Manual Trigger Point Therapy E-Book

Roland Gautschi

• Herausgeber: Thieme
• Kategorie: Fachliteratur
• Sprache: Englisch

Seitenzahl: 1400

Veröffentlichungsjahr: 2019

Beschreibung

Treating pain where it originates!

Manual trigger point therapy combines mechanical, reflex, biochemical, energetic, functional, cognitive-emotional, and behaviorally effective phenomena. As such, it influences not only peripheral nociceptive pain, but also intervenes in the body's pain-processing and transmission mechanisms.

Here you will learn: a systematic, manual-therapeutic approach to recognize and deactivate the potential of trigger points to cause pain and dysfunction; how to treat the accompanying fascial disorders; and how to prevent recurrences.

Key Features:

• Clinical background of myofascial pain and dysfunction
• Muscles, trigger points, and pain patterns at a glance
• Neuromuscular entrapments shown in detail
• Screening tests und pain guides for all common clinical patterns
• Manual treatment of trigger points and fasciae

Manual Trigger Point Therapy is your one-stop, comprehensive introduction to this fascinating, proven technique.

This book includes complimentary access to a digital copy on https://medone.thieme.com.

Watch a special video preview of Manual Trigger Point Therapy here:

Leseprobe

To access the additional media content available with this e-book via Thieme MedOne, please use the code and follow the instructions provided at the back of the e-book.

Overview of the Most Important Muscles

See index (p. 682) for complete listing

Muscle

Page

Abdominal muscles

340

Abductor pollicis longus

470

Adductor longus and brevis

390

Adductor magnus

392

Adductor pollicis

486

Anconeus

446

Biceps brachii

450

Biceps femoris

402

Brachialis

452

Brachioradialis

460

Coracobrachialis

238

Deltoid

218

Diaphragm

356

Epicranius

320

Erector spinae (cervical)

284

Erector spinae (thoracic, lumbar)

328

Extensor carpi radialis longus and brevis

462

Extensor carpi ulnaris

462

Extensor digitorum (hand)

466

Extensor digitorum brevis (foot)

432

Extensor digitorum longus (foot)

428

Extensor hallucis brevis

432

Extensor hallucis longus

428

Extensor indicis

466

Extensor pollicis longus and brevis

470

Flexor carpi radialis and ulnaris

478

Flexor digitorum longus

422

Flexor digitorum superficialis and profundus

480

Flexor hallucis longus

422

Flexor pollicis brevis

486

Flexor pollicis longus

482

Gastrocnemius

414

Gemellus superior and inferior

372

Gluteus maximus

366

Gluteus medius and minimus

368

Gracilis

394

Hamstring muscles

402

Iliopsoas

346

Infraspinatus

222

Intercostal muscles

354

Interossei (hand)

492

Lateral pterygoid

306

Latissimus dorsi

232

Levator scapulae

266

Longissimus capitis and cervicis

284

Longus colli and capitis

278

Lumbricals (hand)

492

Masseter

298

Medial pterygoid

304

Multifidi (cervical)

284

Multifidi (thoracic, lumbar)

328

Oblique abdominal muscles (external and internal)

340

Obliquus capitis inferior and superior

288

Obturator externus

374

Obturator internus

372

Occipitofrontalis

320

Omohyoid

314

Palmaris longus

476

Pectineus

388

Pectoralis major

234

Pectoralis minor

240

Peroneus longus and brevis

430

Piriformis

370

Plantaris

414

Platysma

318

Popliteus

406

Pronator quadratus

484

Pronator teres

474

Quadratus femoris

376

Quadratus lumborum

334

Quadriceps

396

Rectus abdominis

340

Rectus capitis anterior and lateralis

278

Rectus capitis posterior major and minor

288

Rhomboid minor and major

248

Rotatores cervicis

284

Rotatores thoracis and lumborum

328

Sartorius

386

Scalenes

274

Semimembranosus

402

Semispinalis capitis and cervicis

284

Semitendinosus

402

Serratus anterior

244

Serratus posterior inferior

352

Serratus posterior superior

350

Soleus

418

Splenius capitis and cervicis

282

Sternocleidomastoid

270

Subclavius

254

Suboccipital muscles

288

Subscapularis

226

Supinator

472

Supraspinatus

220

Temporalis

300

Tensor fasciae latae

384

Teres major

230

Teres minor

224

Thoracolumbar fascia

358

Tibialis anterior

426

Tibialis posterior

424

Transversus abdominis

340

Trapezius, lower

252

Trapezius, middle

250

Trapezius, upper

262

Triceps brachii

446

Muscle Groups

Page

Facial (mimic) muscles

318

Hypothenar muscles

490

Infrahyoidal muscles

314

Pelvic floor muscles

378

Plantar muscles (deep layer)

438

Plantar muscles (superficial layer)

434

Scapulothoracic gliding space

256

Suprahyoidal muscles

310

Thenar muscles

486

Manual Trigger Point Therapy

Recognizing, Understanding, and Treating Myofascial Pain and Dysfunction

Roland Gautschi, MA, PTSenior InstructorInterest Group for Myofascial Trigger Point TherapyBaden, Switzerland

1178 illustrations

ThiemeStuttgart • New York • Delhi • Rio de Janeiro

Library of Congress Cataloging-in-Publication Data

Names: Gautschi, Roland, 1958- author.

Title: Manual trigger point therapy: recognizing, understanding and treating myofascial pain and dysfunction / Roland Gautschi; translator, Alan Wiser.

Other titles: Manuelle Triggerpunkt-Therapie. English

Description: Stuttgart; New York: Thieme, [2019] | “This book is an authorized translation of the 3rd German edition published and copyrighted 2016 by Georg Thieme Verlag, Stuttgart. Title of the German edition: Manuelle Triggerpunkt-Therapie: Myofasziale Schmerzen und Funktionsstörungen erkennen, verstehen und behandeln.” | Includes bibliographical references and index. |

Identifiers: LCCN 2018056221 (print) | LCCN 2018057606 (ebook) | ISBN 9783132203112 () | ISBN 9783132202917 (hardcover) | ISBN 9783132203112 (eISBN)

Subjects: | MESH: Myofascial Pain Syndromes–therapy | Trigger Points–physiopathology | Pain Management

Classification: LCC RB127 (ebook) | LCC RB127 (print) | NLM WE 550 | DDC 616/.0472–dc23

LC record available at https://lccn.loc.gov/2018056221

Illustrations: Karin Baum, Paphos, Zypern; Martin Hoffmann, Neu-Ulm; Markus Voll, München; Karl Wesker, Berlin Photos: Oskar Vogl, Affalterbach

Translator: Alan Wiser, Ambler, Pennsylvania, USA

© 2019 Georg Thieme Verlag KG

Thieme Publishers StuttgartRüdigerstrasse 14, 70469 Stuttgart, Germany+49 [0]711 8931 421, [email protected]

Thieme Publishers New York333 Seventh Avenue, New York, NY 10001, USA+1-800-782-3488, [email protected]

Thieme Publishers DelhiA-12, Second Floor, Sector-2, Noida-201301,Uttar Pradesh, India+91 120 45 566 00, [email protected]

Thieme Publishers Rio, Thieme Publicações Ltda.Edifício Rodolpho de Paoli, 25⍛ andarAv. Nilo Peçanha, 50 – Sala 2508Rio de Janeiro 20020-906 Brasil+55 21 3172 2297 / [phone]

Cover design: Thieme Publishing GroupCover illustration: Oskar Vogl, AffalterbachTypesetting by DiTech Process Solutions, India

Printed in Germany by CPI Books                    5 4 3 2 1

ISBN 978-3-13220-291-7

Also available as an e-book:eISBN 978-3-13220-311-2

Important note: Medicine is an ever-changing science undergoing continual development. Research and clinical experience are continually expanding our knowledge, in particular our knowledge of proper treatment and drug therapy. Insofar as this book mentions any dosage or application, readers may rest assured that the authors, editors, and publishers have made every effort to ensure that such references are in accordance with the state of knowledge at the time of production of the book.

