April 7, 2011

Trigger Point

Last week, after doing some strenuous work on my son's shoulders, I felt a sharp pain. The pain every massage therapist dreads: a deep twinge in the saddle joint of the thumb. The joint that, by some accounts, makes us distinctively human, that makes our thumbs truly opposable; the joint that's the first to go if you wear out your hands doing massage.

With visions of arthritis and bony deformation dancing in my head, and gloomily recalling how long injured tendons and ligaments take to heal, I put it through the standard active range of motion tests. Adduction and abduction, extension and flexion, fine. I could spread my thumb and fingers, and clench my fist, with no pain. How about opposition?

Ow. Put my thumb in just the right position, and push its tip against the base of the ring-finger, and the pain was exquisite. Okay. How about passive range of motion? Now that was interesting. That, in fact, was fantastic. I was flooded with relief. If I relaxed my thumb and put it through the same motion with my other hand, there was no pain at all. Not a joint problem. Contractile tissue. There was a good chance that it was purely muscular.

The opponens pollicis is a little muscle. We didn't have to study it in school, but I learned it anyway, and now I could see it in my mind's eye, a short, triangular muscle, running from the transcarpal ligament of the wrist up to the base of the thumb. Not where the pain was -- further wristwards than that.

I probed it, working methodically along its two inch length. Sure enough. The band of of taut muscle, distinctly palpable. And in the middle of it --

Ow, again. Yes. The trigger point. Hurt like blazes. And it made the saddle joint hurt too, to press on it.

But press on it I did, deliberately, seven or eight squeezing rolls. And again, at intervals, half a dozen times during the day. Next morning it was fading. I kept working it that day. And now it's gone, completely gone, and so is the saddle-joint pain, like magic.

Trigger points often -- usually -- "refer" their pain elsewhere, generally to a joint moved by the muscle, but sometimes further afield: points in the hands and forearms can result, famously, in headaches. A good proportion of the pain that's diagnosed as various joint problems, arthritis and carpal tunnel syndrome and so forth, are nothing of the sort. Sure, if you x-ray the painful joint, you'll see bony deformations. But most joints, including painless ones that work fine, show bony deformations over time.

Arthritis and carpal tunnel syndrome are real -- don't get me wrong. But you shouldn't accept them as an explanation of joint pain unless ordinary, very treatable trigger points have been ruled out.

I don't really like doing trigger-point massage, as a modality -- as a massage specialty. It's a great party-trick to push on a trigger point till it resolves, and pain elsewhere magically goes away, but more often than not trigger points won't resolve that way. Entrenched ones almost never do. They need to be worked over and and over. And you need to discover how you're abusing the muscle, and stop it, or they'll come right back. As I watched carefully what I was doing with my thumb, I realized that massage had little or nothing to do with my pain: it was the way I kept my mouse-tap thumb tensed as I typed on my laptop keyboard. That's much more the sort of muscle use that results in trigger-points -- long-term motionless or fine-work tension. Human muscles aren't designed for that. They're designed to contract and release, to shorten and lengthen, not to sit still at low tension for hours at a time. That's what people do with their neck muscles as they sit at a desk all day, and that's why practically every desk-worker who comes under my hands has a rich array of trigger-points in the neck and upper back.

We need to learn to stop periodically and stretch and move around. We also need to learn to locate and work our own trigger points. It's much easier to find and work your own than to find and work someone else's. Some people are gifted at finding other people's trigger points; I'm not, particularly. But anyone can find their own.

Travell and Simons, in their two-volume bible of research on myofascial pain, estimate that seventy-five percent of pain presented to physicians is due to trigger-points. Very little of it is diagnosed and treated as such.

There are plenty of other causes of pain. Trigger point therapy is not a cure-all. But it should be in the standard owner's manual for anyone who has a body. You might need to consult with someone who has a good working knowledge of muscular anatomy to locate them at first. Some bodyworkers have this knowledge and some don't; most physical therapists do, though many of them know nothing of trigger points. Few physicians have that sort of practical working knowledge of which muscles govern which movements, so most of them will have no idea where to look when confronted with myofascial pain.

Clair Davies' Trigger Point Workbook is an excellent handbook to start with. It's a book I think everyone should have. But no book is of any use unless you take the time to explore your own body, experiment with it, and work with it.

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