What is a trigger point?
An active trigger point is a hyperirritable spot in skeletal muscle that is associated with a tender knot in the muscle tissue. These muscles often appear tight, weak, do not respond to stretching and cause restricted joint range of motion. When pressed, trigger points are exquisitely tender and can cause pain, tingling, burning and weakness. They can give rise to distinctive referred pain patterns and or a local muscle twitch response. (Travell & Simons, 1983).
Trigger points can be found in muscle, fascia, ligaments, tendons and the periosteum (surface of the bone).
Dry needling is a very effective method of relieving trigger points. Dry needling is a procedure in which an acupuncture needle is inserted into the skin and muscle directly at a myofascial trigger point.
When a needle is successfully inserted into a trigger point it causes a local twitch response. Studies have shown that the twitch response allows a normalising response in the electrical and chemical environment within the muscle and it returns to normal, letting the muscle “Go”. This promotes blood flow and allows proper cellular function to return. Chemicals which help repair and rebuild damaged tissue in the area are also released.
What Factors contribute to Trigger Points?
Many factors can contribute to the formation of trigger points. These include: emotional stress and tension, postural strain, trauma, fatigue, sleep deprivation, prolonged immobility, infections and mineral deficiencies (muscular health). Once a trigger point has developed it can become self perpetuating and persist until it is fully released.
Biomechanical anomalies may lead to an increase in stresses on the body and contribute to the formation and perpetuation of Trigger Points (Fomby, 1997). These abnormalities may include:
- A single initiating event or repetitive microtrauma.
- As a result of lateral ankle sprains and acute knee injuries, or following overuse trauma.
- Compensations for a limb length discrepancy
- Abnormal subtalar joint pronation (tibialis anterior and tibialis posterior) or a hallux limitus (peroneus longus and/or the intrinsic muscles.
- An ankle equinus (the superficial, deep and anterior compartment muscles).
- Plantar fasciitis, heel pain, Achilles tendonitis and Bursitis, acute and chronic ankle pain.
- First metatarsal pain, metatarsalgia, Mortons neuroma,
- Shin splints, Tibialis muscle syndromes, Restless leg syndrome, intermittent claudication, and cramps.
- Aching feet and legs with no other symptoms and post fracture pain.
- Osteo and Rheumatoid Arthritis
- Poor work ergonomics can contribute to muscle and joint stress/ overuse.
- Sports injury. Trigger Point Dry Needling, backed by numerous studies, is an extremely effective tool in the treatment of both acute and chronic sports injuries.
Three Categories of Trigger Points.
An active Trigger Point causes ongoing and persistent muscular pain. It may be a mild ache or excruciating. Active trigger points feel tender to the touch. When pressure is applied to the area, pain can be referred to another part of the body. Active trigger points will lead to weakness of the muscle(s) in which they are located, and may prevent them from fully stretching. An active trigger point may produce a muscle twitch in response to stimulation.
A latent Trigger Point is only painful when compressed. They do not refer pain to other parts of the body. The presence of latent trigger points is thought to be one of the causes of joint stiffness and reduced range of motion present as we age.
Satellite Trigger Points (Secondary Trigger Points) can develop at the point of referred pain of an active Trigger Point. This appears to be due to the increased stress occurring in the involved muscle group and needs to be treated in conjunction with the originating active trigger point. For example, an active trigger point in the calf muscles can create leg pain and eventually a satellite trigger point in the referred pain area of the heel may develop. Treating the heel area will not have a lasting effect unless you treat the originating trigger in the leg.
Symptoms you might notice in an area affected by Trigger Points.
- This site is tender due to hypersensitive nerve endings.
- Studies have found that painful tight areas in muscles mostly contain trigger points, usually accompanied by muscle shortening. If the trigger point is not released the muscle tightness can restrict joint movement and can contribute to recurring neck, hip and low back pain. An example is Achilles tendonitis and Plantar fasciitis, where a combination of trigger points and shortened muscles will cause pain as the associated tendons are put under strain and pull on the bone.
- Muscle weakness. This can cause a muscle imbalance and related biomechanical problems.
- A significant characteristic of a trigger point is that it refers pain. Pain may often be felt at a distance from the site of the trigger point. For example the diagram 1.1 shows pain felt in the shaded area above heel in the Achilles tendon. A corresponding trigger point can be found much higher up in the calf muscles.