Nevertheless, this does not involve, imply, or express any guarantee or responsibility on the part of the publishers in respect to any dosage instructions and forms of applications stated in the book. Every user is requested to examine carefully the manufacturers’ leaflets accompanying each drug and to check, if necessary in consultation with a physician or specialist, whether the dosage schedules mentioned therein or the contraindications stated by the manufacturers differ from the statements made in the present book. Such examination is particularly important with drugs that are either rarely used or have been newly released on the market. Every dosage schedule or every form of application used is entirely at the user’s own risk and responsibility. The authors and publishers request every user to report to the publishers any discrepancies or inaccuracies noticed. If errors in this work are found after publication, errata will be posted at www.thieme.com on the product description page.

Some of the product names, patents, and registered designs referred to in this book are in fact registered trademarks or proprietary names even though specific reference to this fact is not always made in the text. Therefore, the appearance of a name without designation as proprietary is not to be construed as a representation by the publisher that it is in the public domain.

This book, including all parts thereof, is legally protected by copyright. Any use, exploitation, or commercialization outside the narrow limits set by copyright legislation, without the publisher’s consent, is illegal and liable to prosecution. This applies in particular to photostat reproduction, copying, mimeographing, preparation of microfilms, and electronic data processing and storage.

Contents

Videos

Foreword

Siegfried Mense

Foreword

Jan Dommerholt

Preface

About the Book

Myofascial Trigger Point Therapy

1Introduction

1.1 Phenomenology

1.2 Different Types of Trigger Points

1.3 Prevalence

1.4 Relevance

1.5 Historical Review

1.6 Approach

2Myofascial Trigger Points

2.1 Clinical Aspects of Myofascial Trigger Points

2.1.1 Characteristics of Myofascial Trigger Points

2.1.2 Diagnosis of Myofascial Trigger Points

2.2 Pathophysiology

2.2.1 Medical Examination Methods

2.2.2 Histological Examination

2.2.3 Analysis of the Biochemical Environment

2.2.4 Exploration of Local Perfusion

2.2.5 Chronic Muscle Pain — Changes in Nociception

2.2.6 Referred Pain

2.2.7 Energy Crisis Model

2.2.8 Connective Tissue Changes

2.2.9 Central Influences/Processes

2.2.10 Integrative Hypothesis

2.3 Etiology

2.3.1 Causes for the Development of Myofascial Trigger Points

2.3.2 Activating Mechanisms — Deactivating Mechanisms

2.3.3 Predisposing and Perpetuating Factors

3Trigger Point–Induced Disturbances

3.1 Disturbances Induced Directly by Trigger Points

3.1.1 Pain

3.1.2 Motor Dysfunction

3.1.3 Autonomic Disturbances

3.2 Disturbances Induced Indirectly by Trigger Points

3.2.1 Disturbances Resulting from Taut Bands

3.2.2 Disturbances Resulting from Connective Tissue Changes

3.3 Myofascial Syndrome

4Diagnosis of Myofascial Pain

4.1 Clinical Reasoning

4.1.1 Pain in the Neuromusculoskeletal System

4.1.2 Pain Mechanisms

4.1.3 Myofascial Pain

4.2 Principles of Examination

4.2.1 History

4.2.2 Physical Findings

4.2.3 Working Hypothesis

4.2.4 Trial Treatment

4.2.5 Reassessment

4.3 Differential Diagnosis

4.3.1 Muscle-Caused Pain

4.3.2 Joint Dysfunction

4.3.3 Irritation of Neural Structures

4.3.4 Internal Organs

4.3.5 Fibromyalgia Syndrome

5Treatment of Myofascial Pain

5.1 Treatment of Myofascial Trigger Points

5.1.1 Fundamentals

5.1.2 Myofascial Trigger Points: Treatment Possibilities

5.1.3 Manual Trigger Point Therapy

5.1.4 Effectiveness

5.2 Effects of Manual Trigger Point Therapy

5.2.1 Mechanical Aspects

5.2.2 Biochemical Aspects

5.2.3 Reflexive Aspects

5.2.4 Functional Aspects

5.2.5 Cognitive-Behavioral Aspects

5.2.6 Energetic Aspects

5.2.7 Holodynamic Aspects

5.3 Management of Myofascial Pain

5.3.1 Composing a Treatment Plan

5.3.2 Combining Manual Trigger Point Therapy with other Treatment Methods

5.3.3 Self-Management

5.3.4 Resistance to Treatment

6Indications — Contraindications

6.1 Indications

6.1.1 Myofascial Syndrome

6.1.2 Stimulus Summation Problems

6.1.3 Entrapment Neuropathy

6.1.4 Scars and Other Changes in the Connective Tissue

6.2 Contraindications

6.2.1 Absolute Contraindications

6.2.2 Relative Contraindications

7Manual Therapy of the Muscles

7.1 Shoulder

7.1.1 Deltoid

7.1.2 Supraspinatus

7.1.3 Infraspinatus

7.1.4 Teres Minor

7.1.5 Subscapularis

7.1.6 Teres Major

7.1.7 Latissimus Dorsi

7.1.8 Pectoralis Major

7.1.9 Coracobrachialis

7.1.10 Pectoralis Minor

7.1.11 Serratus Anterior

7.1.12 Rhomboid Minor and Major Muscles

7.1.13 Middle Trapezius

7.1.14 Lower Trapezius

7.1.15 Subclavius

7.1.16 Scapulothoracic Gliding Space

7.2 Neck

7.2.1 Upper Trapezius

7.2.2 Levator Scapulae

7.2.3 Sternocleidomastoid

7.2.4 Scalene Muscles

7.2.5 Deep Prevertebral Muscles: Longus Colli, Longus Capitis, Rectus Capitis Anterior, Rectus Capitis Lateralis

7.2.6 Splenius Capitis and Splenius Cervicis

7.2.7 Cervical Erector Spinae Muscles: Semispinalis Capitis and Cervicis, Longissimus Capitis and Cervices, Multifidi, and Rotatores Muscles

7.2.8 Suboccipital Muscles: Rectus Capitis Posterior Major and Minor; Obliquus Capitis Inferior and Superior

7.3 Jaw and Head

7.3.1 Masseter

7.3.2 Temporalis

7.3.3 Medial Pterygoid

7.3.4 Lateral Pterygoid

7.3.5 Suprahyoid Muscles: Digastric, Stylohyoid, Mylohyoid, Geniohyoid

7.3.6 Infrahyoid Muscles: Sternohyoid, Sternothyroid, Thyrohyoid, Omohyoid

7.3.7 Facial (Mimic) Muscles: Orbicularis Oculi, Zygomaticus, Platysma

7.3.8 Occipitofrontalis (of the Epicranius)

7.4 Torso

7.4.1 Erector Spinae

7.4.2 Quadratus Lumborum

7.4.3 Abdominal Muscles: External Oblique, Internal Oblique, Transversus Abdominis; Rectus Abdominis, Pyramidalis

7.4.4 Iliopsoas

7.4.5 Serratus Posterior Superior

7.4.6 Serratus Posterior Inferior

7.4.7 Intercostal Muscles

7.4.8 Diaphragm

7.4.9 Thoracolumbar Fascia

7.5 Buttocks

7.5.1 Gluteus Maximus

7.5.2 Gluteus Medius and Gluteus Minimus

7.5.3 Piriformis

7.5.4 Obturator Internus and Gemelli Muscles

7.5.5 Obturator Externus

7.5.6 Quadratus Femoris

7.5.7 Muscles of the Pelvic Floor

7.6 Thigh and Knee

7.6.1 Tensor Fasciae Latae

7.6.2 Sartorius

7.6.3 Pectineus

7.6.4 Adductor Longus and Brevis

7.6.5 Adductor Magnus

7.6.6 Gracilis

7.6.7 Quadriceps Muscle

7.6.8 Semitendinosus and Semimembranosus, Biceps Femoris

7.6.9 Popliteus

7.7 Lower Leg and Foot

7.7.1 Gastrocnemius and Plantaris

7.7.2 Soleus

7.7.3 Flexor Digitorum Longus and Hallucis Longus

7.7.4 Tibialis Posterior

7.7.5 Tibialis Anterior

7.7.6 Extensor Digitorum Longus, Extensor Hallucis Longus

7.7.7 Peroneus Longus, Brevis, and Tertius

7.7.8 Extensor Digitorum Brevis, Extensor Hallucis Brevis

7.7.9 Muscles of the Sole of the Foot (Superficial Layer): Flexor Digitorum Brevis, Abductor Hallucis, Abductor Digiti Minimi

