published 8/07/07, updated 9/23/08

“But I’ve Already Tried Massage Therapy …”

The delicate issue of trying to find skilful treatment for myofascial trigger points (muscle knots)

by Paul Ingraham, Vancouver, Canada MORE
close
Credentials and qualifications

I am a writer and retired Registered Massage Therapist (unusually well-trained for a massage therapist, a 3000-hour program). I’m almost done with a Bachelor of Health Sciences degree. I am a peer reviewer for The Natural Standard, and a copyeditor for Science-Based Medicine. My most important qualification is more than a decade of workaholic post-graduate study, clinical experience, and constant conversations with readers from around the world, including many experts who have provided countless suggestions and criticisms.

For more information, see: Who Am I to Say? More information about my qualifications, credentials and professional experiences for my readers and customers.

EXCERPT Having trouble finding good help for your trigger points? This article is a condensed excerpt from SaveYourself.ca’s extremely detailed tutorial about myofascial trigger points (muscle knots). It will go a long way to helping you understand why it’s difficult to find effective trigger point therapy.

A young woman with a long history of completely unreasonable chronic headaches sought treatment from three of my colleagues — three well-trained Registered Massage Therapists.

“Registered Massage Therapist” (RMT) is a Canadian professional certification (in the province of British Columbia specifically) — literally the most demanding training program for massage therapy in the world, in fact.1 These people were my colleagues: what would usually be called “medical” massage therapists most other places, and, in theory, the créme de la créme of massage therapy. Any BC-RMT could walk into virtually any jurisdiction in America and be — by far — the best-trained massage therapist available to that population.

My client had seen three of these über therapists before coming to visit me … but had not experienced any relief from her pain whatsoever. She enjoyed the massages she received as pleasant, relaxing experiences, but unfortunately did not find them therapeutically useful.

I soon found out why.

An inexplicable oversight of one of the most common trigger points in the body

Not long after I started her first treatment, I palpated for trigger points in her suboccipital muscle group (the most common cause of fibrositic headaches). This is an assessement procedure I consider to be as automatic as breathing for a client with her symptoms — I can’t imagine not doing it. And I immediately located a highly relevant muscular trigger point (a muscle knot), which is more or less exactly what you’d expect to find in this situation.

What happened next is what makes the story worth telling.

My client said in amazement, “That’s it! That’s where my headache is coming from! You’ve got it! And no one has ever pressed on that spot before.” (Emphasis definitely hers.)

Really? Could this possibly be? I asked her to confirm this in detail, because I found it so strange, and her story did not change.

Treating suboccipital trigger points is one the most elementary things I can imagine a massage therapist doing for a client with chronic tension headaches. It is a classic spot for massage therapy for headaches!2 And yet three other RMTs had not only missed it, but apparently had not even looked for it — an inexplicable oversight.

“No one has ever pressed on that spot before.”

Failing to check for the relevance of suboccipital trigger points goes beyond an “inexplicable oversight.” It seems almost impossible to believe that well-trained massage therapists could make this mistake. But, unfortunately, such failures may be typical of the state of trigger point therapy in the world today.

The trouble with trigger points

On the one hand, muscle knots (trigger points) are the world’s most clinically underestimated factor in chronic pain problems of all kinds. Their clinical significance is extraordinary, and rests on a bedrock of good hard science.3 It’s amazing how often just a little trigger point therapy is all that people need to resolve an otherwise stubborn pain problem.

On the other hand, trigger points are still seriously medically obscure — they are almost entirely unknown to every category of health care professional. And the one kind of therapist that seems most likely be able to help — massage therapists, professionals who work directly with muscle tissue every day — are often unprepared for challenging cases, or even basic ones like the headache story I’ve just told. Clair Davies’ popular and excellent book, The Trigger Point Therapy Workbook, was in large part devoted to trying to educate doctors and massage therapists as well as patients.

Not all trigger point therapy is created equal

A little massage of my headache patient’s trigger points relieved her symptoms for … about one year and counting now.

