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Whether you call them trigger points (TrPs) or simply sore spots in the soft tissue, localised areas of myofascial tissue which feel stiff or painful to touch and may provoke a pattern of referred pain are an extremely common clinical finding, particularly around the neck and shoulder.
This is because myofascial trigger points may be formed in many different ways. For example, if your patient has sustained a direct or indirect muscular injury, suffers from a peripheral joint or spinal pathology, carries out repetitive movements on a daily basis, isn’t sleeping well, has undergone a surgical procedure, has recently increased or changed their training load, feels emotionally stressed, has muscle spasm or sits for prolonged periods (I could go on but it’s basically everyone) then you are likely to locate a point or two during your examination.
The pain from a trigger point (or group of points) may be constant or intermittent but is usually aggravated by using the affected muscle and most patients will have quickly learned to move differently to avoid the pain, causing a loss of muscular extensibility and potentially restricted joint range of motion, depending on the duration.
When you find a TrP then it’s likely to be locally tender when gently pressed but also produce a characteristic pattern of referred pain particular to that muscle. Some practitioners report the presence of a twitch response - a visible or palpable local muscle contraction - when the sore spot is pressed. There may also be autonomic features like localised vasoconstriction (blanching or skin feeling cooler), vasodilation (redness or a skin temperature increase), piloerection (hair standing up) or hypersecretion (sweating) too.
The exact physiological mechanism behind why these hyperirritable spots develop within skeletal muscle is still pretty controversial but altered activity of the motor end plate (neuromuscular junction) causing neurogenic inflammation is a commonly held theory.
Giving your patient comprehensive advice about any of the factors which you think may be perpetuating strain in the affected muscle or muscle group is vital and if you suspect a vitamin deficiency or chronic sleep disturbance then a letter to their GP to request a blood panel might also be an important part of your management strategy.
Non-pharmacological treatments such as acupuncture, acupressure, myofascial release, massage, joint mobilisations or dry needling – among other manual techniques - may be used to relieve pain, giving you the opportunity to provide some remedial exercises which might otherwise be too sore for the patient to carry out.
However, at an initial appointment, the holy grail of physiotherapy for me is finding a pain relieving technique - which may or may not be a manual technique - which the patient can replicate at home to help them manage their symptoms. This is where I find trigger point balls incredibly helpful and one of the reasons why we we stock and sell lots of them here at my clinic.
Trigger point balls and foam rollers are both types of myofascial release tool and both work in a similar way. The pressure from a trigger point ball or a foam roller increases local blood flow in the area you are treating and this helps your patient in several ways:
You can move the ball around to massage the affected area area but I find that this approach is often quite sore, so to begin with I recommend sustained pressure onto the trigger point, building up the pressure as tolerated until it ‘releases’ (feels less sensitive and tight).
Pinning the muscle belly using the ball and moving one of the muscle’s attachments away from the pinned point also works well, particularly when you’re trying to improve tissue extensibility.
I generally use a combination of both techniques and here are two of my favorite trigger point ball exercises for the shoulder and upper back:
Place the ball between your back and the wall. Start by placing the ball between your shoulder blade and spine and lean gently into the ball. Press and hold until the sore point starts to feel less sensitive, then (keeping the ball in the same spot) raise your hand to 90 degrees in front of you and move it slowly across your body and out to the side again. Repeat this ten times.
Turn to face a wall and place the ball between yourself and the wall, just below the middle of your collarbone with your palm on the wall. Lean gently into the ball. Press and hold until the sore point starts to feel less sensitive, then (keeping the ball in the same spot) lift your palm off the wall behind you and back again. Repeat this ten times. You can do this exercise with the arm in different degrees of abduction to target different parts of the muscle.
This was a guest post by Rowan Wilson, a Chartered Physiotherapist at Physiofit Cambridge and Physiofit Newmarket and a big fan of Eureka Physiocare Trigger point balls.