** Don’t assume that the cause of the problem is always at the site of pain!
Will Trigger Point therapy be the only treatment I need?
As with most treatments for any condition, they rarely stand alone. Depending on the causes of your problem, Trigger Point Therapy may be combined with Orthotic therapy, a stretching programme or ergonomic adjustments in your work and home environment.
Trigger Point Examples
With trigger points present in the Tibialis Posterior muscle, patients will complain of pain on the bottom of the foot and in the Achilles tendon, particularly when walking. The running or walking on uneven surfaces will aggravate the symptoms.
**The red shaded areas are where the pain is felt and referred to from the marked trigger points X.
Pain pattern referred from a TrP at its usual location in tibialis posterior (Travell & Simons, 1992).
Satellite trigger points often develop in:
1. Flexor Digitorum Longus and Flexor Hallucis Longus
(Travell & Simons, 1992)
2. Peroneus Longus, Brevis and Tertius.
Pain pattern referred from Trigger Points at commonly observed locations in the Peroneal muscles (Travell & Simons, 1992).
Low Level Laser Therapy
What Is Low Level Laser Light?
Low-level laser light is compressed light of a wavelength from the cold, red part of the spectrum of electromagnetic radiation. It is one color; it travels in a straight line, a single wavelength and it concentrates its beam in a defined spot. These characteristics allow laser light to penetrate the surface of the skin with no heating effect, no damage to the skin and no known side effects. Low level laser light “directs biostimulative light energy to the body’s cells which the cells then convert into chemical energy to promote natural healing and pain relief.”(It’s Only Natural. Dr.G.E. Poesnecker)
Low-Level Laser Therapy uses low level laser light near or over injuries and wounds to improve soft tissue healing and relieve both acute and chronic pain. (This should not be confused with High power Lasers which are used to cut through tissue.)
What Effects Do Laser Light Therapy Have?
Physiologically Laser Light Therapy can improve blood circulation and vasodilation, stimulate cells to repair tissues, reduce inflammation and inhibit pain fibres to reduce pain. Therefore Low level laser Therapy can be beneficial in achieving:
- Acute and chronic pain relief
- An increase in the speed, quality and strength of tissue repair
- Improved blood supply
- Immune system stimulation
- Nerve function stimulation
- Collagen and muscle tissue growth
- Assistance in the building of new and healthy cells and tissue
- Improved wound healing and clot formation
- Reduced inflammation
- Resolution of Trigger Points
Low-level laser therapy does not require constant, ongoing treatments, as is often required with traditional therapies. The Lancet report says “(Relief using) Laser for neck pain lasted for up to 22 weeks. Trials of LLLT for knee osteoarthritis tendonopathies and low back pain reported similar results”. “This contrasts with drug therapies where the effect ends rapidly when treatment is discontinued.” The Lancet Vol. 374 No. 9705 pp 1897-190 (Dr Roberta T Chow MBBS, Prof Mark I Johnson PhD, Prof Rodrigo AB Lopes-Martins PhD, Dec 05, 2009, Prof Jan M Bjordal PT)
Indications for Low Level laser Light Therapy under the care of your Podiatrist may include:
- Pain Relief
- Wound Healing
- Tarsal Tunnel Syndrome (TTS), Morton’s Neuronal
- Achilles Tendonitis, Plantar fasciitis, Heel pain
- Sprains and strains
- Post-operative pain
- Soft tissue injuries
- Post-operative wounds
- Pressure sores
How Long / How Soon/ How Many?
Following an initial assessment actual therapy time will take approximately 15-20 minutes. If combined with needle therapy, this will be longer.
Symptoms may improve after the first treatment with pain reduction and increased range of movement. Sometimes the increased range of movement and flexibility can temporarily create more pain as previously lost, joint and muscle flexibility is restored.
From 3-12 sessions may be required. Ideally at least twice in the first week and then once a week for a further two weeks. This will be influenced by other Podiatric therapies being used in conjunction with the Laser Therapy.
How long do benefits last?
In most cases, once an acute episode is over, patients are unlikely to need further treatment. For a few people, the benefit may only be temporary – they may need periodic treatment.
Where possible the Laser Therapy will be used in conjunction with modalities such as Acupuncture, Trigger point Therapy, Orthotic Therapy and stretching / strengthening for treatment and prevention.