Shoulder Pain
Why does the pain in your shoulder persist? More on the effects of trigger points…
If you’ve ever dealt with chronic pain, you know how debilitating and frustrating it can be. This is especially true if your physician can’t find anything wrong or if that last massage did nothing to diminish the pain. Most of us have experienced the short-term effects of muscular pain — whether it’s from waking up with a stiff neck, to next day soreness from overdoing it at the gym. These aches and pains tend to work themselves out and usually dissipate within a few days. But what happens when the pain does not go away? The underlying source could be trigger points.
The science behind trigger points and related myofascial pain has been around for many years, yet it remains widely unknown to many healthcare practitioners. The pioneering work of Dr. Janet G. Travell in the 1950’s led to numerous scientific studies, which prove the existence of trigger points by way of electromyographical instruments and the use of an electron microscope. Her research and efficacy in the field eventually led to her appointment as President John F. Kennedy’s personal physician to the White House. Together with long time colleague, David G. Simons M.D., Travell published over 100 scientific articles and books, most notably the two-volume “Myofascial Pain and Dysfunction: The Trigger Point Manual.”
According to Travell and Simons, a trigger point is “a highly irritable localized spot of exquisite tenderness in a nodule in a palpable taut band of muscle tissue.” Let’s break that down. Firstly, trigger points are painful! There’s no doubt about it. They especially hurt when you press on them directly. Secondly, these tiny contractions form a nodule in the muscle fiber which emit a measurable electrical charge and can be felt as knots or lumps. And finally, these nodules can shorten your muscle, limit your range of motion, and often feel like a cord or tendon under the skin. Okay, so we’ve defined what a trigger point is, but what exactly does a trigger point do? And why should we care? The most important thing to remember when talking about trigger points is that they refer pain to other parts of the body. Herein lies the key to understanding and treating that mysterious shoulder pain that just won’t go away. Let’s take a look at the diagram below.
The first image depicts trigger points in the three scalene muscles of the anterior neck. The 2nd and 3rd images show its referral patterns — front and back. As you can see, they cast a wide distribution of pain. And believe it or not, these tiny little muscles that rarely hurt themselves are usually at the top of the list for that nagging pain along the upper border of the scapula and down the front of the shoulder. One would think that massaging the area that hurts makes the most sense logically. Yes, but that is only half of the solution. While trigger points in some muscles refer their pain locally, a vast majority of them send their pain elsewhere. The area along the upper border of the scapula for example, is a common site for referral pain. When you consider that only half of the eight muscles that refer pain to this region lie in the immediate area, you can see why relief can elude some people.
Trigger points need direct manipulation in order to be deactivated and released. If trigger points are missed or not treated directly, they can become latent. This means that if you strain a muscle by over-stretching or over-using it, the trigger point will remain even though the pain may diminish. The next time the muscle experiences trauma or stress, the trigger point will re-emerge. Stretching alone will not de-activate them. In some cases, stretching can make them worse! Stretching muscles with active trigger points is only indicated after they’ve been worked on manually.
So how do trigger points develop? There can be numerous reasons, ranging from repetitive strain to postural imbalances. The scalene muscles for example, help to flex and turn the neck, as well as raise the first and second ribs during inhalation. If you’re prone to wearing a heavy backpack, lifting heavy objects, sitting at the computer with your arms out in front of you, have a forward head posture, or one of the many who breathe shallowly with your upper chest, then you may have trigger points in these muscles. Trigger points in the scalenes have also been known to cause pain, numbness and tingling down the arm and into the hand. Common misdiagnoses include thoracic outlet syndrome, neuro-vascular entrapment, and carpal tunnel syndrome. Yet one of the main reasons for these symptoms lies in the fact that shortened scalene muscles resulting from trigger points, will keep the first and second ribs elevated, which in turn puts pressure on the nerves and blood vessels that pass beneath them.
Trigger points have also been known to setup other trigger points, known as satellite trigger points, in their referral sites. This cascading effect is one of the many reasons why a comprehensive treatment plan which includes all the muscles that refer pain to a particular area must be treated in order to be effective. Good results can often be seen after one session, but a series of treatments is often indicated, especially for those who’ve been dealing with long term pain.