Both my own patients, and readers and consultation clients from around the world, routinely tell me that they have “already tried massage therapy.” And, indeed, they have already tried massage therapy — but it’s pretty clear that they haven’t received good trigger point therapy. Instead, they have usually received the kind of treatment seen in the above example: pleasant enough, but unfocussed and ineffective.

In another common and disappointing scenario, massage therapy is focussed … but focussed on the wrong tissue. This was a more determined and experienced patient who really was completely justified in saying that she had “already tried massage therapy,” yet she too had not actually received appropriate therapy …

This middle-aged woman had severe, chronic shoulder pain on the “end” of her shoulder — where an officer’s epaulets would be — and radiating downwards on the side of her arm and through her biceps almost to the elbow. It was a nagging, sickening pain, like a toothache in her deltoid muscle.

She had been diagnosed with a whole bunch of common shoulder conditions, basically all of them — a typical scenario when someone has a vicious trigger point. Such people tend to get diagnosed with every possible thing except what they actually have.

It was a nagging, sickening pain, like a toothache in her deltoid muscle.

What made her case a bit unusual was that she really had given physical therapy and massage therapy a good chance to work. She had seen a massage therapist and a physiotherapist concurrently and frequently for 12 weeks. But she had gotten exactly no relief. My first impression was, “Uh oh. If two therapists working with a cooperative, diligent client continuously for 12 weeks couldn’t help this woman … what chance did I stand of making a difference?

I cautiously quizzed her about exactly what kind of therapy she had received. “Oh, trigger point therapy,” she said. “She did detailed trigger point therapy on my shoulder muscles.” That sounded good. She almost certainly had shoulder trigger points! Why hadn’t she gotten relief?

“Did your massage therapist ever work here, on the back of your shoulder blade, several inches away from the location of your symptoms?”

“Oh, no,” she replied. “No, she only worked here,” she said, pointing clearly at her deltoid and biceps — the exact location of the symptoms.

Uh oh. There’s the problem, I thought.

“Twelve weeks of that?” I asked. “Only there?”

She nodded. “Why? Is that bad?”

It’s a critical oversight, that’s for sure. The most interesting characteristic of trigger point pain — the thing that makes them so important — is a phenomenon called “referred pain.” The body, somewhat inept at precisely locating internal pain, experiences muscle pain in a broad area around or near a trigger point … exactly like heart attacks are felt in the arm as well as the chest. The pattern for each muscle is distinctive, almost a fingerprint. The infraspinatus muscle “refers” pain into precisely the location of her symptoms. The pain is often not felt at the actual location of the trigger point. Every massage therapist should know this. A massage therapist who doesn’t is flying blind, doing massage that is about as therapeutic as a manicure.

This is what patients face, trying to get help for countless frustrating pain problems — pain problems that don’t make it onto the medical radar, but are quite capable of significantly reducing quality of life drastically.

That woman’s shoulder problem, after almost a year of misery and misdiagnosis, was 100% relieved by a single appointment of infraspinatus treatment. Just one properly directed massage. She sure was happy! It doesn’t always go quite that neatly, of course — often I have to spend a fair bit of time finding trigger points that are relevant to the problem, and it’s a little more understandable that another therapist could have missed them. But the point is that a therapist should be trying to do that. Without that process of exploration, it isn’t good trigger point therapy.

Even worse …

Since 2001, I have been systematically asking patients why they left previous massage therapists, and I have heard it all. Excessive pressure is the most common problem, and massage that is only “skin deep” and unsatisfing is a close second. But I have also heard quite the litany of other basic problems with customer service. Here are three compelling examples of stories my clients have told me.

The most common reason patients leave massage therapists is “too much pressure.” The second most common? “Not enough pressure.”

“He spent the entire time talking, mostly telling stories with lots of hand gestures. I’ll bet, in the entire hour, he spent less than 50% of the time with his hands actually on my body. Furthermore, he was a middle-aged man, and his topic-of-the-day was how he was feeling frustrated because he was still attracted to young women. Good grief!”
“I had been three times already, and every time she ignored what I asked her to work on. The fourth time I went, I told her that I was feeling frustrated by this, and that I really did not want to work on my lower back, but wanted to work on my shoulders instead. I was that clear. Shoulders. Not back. No lower back, please. Then she started the massage with 15 minutes of work on my lower back. I was so flabbergasted I didn’t even say anything. What do you say to someone like that?”
“The pain was ridiculous. I told her I was sensitive. I told her I didn’t want a no-pain-no-gain treatment. I stopped her at least a half dozen times and asked her to back off, and she would at first, and then it would creep right back up to agonizing again. I was a wreck for days!”

