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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.

Check out these ChiroUp 15 Minute to Excellence video tutorials for a review of three pervasive functional deficits.

Upper crossed syndrome

Lower crossed syndrome

Foot Hyperpronation

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. (See our previous blog or this comparison synopsis for more on differentiating MPS from fibromyalgia.)

Differentiating Muscle Pain

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

Most anyone can practice a game like golf or soccer, but what separates champions from weekend warriors is motivation and focused practice. The champions train at a level far beyond monotonous run-throughs of what they already know; they incessantly practice the TOP new strategies and skills for EVERY situation. Our practices and patients deserve no less.

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

ChiroUp is that resource! If you’re not yet a ChiroUp subscriber (and receiving this blog doesn’t make you a subscriber), then you’ll want to check out what you’ve been missing.

 

  • Access hundreds of vetted best-practice tutorials so you can practice with greater confidence knowing your care is the most effective & up-to-date.
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References

The following references are taken from the newest ChiroUp protocol (#102)- Myofascial Pain Syndrome

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