7.7.10 Muscles of the Sole of the Foot (Deep Layer): Quadratus Plantae, Flexor Hallucis Brevis, Adductor Hallucis, Lumbricals, Interossei

7.8 Upper Arm

7.8.1 Triceps Brachii, Anconeus

7.8.2 Biceps Brachii

7.8.3 Brachialis

7.9 Forearm and Hand

7.9.1 Brachioradialis

7.9.2 Extensors of the Hand: Extensor Carpi Radialis Longus and Brevis, Extensor Carpi Ulnaris

7.9.3 Finger Extensors: Extensor Digitorum Communis, Extensor Digiti Minimi, Extensor Indicis

7.9.4 Abductor Pollicis Longus, Extensor Pollicis Longus and Brevis

7.9.5 Supinator

7.9.6 Pronator Teres

7.9.7 Palmaris Longus

7.9.8 Flexors of the Hand: Flexor Carpi Radialis and Ulnaris

7.9.9 Flexors of the Fingers: Flexor Digitorum Superficialis and Profundus

7.9.10 Flexor Pollicis Longus

7.9.11 Pronator Quadratus

7.9.12 Thenar Muscles: Abductor Pollicis Brevis, Adductor Pollicis, Flexor Pollicis Brevis, Opponens Pollicis

7.9.13 Hypothenar Muscles: Abductor Digiti Minimi, Flexor Digiti Minimi, Opponens Digiti Minimi, Palmaris Brevis

7.9.14 Interdigital Muscles: Lumbricals and Interossei

8Neuromuscular Entrapments

8.1 Nerve Root Compression

8.2 Upper Extremity

8.2.1 Brachial Plexus

8.2.2 Musculocutaneous Nerve

8.2.3 Axillary Nerve

8.2.4 Median Nerve

8.2.5 Radial Nerve

8.2.6 Ulnar Nerve

8.3 Lower Extremity

8.3.1 Lumbar and Lumbosacral Plexus

8.3.2 Femoral Nerve

8.3.3 Lateral Femoral Cutaneous Nerve

8.3.4 Iliohypogastric Nerve, Ilioinguinal Nerve, Genitofemoral Nerve

8.3.5 Obturator Nerve

8.3.6 Sciatic Nerve

8.3.7 Peroneal (Fibular) Nerve

8.3.8 Tibial Nerve

8.4 Other Entrapments

8.4.1 Greater Occipital Nerve/Posterior Ramus of the 2nd Cervical Nerve

8.4.2 Posterior Rami of the Spinal Nerves

8.4.3 Entrapments in the Terminal Nerve Segment (Distal Mini-Entrapments)

9Clinical Aspects

9.1 Screening Tests

9.1.1 Cervical Spine

9.1.2 Thoracic spine

9.1.3 Shoulder

9.1.4 Elbow

9.1.5 Forearm and Hand

9.1.6 Lumbar, Pelvis, and Hip Region

9.1.7 Knee

9.1.8 Lower Leg and Foot

9.1.9 Jaw

9.2 Pain Guides

9.3 Clinical Presentations

9.3.1 Posterior and Anterior Neck Pain and Headaches

9.3.2 Craniomandibular Dysfunction (CMD)

9.3.3 Shoulder Pain

9.3.4 Interscapular and Subscapular Pain

9.3.5 Thoracic Pain

9.3.6 Elbow Pain

9.3.7 Forearm and Hand Pain

9.3.8 Low Back Pain (Nonspecific Lower Back Pain)

9.3.9 Hip and Groin Pain

9.3.10 Knee Pain

9.3.11 Achillodynia

9.3.12 Lower Leg and Foot Pain

Appendix

10Bibliography

11Glossary

12Muscle Abbreviations

13List of Abbreviations

14Index of Clinical Tips

Index

Videos

Videos

Video 1: Screening tests, shoulder: overview examination.

Video 2: Screening tests, shoulder: differentiation of active/passive structures using the example of the internal/external rotators.

Video 3: Screening tests, shoulder: differentiation in abduction with end-range pain.

Video 4: Palpatory diagnosis with flat palpation using the example of the infraspinatus muscle.

Video 5: Palpatory diagnosis with pincer grip using the example of the pectoralis major muscle.

Video 6: Diagnostic provocation test using the example of the supraspinatus muscle.

Video 7: Illustration of the manual techniques I, II and III by using a simple model.

Video 8: Basic principle of the techniques I, II, III and IV using the example of the infraspinatus muscle.

Video 9: Differentiation of the techniques IIa and IIb, Ia and Ib, IVa and IVb using the example of the infraspinatus muscle.

Video 10: “Pincer grip” and “piercing grip” using the example of the sternocleidomastoid muscle.

Video 11: “Grip as squeezing toothpaste from a tube” using the example of the sternocleidomastoid muscle.

Video 12: “Ignition key grip” using the example of the sternocleidomastoid muscle.

Video 13: Tips for the therapist in using the manual techniques.

Video 14: Levator scapulae muscle: palpatory diagnosis and treatment.

Video 15: Subscapularis muscle: access and treatment from lateral.

Video 16: Supraspinatus muscle: direct treatment.

Video 17: Supraspinatus muscle: treatment of the insertion site.

Video 18: Sternocleidomastoid muscle: example of a treatment sequence.

Foreword

This comprehensive book deals with practically all aspects of myofascial trigger points, from the as yet imperfectly understood pathophysiology to the actual practical therapy. The subject of the book is of immense importance—as the life expectancy of the population in the developed nations increases, disorders of the musculoskeletal system also become ever more common. In addition to the aging of the population, physical inactivity and unhealthy nutrition are further factors that increase the prevalence of musculoskeletal disorders.

A very important shortcoming in this context is that many physicians, at least in Germany, do not physically examine their patients. The reason for this is in part financial because the insurance companies, especially in Germany, pay either nothing or insufficiently, for a complete physical examination. A further reason is that medical students are not educated in diagnostic techniques using muscle palpation. In most countries, a medical discipline dealing specifically with muscle pain is not available. In this sense, the muscular system is in fact an “orphan organ” (quoted from Professor David Simons). The situation is all the more incomprehensible in view of the fact that muscular pain is one of the most common complaints of the population. Many patients with trigger points that are relatively simple to treat stumble from doctor to doctor because they cannot find anyone to provide relief of their symptoms. Trigger point patients have normal laboratory values, and modern imaging techniques do not show any changes in muscle at all. If the physician or physical therapist is not educated in trigger point diagnosis or in recognition of functional muscle pain, the patient runs the risk of being seen as a hypochondriac. Overall, the lack of specialized therapists leads to an enormous economic burden in the form of health care costs and loss of workdays. Furthermore, the deficient knowledge base and the lack of acceptance of trigger points represent an additional psychological stress for patients because they sense the therapist’s skepticism.

