antagonists.
For example, a patient might describe pain in their adductors (inner thigh) muscles when you put those muscles on stretch. They might feel tension or discomfort in the adductors but not realize that the gluteus muscles are quietly limiting the adductor stretch from the other side of the hip joint. These gluteal fibers might not produce any pain during the adductor stretch (though they often do), but if you palpate them, you will find that instead of softening as they passively shorten, they harden. If you manage to lengthen the adductors sufficiently and ask the client what they’re feeling, they might report cramping or pain or even what they call “stretching” in the hardened, bunched up gluteal fibers at the end of the adductor stretch. This is due to shortening dysfunction.
CHUCK DUFF founded the Coaching The Body® (CTB) Institute in 2001, and has taught thousands of students highly effective techniques for resolving pain. CTB integrates trigger-point therapy, movement-based techniques derived from traditional Thai bodywork and other approaches, along with insights from modern neuroscience. For more information on his new book, “Ending Pain: Coaching the Body with Neuroscience, Movement, and Trigger Point Therapy,” go to coachingthebody.com.
COMMENTS
[1] This is not to say that strength is a bad thing. Athletes can tolerate much higher levels of insult to their muscles because they train and have vascular and strength reserves. They are much more likely to self-repair trigger points than someone without those reserves. In the CTB system, balanced strength and flexibility is an important goal that we pursue after the initial phases of treatment.
