Problems and limitations of trigger point therapy, and how to take advantage of them

A few days ago, I reported on the evidence that trigger point (muscle knot) diagnosis is unreliable, and that it’s difficult to treat what you can’t find. That led me to some surprisingly fresh ideas about why SaveYourself.ca exists. I’ve been writing a few thousand words per week on this subject matter for a decade, and yet I had never quite put it like this before …

Trigger point therapy can be pretty hit or miss. If you do it yourself, you may be less effective than a professional, but at least you won’t go broke trying. It’s best not to pay upwards of a buck a minute for trial and error when you can experiment on yourself at no charge, and safely.

This is the raison d’etre of this website, actually: in situations where the professionals are nearly as unreliable as you are, save yourself instead of paying for professional shots in the dark. Obviously there are limitations to self-treatment — some spots you just can’t reach! — just as there are limitations to professional therapy. The only really dramatic difference between professional care and self-treatment is the cost.

The beauty of trigger points is that you can use the worst things about them to your own advantage. They may be tricky and stubborn and weird, but you have time to mess around. You can wait. You can experiment. You can fiddle. For free. For years, if necessary — as long as there’s evidence that you’re gaining ground.

This is raison d’etre of this website, actually: in situations where the professionals are nearly as unreliable as you are, save yourself instead of paying for professional shots in the dark.

At the risk of stating the blindingly obvious, this doesn’t apply in lot of other medical situations. You really cannot and should not experiment on your own with self-treatment of cancer — tragically, these days some people have precisely that idea, and it’s extremely unwise. But with trigger points, you can. Trigger points at their worst are really awful, but they haven’t killed anyone yet. You really can afford to experiment, take your time, screw up, try again, and so on, for as long as necessary.

There are three basic problems with trigger point therapy, for both the pros and their patients:

1. Locating trigger points can be tricky, and it’s hard to treat what you can’t find.
2. Even when you’ve found trigger points, they don’t necessarily go away just because you squish ‘em, stretch ‘em, heat ‘em, or any of the other common treatment themes.
3. And even if they do go away, they usually don’t stay away: trigger points have a nasty habit of coming back.

Fumbling around with diagnosis

Trigger points are really not at all easy to confidently locate, and research has clearly shown that even the professionals cannot really be counted on to find them for you. Thus, hunting for trigger points invariably involves a certain amount of expensive fumbling around. As a Registered Massage Therapist, I am painfully aware that $1.67 is flying out of my patient’s pocket every single minute as I hunt around for their trigger points — I had better be damned good to justify that, and the sad truth is that sometimes I’m not.

Case in point: sometime recently I spent a good ten minutes looking for and missing a trigger point in the tensor fascia latae muscle on the side of the hip. My client was chatting away happily, and I wasn’t getting all the verbal cues I needed from him. I spent much of that ten minutes assuming that I was basically already there, until I finally got a word in edgewise and asked him what he was feeling. To my mild horror, it turned out that I’d been barking up the wrong tree. That ten minutes cost him $16, and it was basically completely useless except as “overhead” — more than the usual amount of paid fumbling that is unavoidable in this kind of therapy. My goal as a therapist is to reduce that overhead as much as humanly possible, but there are inevitably some incidents like this, time that is wasted in every other sense.

The right professional may be able to “fumble better,” and give patients a lot of good treatment ideas. But, as your own patient, you definitely have an advantage: you literally have all day to find the right spot.

Fumbling around with treatment

And then there’s the mystery factor, the overall scientific cluelessness about why trigger points form in the first place — not what they are, but why they happen — the impossibility of being confident about exactly what flavour of treatment is going to make them go away. Professionals are definitely not privy to some magic trigger-point-begone formula, and while extensive hands-on experience undoubtedly leads to somewhat higher quality experimentation, it’s experimentation nevertheless, and — once again — our experimenting is expensive.

Professionals are definitely not privy to some magic trigger-point-begone formula.

Case in point: after no less than several years of working with a patient regularly, one day we stumbled upon a different approach to her chronic pain that was distinctly more effective. She called me the next day and said, “Wow, that worked better than usual.” That was a couple of years ago, and we have been using the new approach ever since, consistently obtaining much better results than anything we saw for the first few years. The innovation also led to direct and clear improvements in her self-treatment methods, to the point where — hallelujah — she has stopped coming to see me regularly, and turns up only once in a while for a little “extra help.” But it took me years of regular therapy to stumble on what is, in retrospect, a minor adjustment in my technique that I could have tested at any point. I estimate that this client paid me something like $8,000 for fumbling around with an approach that was wrong for her.

But patients can and should experiment with different approaches willy nilly. As a patient doing self-treatment, you might or might not get results, but at least the insult of a geat expense is not added to your injury.

Fumbling around with perpetuating factors

The third basic problem with trigger point therapy is that trigger points, like Dr. Seuss’s cat, come back. The forces that tended to lead to them in the first place routinely result in their resurgence. Even “successful” trigger point therapy is notoriously prone to being temporary. But, once again, we can snatch victory from the jaws of defeat thanks to the logic of self-treatment: if your benefits are going to be brief, better that they also be cheap!

It’s also largely up to patients to make changes in their lives that make them less prone to persistent trigger points. A good therapist may have excellent suggestions for things to try, but an educated patient is nearly as capable. How hard is it, really, to guess that your crappy, uncomfortable office chair may be the reason your trigger points just keep coming back? If stress seems to be a factor in the stubbornness of your muscle pain, that’s not particularly difficult to figure out — certainly not after doing a bunch of reading on this website — and it’s also a deeply personal problem to solve, and the solution likely doesn’t have much to do with physical therapy or massage therapy.

Case in point: many times I have provided guidance to patients as they try to undertand and solve the problems in their life that may be contributing to chronic pain, whether it’s serious insomnia or a nasty computer workstation. Doubtless most of them would graciously give me partial credit for their successes — at least to my face. But I am aware of many cases where my input was barely more significant than encouragement and reinforcing the obvious, and one young man in particular who really did not need me, but thought that he did. He had a particularly uncomfortable work situation — so much so that it was really quite obvious that he needed to fix that more than any other single thing. From the start, I tried to tackle it on his own, but he insisted on paying me to walk him through it and make trivial suggestions based on my expertise with desks. His enthusiasm and determination was infectious, and for a few sessions I took his money and we had animated, detailed conversations about his ergonomical dilemmas, and I’m sure it was worthless. But soon enough it started to feel like exploitation. Was I helping him? Sure, a little. Was it worth my fee for a young man earning barely more than minimum wage? Not even close. I “fired” him soon after.

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The clinical experiences I’ve described here all deepened my conviction that “home care exercises” are not just something to prescribe at the end of the appointment, but practically the whole game, and the point of this website.