Because the formation of myofascial trigger points and many other chronic muscle disorders have only a hypothetical basis, there is also no generally accepted causal therapy to date. So there are multiple therapeutic approaches, many of which on closer inspection have no solid basis. This book provides the interested reader with guidelines for the treatment of the patient with trigger points. It also delineates the limitations of the various treatment methods.

The situation in research is deficient too, as it is in clinical practice. To the present time, there is still no systematic research of the histology of trigger points. The single large study stems from an Austrian work group, who, however, used postmortem biopsies, and therefore had to solve the problem of taking the samples before rigor mortis set in. A controlled study would be necessary using open biopsies from patients and appropriate controls from muscles that show no abnormalities. It is almost impossible to get funding for such research at this time, however, because many reviewers are not familiar with the problem. Conference presentations unfortunately often mention trigger points in the same breath as the tender points in fibromyalgia and acupuncture points, leading to the impression that myofascial trigger points are ill-defined, unreliable, and somewhat esoteric.

It is therefore high time to place the depiction of trigger points on a solid foundation. That is exactly what this book accomplishes. In terms of fundamental and critical treatment of the basics and therapeutic approach, this book fills a void in German medical literature and most closely corresponds to the American trigger point handbook by David Simons and Janet Travell. My hope is that this book will be widely disseminated and that reading it will dispel many ambiguities in regard to the etiology, diagnostics, and therapy of myofascial trigger points.

Siegfried Mense, MDProfessor, Department of Anatomy and Cell BiologyMedical Faculty Mannheim of the University ofHeidelbergCenter for Biomedicine and Medical Technology,Mannheim (CBTM)Section of Macroscopic AnatomyMannheim, Germany

Foreword

In 2010, when Roland Gautschi completed the German edition of this book, I was very impressed with the wealth of information he had pieced together into a phenomenal resource with up-to-date information, outstanding full-color illustrations, and solid overviews of complex materials and concepts, in addition to providing many excellent clinical pearls and evidence-informed guidelines. In other words, the book was not only attractive to academics, but also served the needs of clinicians, including physicians, physiotherapists, chiropractors, osteopaths, and occupational therapists, among others. When I shared with the author, while we both attended a conference in Toledo, Spain, that the book deserved to be translated into English and possibly other languages, I sensed that the very thought of spending even more time on this book was too overwhelming to even consider at that time. Given the volume of this text, I can only imagine the numerous hours Gautschi must have spent away from family and friends to synthesize a work of this magnitude.

Nine years later, the translation in English is in our hands and I am confident that the book will soon be in the treatment rooms of many practitioners around the world. Now that this excellent book is available to a much broader audience, I hope that many English-speaking clinicians and researchers will reach out to this marvelous resource to refresh their knowledge about myofascial pain and trigger points, or to get ideas about the clinical management for a particular patient. Of course, in 9 years we’ve seen a lot of advancements in research. While some of the information and referenced studies of the original book have been updated in subsequent German editions, other concepts are maintained in it, and so, feature in this first English edition too. For example, since the publication of the German editions the nomenclature has changed a bit in the myofascial pain literature and concepts of primary, secondary, and satellite trigger points have since been abandoned. For an English-language book, the development of Swiss and German myofascial pain societies may not be all that interesting to many readers, but at the same time, it is worthwhile learning about the experiences of clinicians in other countries. Unfortunately, the book does not include much information about the development of trigger point courses in the rest of the world, such as the United States, Spain, Italy, etc. Nevertheless, there is an abundance of information in this book that has withstood the test of time that clearly outweigh such minor details.

The first six chapters provide an excellent overview of the diagnosis and pathophysiology of myofascial pain and the clinical importance of trigger points. The author managed to integrate current pain science concepts into the myofascial pain “story” to create the foundation for clinical manual therapy management principles. Manual techniques are primarily based on the work of Swiss rheumatologist, Beat Dejung. The clinical chapters are divided into specific body regions and are consistently organized. Each chapter is abundantly illustrated with overviews of pertinent anatomy and multiple high-quality color photographs of clinical techniques and manual therapy positions. Each muscle includes a section with “tips for the therapist,” which gives, especially to more recent graduates, the benefit of tapping into Gautschi’s rich clinical experience.

In summary, this book fills a void in the English-language literature on myofascial pain. I anticipate that the book will follow the footsteps of its German parent and soon will be a staple in clinics all over the world. It is an honor to prepare this foreword and I congratulate Roland Gautschi with this accomplishment.

Jan Dommerholt, PT, DPT, MPS, DAIPMPresident and CEOBethesda PhysiocareBethesda, Maryland

Preface

I am very pleased about the English edition of this trigger point book. This was made possible thanks to the great and ongoing response this book has received with regard to the previous editions (first German ed. 2010, third ed. 2016). I attribute this to the keen interest in the topic: recognizing, understanding, and treating problems that develop due to trigger points and fascial changes. I also see this as a sign of appreciation in the concept of the book, made possible by Thieme Publishers.

I have been delighted by the extensive feedback the book has received. Many fellow practitioners with many long years of professional experience have said the trigger point book is not, as might otherwise be expected with technical literature, stashed away on a bookshelf gathering dust. But rather, it is always within reach on their work tables, providing a constant source of useful information as required in everyday practice. Many young therapists, too, have emphasized that they have obtained valuable assistance and support in their practical work from this trigger point compendium.

What features are highlighted in this book?

The occasionally expressed reservations regarding trigger point therapy primarily involve three points:

1. Myofascial problems and trigger points are only secondary problems.

2. Trigger point therapy, as a hands-on treatment, leads to the patient becoming dependent on the therapy or therapist.

3. Trigger point therapy causes pain, which the patient should not have to tolerate.

Trigger point therapy is usually painful, but the pain that occurs during treatment can and should be used therapeutically. Patients are usually thankful, and, in spite of the pain, relieved when their therapists finds the “sore spot” and treats it thoroughly. The goal of myofascial trigger point therapy is the patient’s independence, and the therapist utilizes trigger point therapy to achieving this goal. The patient can contribute a lot to the therapy, and a dedicated section clearly outlines what the patient can accomplish using selfmanagement to resolve myofascial problems and to prevent them from recurring. Myofascial problems can, of course, be caused secondarily. But they are often the primary causative factor responsible for pain and dysfunction. In chronic pain, the postulated linear relationship of primary–secondary is, in many cases, no longer valid. Instead, problems with stimulus summation may be present, which are likewise highlighted in this book.

This English edition has provided the opportunity to revise, supplement, and update the book. Due to the strongly growing interest in fascia and developing fascial research, the theme of fascia has an even greater focus in this English edition. Sections about the structure, features, and functions of connective tissue, about fascial changes and their significance in the development and perpetuation of myofascial trigger points (mTrPs), and about muscle-fascial interaction (such as the catapult effect and musclefascial cycle during bending) elucidate the connection and interaction of contractile and non-contractile components in myofascial dysfunction. The sections “Stretching” and “Functional Training” have also been revised and expanded from a fascial perspective. In addition to the above, this edition examines a critical controversy concerning the clinical diagnostic investigation of mTrPs and the question as to how mTrPs develop from both a clinical and pathophysiological perspective (etiology). The discussion covers to what extent mTrPs are a phenomenon that is peripherally caused and/or centrally caused, and how peripheral processes and central processes possibly collaborate in the development of mTrPs. The section “Differential Diagnosis” provides updated information concerning the fibromyalgia syndrome and its relationship to the myofascial syndrome. The chapter “Entrapment Neuropathys” has been enhanced with information concerning the differentiation of intra- and extraneural entrapments, as well as information about clinical clues to help differentiate whether a neural or a myofascial structure is the source of symptoms generated by manual provocation. The chapter “Diagnosis of Myofascial Pain,” and the sections “Screening-Tests” and “Contraindications” have been revised and complemented (the latter now includes discussion of direct oral anticoagulants).