This is a random sampling from about one third of such recent conversations that I’ve had in the last month or so. And these are Registered Massage Therapists in Vancouver, Canada, with our vaunted standards. What’s a patient to do in a sleepy midwestern town in the US? In a jurisdiction where “medical” massage is an unheard of specialization, and the only massage to be had comes from an old hippy bodyworker who has scientology posters, a crystal collection on the credenza, and wants to know what colour the pressure makes you think of?

Oh, dear.

One day I got a somewhat cranky email from a representative of an association of trigger point therapists, criticizing me for giving the impression to the public that patients can’t find good help for their trigger points. And yet her own organization’s so-called “directory” of therapists offers barely more than a few dozen therapists listed for the entire United States … and 90% of them were in the big cities. As much as I agree that there are many dedicated and talented trigger point therapists out there trying to help, there simply aren’t enough of them.

The reality is that it is difficult for patients to find good trigger point therapy, and I receive an enormous amount of email from people frustrated by exactly this problem.

Why is massage therapy imperfect?

I’ve chosen to share stories of poor quality massage therapy because I genuinely believe that it’s vital knowledge for patients. Trigger points matter. Massage therapists are the single most likely source of aid … yet the quality of the services are highly variable! Patients need to understand the problem.

Training and certification standards vary dramatically around the world, and are literally zilch in many states and provinces in North America.
The profession attracts people with beliefs that are not consistent with medical science. Some such beliefs are quite outlandish.4
Industry turnover is high. Many therapists burn out early with arm and hand injuries, long before they have the chance to get more seasoned, confident, and skilful.
Both public and private insurance for massage is sketchy, which is a catch-22: the profession has difficulty standardizing and upgrading without insurance industry support, but insurers won’t offer funds for massage therapy until it’s more medically credible.

How can you find a therapist you want to work with?

As in any profession, there are many excellent practitioners. For more information about the challenge of finding good therapy for your trigger points, see: Do you know a good massage therapist in _______?

More information

This article was an excerpt from the advanced tutorial, Save Yourself from Trigger Points & Myofascial Pain Syndrome! The whole tutorial contains waaaaay more information — it is an advanced troubleshooting guide for people with muscle pain — and costs $19.95. To learn more, either visit the tutorial (the first several sections are free) or just click this button to go directly to the store to buy it. No password or account is required, it takes about 2 minutes, and delivery is electronic and immediate. Thanks for visiting SaveYourself.ca!

secure, instant digital delivery
money-back guarantee
call 778-968-0930 for assistance

Got neck, back or knee pain? Note that the trigger point tutorial is given away as a free bonus with the neck pain, back pain, and IT band pain tutorials, so you might want to buy one of those for a 2-for-1 deal.

Notes

See Massage Therapy In British Columbia (Canada) Return to text.
See Massage Therapy for Tension Headaches. Return to text.
For a fresh example of trigger point research, see Toxic Muscle Knots. Return to text.
Massage Therapy: Riddled with quackery. Barrett. 2006. This article by Dr. Stephen Barrett expresses the opinion that scientifically unsupportable ideas are common in the profession of massage therapy. He avoids a blanket condemnation of the profession, arguing that “ordinary massage and the legitimate practice of massage therapy should not be categorized as quackery.” However, he writes, “many therapists make claims that go far beyond what massage can accomplish. And even worse, massage therapy schools, publications, and professional groups are an integral part of the deception.” A number of references are provided to support his view. I agree with almost every detail of the article and wrote a letter of support to Dr. Barrett, which is published as an addendum to it. That said, the article does conspicuously neglects important points that should fairly be said in favour of massage therapy, and it contains a few minor false statements. But I applaud the intent and embrace and welcome most of the criticism. I wish it weren’t mostly true, but I believe that it is. Return to text.