5 Trigger Point Chiropractic Treatment Mistakes to Avoid
Reading time: 4 minutes
Musculoskeletal icon, David Simons (i.e., Travell & Simons) reported that two of the three most commonly overlooked causes of MSK pain were articular joint dysfunction and myofascial pain syndrome/ trigger points. (1) While evidence-based chiropractors are THE experts at managing the former, identifying and eliminating all of the associated trigger points can prove slightly more elusive.
Trigger points are present in up to 9 out of 10 musculoskeletal presentations, so limiting management missteps is crucial for optimal clinical outcomes. This week’s blog reviews our top five errors when treating the most common musculoskeletal symptom.
Mistake #1: Missing the Point
There are ample potential sites of involvement for trigger points; the body’s 600+ muscles account for nearly half of its weight, and fascia attaches, encloses, or separates almost every tissue. (5)
Trigger points, in general, can be elusive; however, some are more notorious than others. We asked our friend and guru, Dr. Tom Hyde, to define the most overlooked trigger points. Here’s his reply:
What a loaded question, and happy Sunday to you too. If you ask 10,000 people, there will be all combinations as well as overlap. This also depends on the clinician and their ability to look for and ID trigger points, then how to treat them. Here’s my quick list of five commonly overlooked trigger points:
Solution #1
Check out this video tutorial to identify and manage the most overlooked trigger points – and see if your list matches Dr. Hyde’s.
Mistake #2: Not Addressing Mechanical Origins
Myofascial trigger points arise when a combination of contributing factors exceeds tissue capacity. Some experts believe that trigger points may develop in an effort to stabilize the neighboring joints. Thus, some trigger points may be a brain problem (meaning, dysfunction in the stability and movement pattern results in faulty corrections) and not necessarily a pure muscle problem. Stabilizing the correct closed chain and open-chain functions of the surrounding joints is essential when managing MPS.
Rudimentary isolated treatment modalities may resolve trigger points of recent onset. (47) However, cases become recalcitrant when perpetuating factors are not adequately addressed. One study defined the average MPS duration as greater than five years. (47)
Solution #2
Rehabilitation exercise is a crucial component of any successful MPS treatment program. The goal of exercise is to improve flexibility and strength while correcting faulty biomechanics and postures. (101) Rehab must seek to eliminate postural stressors, including sustained stretch, a known risk factor for muscular problems.
Stretching, strengthening, and rehab exercises should address functional deficits, including upper crossed syndrome and lower crossed syndrome, plus foundational issues like foot hyperpronation or leg length inequalities.
Mistake #3: Overlooking Systemic Contributors
Saxena et al. separated trigger point contributing factors into four general categories: (26)
Traumatic events - falls, accidents, surgery.
Ergonomic factors - poor posture, repetitive overuse, sustained pressure.
Structural factors - osteoarthritis, scoliosis, kyphosis, spondylolisthesis.
Systemic factors - vitamin D deficiency, iron deficiency, hypothyroidism, hypoglycemia, stress, dehydration, insomnia.
While evidence-based chiropractors routinely consider trauma, ergonomics, and structure, the potential systemic considerations are easily overlooked.
Solution #3
Routinely screen or test for systemic factors like vitamin deficiencies and coexistent medical conditions. Patients with Vitamin B or D deficiency may require supplementation. (13) Use the following infographics to help automate your essential patient education.
Hydration Recommendations
Healthy Sleep
Mind-Body Stress Reduction
Mistake #4: Employing Passive Modalities Long-term
The passive treatment spectrum includes modalities, dry needling, manual therapy (i.e., ischemic compression, myofascial release, etc.), injections, and medications. (50)
Passive Care Options
From the ChiroUp Best Practice Protocol for MPS
Various therapeutic modalities have been advocated for managing myofascial pain syndrome, including interferential current and TENS. (51-54) Low-level laser therapy (LLLT) has been shown to help pain and disability in patients with myofascial pain syndrome. (53,55-58, 119) Extracorporeal shock wave therapy (ESWT) has also been employed successfully. (55,59) Therapeutic ultrasound has low-level support (55,60-62) but without conclusive benefit. (54) Local heat applied over trigger points is a primitive modality that has demonstrated some merit. (63) Conversely, several studies have effectively incorporated cold therapy in the management of myofascial pain syndrome. (64,87,90) Several studies have suggested that dry needling may relieve pain and lessen disability for MPS patients. (68-74) Some studies document the utility of acupuncture and electroacupuncture for the management of myofascial pain syndrome. (74-75)
Solution #4
Evidence-based clinicians must recognize that the primary benefit of any passive modality lies in its ability to provide short-term palliative relief, thereby allowing the patient to participate in a more active, self-managed program. (53,67) Employing passive modalities for extended periods disempowers patients and fosters chronic pain situations. Care should transition from passive to active as quickly as possible. (See Mistake #2 for inspiration)
Mistake #5: Confusing MPS with Fibromyalgia
Myofascial pain syndrome and fibromyalgia share several overlapping features and may coincide; however, they are uniquely distinct conditions. Myofascial pain syndrome consists of local trigger points in one or more muscles with specific pain patterns, whereas fibromyalgia encompasses widespread hypersensitive tender points, affecting almost every palpable tissue.
Clinically, trigger points are focal and palpably identifiable irritations of particular muscles that produce referred pain. In contrast, fibromyalgia involves multiple tender points that are not palpably distinguishable from the surrounding tissue.
Solution #5
While MPS trigger points generally respond well to manual therapy, fibromyalgia patients improve with a less touch, more talk (education & counseling) approach.
(Bonus) Mistake #6: Not Consistently Employing Best Practices
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In the game of MSK clinical care, there’s a vast difference between merely treating someone vs. consistently applying best practices for every presentation. The emerging healthcare model demands clinical excellence and will stop reimbursing the former. 😱 Providers need a straightforward resource they can quickly use in daily practice.
Bonus Solution
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The following references are taken from the newest ChiroUp protocol (#102)- Myofascial Pain Syndrome
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Parab M, Bedekar N, Shyam A, Sancheti P. Immediate effects of myofascial release and cryo-stretching in management of upper trapezius trigger points–A comparative study. Journal of Society of Indian Physiotherapists. 2020 Sep 15;4(2):74-8. Link
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Borg-Stein J, Iaccarino MA. Myofascial pain syndrome treatments. Physical Medicine and Rehabilitation Clinics. 2014 May 1;25(2):357-74. Link
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