To improve visualization of the book’s contents, approximately 1200 figures are included and 18 videos demonstrate the diagnostic investigation procedure (screening tests and palpatory diagnostics) and the manual therapy of trigger points and fascia.

Acknowledgements

I am very thankful for the fortunate circumstances that made this book possible.

In particular I am highly grateful to

• My parents;

• All my teachers, especially Dr. Beat Dejung, the persevering and generous pioneer and founder of manual trigger point therapy, who passed on his rich knowledge to us unselfishly;

• The patients for their trust, patience and commitment to see pain not only as a problem, but (also) as an opportunity;

• The participants of many previous courses in trigger point therapy for their diverse and thorough questions that helped clarify the subject matter;

• My colleagues from the IMTT Instructor Team, especially Johannes Mathis — twenty years ago we started teaching our first trigger point courses together, creating the “blanks” of the systematic muscle presentation — as well as Yvonne Mussato for reading the manuscript of the whole practical part and her inspiring feedback;

• Prof. Dr. Siegfried Mense who wrote, as an international recognized authority in the field of muscle research, a foreword to this book and thus helped to bridge the gap between the practice of trigger point therapy and the scientific research;

• Dr. Robert Schleip and Hugo Stam for their valuable inputs and their willingness to review with their expert knowledge the relevant chapters (fascial structures or neurodynamic aspects) as well as for bringing in helpful impulses;

• Dr. Daniel Grob, Dr. Heinz O. Hofer, Dr. Gunnar Licht, and Dr. Hans-Werner Weisskircher for review and suggestions on the clinical pictures (Chapter 9.3);

• Malibu Forrer (model) and Oskar Vogl (photographer) for their unwavering patience and perseverance during the photo shooting for the practice section as well as Thomas Basler who was kind enough to be spontaneouslyon hand as a model for the theory part of the book;

• Judith, my wife, as well as our daughters Moira and Vera.

I am very happy that this English translation can now appear 9 years after the German first edition. I would like to thank Alan Wiser for the accurate translation, my two counter readers, Becca Tormey and Heinz O. Hofer for their valuable feedback and tips, as well as Delia DeTurris from Thieme Publishers, New York, Angelika-M. Findgott, Gabriele Kuhn-Giovannini and Joanne Stead from Thieme Publishers, Stuttgart, and Nidhi Chopra and Prakash Naorem from Thieme Publishers, Delhi for their flexibility and professionalism; they all make this English edition possible. Special thanks to Dr. Jan Dommerholt for his elaborated and sensitive foreword, which ennobles this English edition.

Outlook

The approach to myofascial disturbances and trigger point therapy presented here is based on a phenomenological perspective (see “Approach”). It enables the essence of trigger point therapy to be independently reviewed and confirmed, or rejected and further developed. The trigger point book presented here is incomplete; it requires you and your therapeutic care to fulfill it. Only in that manner can it bloom and bear fruit. Thank you—please enjoy using this book!

Roland Gautschi, MA, PT

About the Book

Climbing “Mount Myofascialis”

The reader is invited to use this book as an expedition report and guidebook to explore the “Mount Myofascialis”. Welcome to this journey of discovery!

The subtitle of the book, Recognizing, Understanding and Treating Myofascial Pain and Dysfunction, outlines its agenda:

•Recognizing myofascial problems: How does the “myofascial landscape” appear? Which indications point us to the myofascial path? What trail markers guide us on our journey? How do we recognize myofascial problems in practice?

•Understanding myofascial problems: What do we currently know about myofascial pain and dysfunction? Which hypotheses and conceptual models predominate? The most important scientific studies and concepts of the last 30 years are reviewed and put into context. Through this process, a mosaic-like map of the myofascial terrain emerges.

•Treating myofascial problems: Evidence-informed and evidence-based practices in the treatment of myofascial conditions, based on up-to-date scientific research, are presented in detail.

This textbook is directed primarily to the practitioner. Based on a practitioner’s everyday experience, it was developed specifically for use in practice. A busy practitioner seldom has time to read a 700-page book from cover to cover, page-by-page. Therefore, this book is designed in a way that the practitioner can open and read it from any section.

The table of contents provides an overview and thus an initial orientation to appropriate entry points. There are frequent cross references within the text that refer to chapters and passages in the book that provide further details, corresponding points, or more in-depth information, thus acting as a guide to the network within the book. Key points are highlighted in orange boxes, making it possible to scan the material quickly. Summaries marked with a blue background review the essential points at the end of a section. In the theoretical portion of the book, the clinical relevance to everyday clinical practice is presented under the heading “Clinical Tips” with a yellow background in such a manner as to crosslink the practical part of the book with the theoretical fundamentals. Finally, the index enables one to find the desired information directly.

The internal structure of the book is mirrored in the table of contents. There are two main sections: a practical, clinical section and a section dealing with basic principles.

Clinical Section

The practical, clinical part of the book presents the individual muscles and their treatment in the written form (including the anatomy, function, referred pain patterns, symptoms provoked by trigger points, factors leading to trigger point formation, recommendations for patients, and tips for the therapist). In addition, the figures illustrate referred pain patterns, the manual therapy of the trigger points and fascias, as well as stretching methods (Chapter 7). An overview directory of the muscles on the inside front cover and a thumb index offer a quick guide to this extensive chapter. Because taut bands caused by trigger points are capable of exerting pressure on peripheral nerves, thereby causing secondary neural problems, particular attention is given to localization and treatment of commonly occurring neuromuscular entrapments (Chapter 8). Finally, we demonstrate how myofascial pain is differentiated and how myofascial trigger points can be identified in the course of everyday clinical practice (Chapter 9). Screening tests (Chapter 9.1) and pain guides (Chapter 9.2) are presented for common clinical presentations (Chapter 9.3).

Basic Principles Section

Therapeutic treatment should be supported by the best scientific knowledge currently available. The portion of the book dealing with basic principles provides these fundamentals. Chapter 1 introduces the phenomenon of myofascial pain (Chapter 1.1) and the different types of trigger points (Chapter 1.2). It also discusses the incidence (Chapter 1.3) and importance of myofascial trigger points (Chapter 1.4), gives a short historical review of the roots of trigger point science (Chapter 1.5), and places trigger point therapy in its proper scientific context (Chapter 1.6).

Chapter 2 deals with the questions of how myofascial trigger points manifest themselves clinically (Chapter 2.1), which pathophysiological changes underlie myofascial pain and dysfunction, and which explanatory models for myofascial pain are currently under discussion (Chapter 2.2), as is the question of how and by what means trigger points develop (Chapter 2.3). The disturbances caused or perpetuated by trigger point activity are diverse (Chapter 3). Myofascial trigger points can generate locomotor-system problems both directly (Chapter 3.1) and indirectly (Chapter 3.2). The diagnostic workup of myofascial pain (Chapter 4) is part of the clinical reasoning process of neuromusculoskeletal medicine (Chapter 4.1). The principles of examination (Chapter 4.2) and differential diagnostic clues are presented (Chapter 4.3). Myofascial pain therapy (Chapter 5) includes both the treatment of myofascial trigger points and fascias in the narrower sense (Chapter 5.1), as well as the management of myofascial pain in which other therapeutic approaches are commonly combined as part of an integrated, multimodal therapy program (Chapter 5.3). Specific attention is given to the mechanical, biochemical, reflexive, cognitive-behavior-centered, energetic, and holistic aspects of the various levels of manual trigger point therapy’s impact (Chapter 5.2). An explanation of the indications (Chapter 6.1) and contraindications (Chapter 6.2) for trigger point therapy round out the theoretical part of the book and lead into the practical sections.

Myofascial Trigger Point Therapy

Summary

Much of the acute and chronic pain in the musculoskeletal system originates in the muscles, where it is caused by myofascial trigger points (mTrPs) and associated fascia disorders (Travell and Simons 1999; Dejung 2009).

MTrPs pertain to solidly researched, scientific phenomena within the scope of neuromusculoskeletal medicine. The following have been pathophysiologically shown: local hypoxia in the center of mTrPs (Brückle et al. 1990); a modified EMG potential, interpreted as a sign of malfunction of the motor endplate (Travell and Simons 1999); and characteristic anomalies of the biochemical milieu with marked increase in the concentration of substance P, calcitonin gene-related peptide, and bradykinin among others, with a clearly decreased pH value (Shah et al. 2005, 2008). Rigor complexes within the core zone of the mTrPs (myosin and actin filaments persist in a maximally approximated position) have been histomorphologically documented with reactive overextension of the bordering sarcomeres (Travell and Simons 1999) and connective tissue changes (Feigl-Reitinger et al. 1998). It has also been documented that mTrPs have a significant effect on the muscle activation pattern and thus on the motor and musculoskeletal functions (and dysfunctions) (Arendt-Nielsen and Graven-Nielsen 2008; Ge et al. 2012, 2014; Ibarra et al. 2011; Ivanichev 2007; Lucas et al. 2004, 2010).

Basic clinical diagnostic criteria (taut band in a muscle, point of maximal tenderness within the taut band, reproduction of the symptoms) allow a skilled examiner to reliably diagnose mTrPs in everyday clinical practice (Gerwin et al. 1997; Licht et al. 2007).

MTrPs develop from overload or traumatic overstretching of the muscles, often leading to the formation of oxygen-poor zones in the muscle (hypoxia). Hypoxia results in a lack of adenosine triphosphate, and because of this the myosin and actin filaments in these areas are unable to separate from each other (rigor complexes), causing local reactive soft-tissue changes (contractions, adhesions). These small sites of affected muscle tissue can be palpated as mTrPs. Provocation by pressure triggers pain, which often irradiates to other regions of the body (referred pain). MTrPs can cause not only pain but also paresthesias, muscle weakness without primary atrophy, restricted range of motion, proprioceptive disturbances with impairment of coordination, and vegetative reactions. “Myofascial syndrome” is a term used to describe the sum of all symptoms caused by active mTrPs and associated fascia disorders. From experience, targeted trigger point therapy can usually eliminate these problems, even in the case of long-standing symptoms.

Manual trigger point therapy is a systematic, manual-therapeutic interventional strategy with the goal of deactivating the potential of the mTrPs to cause disturbances, treating the accompanying connective tissue changes and preventing recurrences. The form of trigger point therapy represented here involves a systematic six-step program (Swiss approach). This program utilizes four manual therapy techniques (techniques I–IV) to selectively deactivate the trigger points, and, especially in chronic pain patients, to stretch the reactively modified and shortened connective tissue. Home exercises for stretching/relaxing (technique V) break up the monotony of working postures and encourage the muscles to regenerate. Functional training (technique VI) supports the healing process through appropriate weight-bearing exercises and movements, which make the muscles more resilient while better ergonomics reduce failure load. In addition to local therapy of the mTrPs and the fascia disturbances, one must also identify the perpetuating factors and include them in the therapy in order to attain sustainable success in the treatment of chronic myofascial pain. Manual trigger point therapy in the form described here is a differentiated method and is performed by specially trained physical therapists and physicians.

Manual trigger point therapy combines mechanical, reflex, biochemical, energetic, functional, cognitive–emotional, and behaviorally effective phenomena (Gautschi 2008). Manual trigger point therapy thus influences not only the peripheral nociceptive pain but also, at the same time, intervenes in the body’s pain processing and output mechanisms.

Myofascial trigger point therapy:

• Helps clarify (in terms of differential diagnosis) to what extent the muscles participate in the genesis and perpetuation of the pain and/or functional disturbance.

• Makes it possible to locate mTrPs and fascia changes which are relevant for myofascial pain and dysfunction.

• Releases (in a targeted manner) the muscular zones that are unable to decontract, thereby deactivating the potential of the mTrPs to cause disturbances.

• Stretches and releases connective tissue adhesions and pathological crosslinks (shortening of the inter- and intramuscular collagen tissue).

• Recognizes sustaining factors and integrates them into the treatment plan.

• Acknowledges the fact that the site of origin of pain often does not coincide with the site of its perception.

1 Introduction

“Here it is a question, not of an opinion to be enforced, but rather of a method to be conveyed that anyone may use as a tool in his own way.”

(Goethe to Hegel, October 7, 1820)

Chronic pain is a challenge — to the patient, to the therapist, and to the healthcare system. This book shows how trigger point therapy can contribute to accepting this challenge and meeting it head on. A trigger point (TrP) is quite literally a point from which certain symptoms, typical for each patient, are “triggered,” usually in the form of referred pain.

In workshops on trigger point therapy, each participant is guided through a palpation sequence to find points of maximum tenderness in tense muscle fiber bundles in the infraspinatus muscle, and to use the thumbs to put pressure on these areas. This causes pain in 70–90% of the participants, not only locally at the pressure-provocation site, but also radiating to other parts of the body — to the shoulder (anterior and posterior aspects and “deep in the joint”), to the upper arm (anterior, and lateral), as well as to the elbow, forearm, and down as far as the hand and fingers (Fig. 1.1). This type of radiating pain is known as referred pain.

These sensitive points in the infraspinatus muscle, located behind the shoulder, are TrPs, which can cause not only pain that is felt anteriorly to the shoulder or “deep within the joint,” but also pain in the elbow and forearm. TrPs not only cause pain, but also trigger dysesthesias (tingling sensations and feelings of tightness or heaviness) and weakness.

Fig. 1.1 Myofascial trigger points (x) and referred pain (red) in the infraspinatus muscle.

Localization of the radiating pain represents neither a radicular segmental innervation pattern (i.e., it does not conform to any dermatome) nor does it correspond to an area innervated by a particular peripheral nerve. Current concepts used to explain non-localized pain are therefore unable to explain the frequently occurring phenomenon of referred pain. This is probably a reason, among others, why myofascial pain induced by TrPs so far often is not recognized.

Note

A medical approach to treat chronic pain of the neuromusculoskeletal system that does not appropriately incorporate the widespread phenomenon of referred pain into its diagnostic and therapeutic strategy is often doomed to failure and serves just to foster chronification of the pain.

The goal of this textbook is to elucidate the significance of myofascial trigger points (mTrPs) in the origin and perpetuation of pain and functional disturbances in the neuromusculoskeletal system and to demonstrate how to achieve targeted and effective manual therapy for TrPs.

The first part of the book presents the basic principles: The clinical presentation (Chapter 2.1), pathophysiology (Chapter 2.2), and etiology (Chapter 2.3) of mTrPs are highlighted, as are the diagnosis of myofascial disturbances (Chapter 4) and the options for treatment (Chapter 5). The book presents two complementary aspects of trigger point therapy: On the one hand, it presents the therapy as a treatment technique — a therapeutic intervention strategy that deactivates the potential of the mTrPs to cause disturbances (Chapter 5.1). On the other hand, it explores a global treatment concept for the diagnosis and treatment of pain and functional disturbances caused by myofascial disorder (Chapter 5.3). Particular attention is given to disturbances caused directly and indirectly by TrPs (Chapter 3), to the effects of manual trigger point therapy (Chapter 5.2) as well as to indications and contraindications for trigger point therapy (Chapter 6).

The second part of the book gives a thorough written and visual representation of manual therapy of the muscles (Chapter 7), and, subsequently, discusses common neuromuscular entrapment syndromes (Chapter 8). To ease the transition into everyday clinical practice, the book provides sections on screening tests (Chapter 9.1) and pain guides (Chapter 9.2) to common clinical presentations (Chapter 9.3).

1.1 Phenomenology

“A rose is a rose is a rose.”

(Gertrude Stein)

When palpating a muscle perpendicular to its fiber orientation, the examiner often encounters contracted muscle bundles. Following the course of one of these taut bands with the examining hand reveals that it is not uniformly tender. There are areas that are clearly more or less tender than others. If one stimulates the area of maximal tenderness by applying pressure, this triggers pain. This pain can be local, but it frequently radiates. Thus there is pain, not only in the area of pressure provocation, but also spreading to other areas of the body at a distance from the original site. This phenomenon of radiating pain is called referred pain (Travell and Simons 1999; Fig. 1.1, Fig. 1.2).

If, by applying pressure to a point, the same pain (local or transmitted) is elicited as the patient experiences during his or her everyday activities, then that point is an active trigger point (TrP). From a phenomenologic standpoint, reproducing the patient’s symptoms by applying pressure to the TrP is the key criterion for a TrP.

Although pain caused by muscles is frequent (Chapter 1.3), their causative relationship is often not recognized. They are often overlooked as the source, because the site where the pain originates and the site where it is actually felt are usually far apart (Fig. 1.3). For example, the source of back pain often lies within the abdominal muscles (1); headaches can arise from the cervical muscles (2); for many patients, the cause of elbow problems can be found in the neck and shoulder muscles (3); leg pain commonly originates in the muscles of the buttocks (4); and Achilles tendon pain usually arises in the calf (5).

Fig. 1.2 Myofascial trigger points (x) and referred pain (red) in the upper trapezius muscle (from Travell and Simons 1999).

Fig. 1.3 The trigger points causing the symptomatic pain are often far away from the site of pain. 1. Source of back pain in the abdominal muscles. 2. Cause of headaches in the neck muscles. 3. Elbow problems from the neck and shoulder muscles. 4. Leg pains from the buttock muscles. 5. Pain in the Achilles tendon originates in the calf.

Note

The phenomenon of radiating pain (referred pain) is very common. Appropriate therapy of the neuromusculoskeletal system can be provided only if one is always aware that in many cases pain does not originate from the site where it is felt.

1.2 Different Types of Trigger Points

There are several different types of trigger points (TrPs).

•Active trigger points demonstrate a characteristic pain pattern, not only upon physiologic stress and movement, but even at rest. Stimulating an active TrP mechanically by means of pressure or stretching reproduces the same pain (local or radiating) that the patient has as his symptomatic pain.

•Latent trigger points are hypersensitive tissue areas not spontaneously painful at rest or during physiologic stress or movement. They are clinically silent. Pain, usually radiating pain, is not present until triggered by palpation (pressure provocation). However, this is not the pain that the patient experiences in his or her everyday activities. Latent TrPs can exhibit all the clinical characteristics of active TrPs, with one exception: It is not possible to reproduce current symptoms from latent TrPs. (Incidentally, everyone has latent TrPs — and, for the most part, does well with them.)

• A tender and hyperirritable spot in the muscle tissue is called a myofascial trigger point (mTrP) (Fig. 1.1). If it is located in tissue other than muscle, it is named accordingly as a tendinous, ligamentous (Fig. 1.4), periosteal or subcutaneous trigger point (Table 1.1). MTrPs are the most common and best studied kind of TrPs.

• TrPs occur as primary TrPs, secondary TrPs, and satellite TrPs, depending on the type and timing of their emergence (see Glossary, p. 670).

To help differentiate between TrPs and tender points and the fibromyalgia syndrome, see Chapter 4.3.5.

Fig. 1.4 Ligamentous trigger point (X) with referred pain (red) in the collateral fibular ligament (from Travell and Simons 1999).

Table 1.1 Different trigger point types depending on the type of tissue (from Travell and Simons 1999)

Tissue

Trigger point type

Muscle

Myofascial trigger point

Tendon

Tendinous trigger point

Ligament

Ligamentous trigger point

Periosteum

Periosteal trigger point

Subcutaneous tissue

Subcutaneous trigger point

1.3 Prevalence

“The trigger point, as we currently define it, is certainly the most common manifestation of pain in the locomotor system, if not in the entire organism.”

(Prof. Karl Lewit in the Introduction to Dejung 2009)

Muscles collectively form the largest organ of the human body. All the skeletal muscle fibers together make up an average of 40–50% of body weight. In trained body builders, this percentage can rise to about 65% (Schünke 2000). Even from a purely quantitative approach, it is therefore obvious that pain can arise directly from skeletal muscle. So it is all the more astounding that in modern medical education and in medical textbooks about pain diagnosis, hardly any attention has been given to the muscles in general and mTrPs in particular (Mense et al. 2003).

The incidence of active mTrPs in medical consultations varies, depending on the patient group selected: Of 61 patients examined in a general medical practice, Skootsky (1989) found that, along with influenza, diarrhea, cough, insomnia, skin tears and cuts, alcohol and medication abuse, appendicitis, and allergic rhinitis, about 30% of the patients suffered from a primary myofascial pain. In one study of patients examined in specialized pain centers, active mTrPs were found in 85% of 283 patients (Fishbain 1986), and in another, 93% of 96 patients (Gerwin 1995). In a study of 296 patients in a dental clinic specializing in head and neck pain, Friction (1990) determined that the pain had a primary muscular cause in 55% of the patients. On the basis of this data, Travell and Simons concluded that: “Active myofascial trigger points are clearly very common and are a major source of musculoskeletal pain and dysfunction” (Travell and Simons 1999). This assessment has been corroborated by multiple studies showing that mTrPs very commonly play a role in patients with many types of problems, including: tension headaches (Alonso-Blanco et al. 2012a, Bendtsen et al. 2011, Buchmann et al. 2007, Couppé et al. 2007, Fernandez-de-las-Penas et al. 2006b, 2006c, 2009a, and 2010, von Stülpnagel et al. 2009); migraine (Buchmann et al. 2008, Calandre et al. 2006, Fernandez-de-las-Penas 2006d, Giamberardino et al. 2007, Tali et al. 2014); neck pain (Fernandez-de-las-Penas et al. 2007, Gerber et al. 2014, Munoz-Munoz et al. 2012, Vazquez-Delgado et al. 2009); problems after whiplash injury (Castaldo et al. 2014, Dommerholt et al. 2015, Ettlin et al. 2008, Freeman et al. 2009); nonspecific back pain (Borg-Stein et al. 2006, Chen and Nizar 2011, Iglesias-Gonzales et al. 2013, Nice et al. 1992, Nioo and van der Does 1994, Simons et al. 1983); nonspecific neck, shoulder, and arm pain (Fernandez-de-las-Penas et al. 2012), shoulder pain (Buchmann et al. 2009, Bron 2011, Bron et al. 2011, Ge et al. 2007, Hains et al. 2010a, Hidalgo-Lozano et al. 2013, Paz et al. 2014, Sergienko and Kalichman 2015, Sola et al. 1955) and shoulder pain associated with subacromial impingement (Alburquerque-Sendín 2013, Hidalgo-Lozano et al. 2010); lateral elbow pain (Fernandez-Carnero et al. 2007, 2008, Fernandez-de-las-Penas 2012, Gonzalez-Iglesias et al. 2011, Shmushkevich and Kalichman 2013); forearm and hand pain (Hwang et al. 2005); posture and stress-related pains associated with computer use (Treaster et al. 2006); knee pain (Henry et al. 2012, Mayoral et al. 2013); temporomandibular joint (Ardic et al. 2006, Fernández-Carnero et al. 2010, Itoh et al. 2012, Vazquez et al. 2010); tinnitus (Rocha and Sanchez 2007); and pains in the bladder and urogenital region (Anderson et al. 2006, 2009, 2011, Doggweiler-Wiygul 2004, FitzGerald et al. 2009, Jarrell 2004, Weiss 2001).

To supplement these data, which (with the exception of Bron 2011, Bron et al. 2011 and Fernandez-de-las-Penas et al. 2006b, 2007, 2012) have been collected primarily in the medical arena, there has been, until now, a lack of studies designed specifically for the physical therapy practice. One can assume, however, that due to the medical distribution of the selection, a higher-than-average proportion of pain is of myofascial origin.

Note

TrPs are widespread and are a very common cause of pain.

1.4 Relevance

Pain in the musculoskeletal system is very common and causes high medical costs.

Dejung (2009) researched the costs resulting from pain disorders: In Germany, the indirect costs generated as a result of disability from back pain in 1997 were estimated to be approx. 13.7 billion US dollars. Among them, the small group of chronically ill patients is responsible for the major portion of both direct and indirect costs (bibliography in Dejung 2009).

Because mTrPs are one of the most common causes of chronic pain in the musculoskeletal system (Fishbain 1986, Rosomoff et al. 1989, Friction 1990, Masi 1993, Gerwin 1995, 2014, Travell and Simons 1999, Dejung 2009), trigger point therapy assumes a high degree of significance, not only from a therapeutic-ethical standpoint, because it helps to alleviate needless chronic pain, but also from a politico-economic standpoint, because it reduces healthcare costs.

Why is it that myofascial pain is frequently not recognized?

One reason is certainly the fact that pain very often radiates from the muscle as referred pain. The site at which pain is felt and the site of origin of the pain are not identical, and this fact makes it difficult to determine the connection between the problem in the muscle (mTrP) and the clinical presentation of the pain.

On the other hand, myofascial pain is a clinical diagnosis — the active mTrPs can be reliably identified only by means of palpation using clearly defined diagnostic criteria. There are no abnormal findings on radiologic or chemical lab tests. Unfortunately, myofascial pain is still misdiagnosed far too often, with the cause of pain being wrongly attributed to an abnormal finding on an imaging study. The result is that patients do not receive proper treatment and may even receive unnecessary surgery, since what is being treated is not the cause of the pain.

For this reason, Dejung (2009) postulates and describes a new paradigm for pain and musculoskeletal medicine: “Many pains in the musculoskeletal-system originate in the muscles. Due to overload or overstretch, contraction zones can develop within the muscle in which the sarcomere is unable to relax, the core of which is ischemic and therefore painful. The affected points in the muscle are palpable as taut bands with tender spots. At these points (trigger points), one can provoke pain, which is often transmitted to other regions of the body (referred pain). By using appropriate treatment, this pathology can be remedied, even if it has been present for a long time” (Dejung 2009).

1.5 Historical Review

Many possible causes of musculoskeletal pain have been considered in the last 100 years. Neuropathies, degenerative and inflammatory joint diseases or articular dysfunction (“blockages”), as well as the current increased interest in neuroplastic changes in the central nervous system (CNS), have been and continue to be the center of interest. Muscles as a possible cause of pain were, as a rule, overlooked, and even today, muscles are often ignored as the primary cause of pain and functional limitations. As an example, studies concerning back pain differentiate between “specific” and “nonspecific” back pain. Specific back pain has a known structure-specific cause (e.g., herniated disc, spinal stenosis, spondylolisthesis, instability, depressed fracture, tumor) and makes up just less than 20% of the cases. For decades, the opinion leaders in back pain research have agreed that, in about 80% of cases, the cause of lower back pain is not known (e.g., Nachemson 1985, 1992, Haldemann 1990, Dejung 2009). That a considerable proportion of these so-called nonspecific back pain cases could represent problems that are caused not by nonspecific, but by specific causes, namely by the muscles, thus making them accessible to therapy (see Chapter 9.3.8), had not been examined to this point. Müller (2001), for instance, listed 46 causes that should be considered in the differential diagnosis of back pain, but mTrPs were not among them.

For centuries, however, points in the muscles that elicit pain have repeatedly been described, presented, and successfully treated in a variety of cultural groups. The practice of massage, for example, was pictured in stone relief carvings in Far Eastern temples that were constructed over 1000 years ago.

In Western culture, the first descriptions of muscular findings date back about 500 years. As early as the 16th century, the French physician de Baillou (1538–1616) describes clinically what we now know as the myofascial syndrome (Ruhmann 1940). In 1816, Balfour, a British doctor, mentions nodular, pressure-sensitive areas of swelling and thickening in muscle tissue, from which pain radiates out into neighboring regions (Stockman 1904). In 1843, Froriep, a German surgeon, describes “muscle callus” as a sensitive hardening in the muscle and reports that alleviation could be attained through manual therapy. In 1898, Strauss, also a German physician, mentions tender nodules and painful, palpable taut bands in connection with the cause of pain.

Subsequently, many terms have been used to refer to myofascial findings. Adler, in 1900, terms the phenomenon “muscle rheumatism,” and even describes provocable pain radiating out from the nidus of pain. Gowers coins the term “fibrositis” in 1904. Telling speaks of “fibromyositis” in 1911, while Llewellyn and Jones in 1915 speak of sensitive nodules with radiating pain as being typical of “myofibrositis.” In 1916, Schmidt names the same phenomenon “myalgia” and mentions contracted muscle fiber bundles as being characteristic. Schade, in 1919, coins the term “myogelosis,” postulating viscosity changes in the muscle. In 1925, F. Lange describes “muscle hardening” that persists in narcosis and even after death. He interpreted his observations as meaning that the palpable phenomena were not caused by nerve innervation. Albee uses the designation “myofasciitis” in 1927; Claton and Livingston use “neurofibrositis” in 1930; in 1941, Good uses “rheumatic myalgia” and Gutstein, in 1954, uses “myodysneuria,” all to describe what we know by the term “myofascial syndrome.” M. Lange, in 1931, wrote a first manual of painful points in the muscle, in which he even describes the local twitch response (LTR), but does not mention referred pain. As early as 1931, he used the knuckles and wood rods to treat the painful phenomena. In 1937, Kraus was the first to document the treatment of the painful foci with ethyl chloride.

Note

Examples of terms used frequently in the older professional literature to characterize myofascial pain and the underlying pathological changes in the muscle tissue:

• Myogelosis

• Muscle hardening

• Muscle callus

• Muscular rheumatism

• Rheumatic myalgia

• Myofasciitis

• Fibrositis

• Myofibrositis

• Neurofibrositis

• Myodysneuria

• Myalgia

• Myopathy

Since then, the terms “myofascial pain,” “myofascial syndrome,” and “myofascial pain syndrome” have gained acceptance, as well as “myofascial trigger point,” as the morphogenic substrate for myofascial pain.

The British physician, Jonas H. Kellgren was the first to investigate the pattern of pain radiation. He infiltrated muscles with hypertonic saline solution and described the areas into which the pain radiated. He demonstrated that the respective transmitted pains for a particular muscle were reproducible on repeated trials. At the same time, he determined that the pain provoked by injection was identical with that experienced during muscle contraction under ischemic conditions (compression). In 1938 he published his research under the title, “Observations on Referred Pain Arising from Muscle.” Despite Kellgren’s belief that the referred pain, as he described it, did not extend beyond the dermatome border — a view no longer shared today — the notion that muscle tissue can cause radiating pain was an important milestone on the path to today’s understanding of mTrPs (Fig. 1.5).

Steindler introduced the term “trigger point” in 1940 in connection with a series of articles he published about myofascial pains originating in the gluteal muscles (Steindler et al. 1938, Steindler 1940).

Janet Travell (1901–1997), personal physician to two US presidents, J.F. Kennedy and L.B. Johnson, is credited as a great pioneer in bringing knowledge of myofascial pain into the awareness of many medical practitioners and therapists, and for making the term “mTrPs” known and generally accepted (Fig. 1.6). In the 1930s, as a cardiologist and medical investigator, Travell became interested in musculoskeletal pain, having read the description of radiating pain in various publications (Travell 1968). In 1942, Travell was the first to use the