Trigger points are painful nodules in muscular tissue, commonly found in the upper back, low back, and gluteal muscles. Trigger points are frequently chronic, persisting from day to day without much relief. When someone says, “My muscles are all in knots”, those knots are most likely trigger points.
The formal definition of a trigger point describes a localized region of tenderness, located in a tight band of muscle, which is associated with a palpable twitch in response to deep pressure over the tight band.1 Such deep pressure usually results in pain radiating from the trigger point to the surrounding soft tissues. Formally, if the twitch response is not present, the localized muscle tightness cannot accurately be termed a trigger point. It may also be argued that characterizing a local muscle “knot” as a trigger point requires the presence of the above mentioned radiating pain. These definitions are of importance when making decisions about appropriate care for painful muscle knots.
As with any care management decision-making process, some procedures make sense and others do not. Many so-called pain management physicians will recommend injecting painful trigger points with an anesthetic or even botulinum toxin.2,3 Such an invasive procedure is rarely required. Pain management practitioners and even specialists in internal medicine will recommend muscle relaxers such as Robaxin, Flexeril, or even Soma in attempts to diminish muscular pain in the shoulders or low back that may or may not be associated with the presence of trigger points. The problem with such medications is they do not address the underlying cause of the painful muscle knots. Further, their efficacy with respect to muscular pain is questionable.
The mistake, as is frequently the case, is in thinking of trigger points as a real entity. But trigger points do not exist in a vacuum. These painful muscle knots arise as a consequence of mechanical disturbances and stress in the rest of the body. Attempting to treat the trigger points themselves with injections or medications misses the real problem. Trigger points have arisen in a person’s shoulders or low back owing to chronic issues elsewhere, typically involving the spinal column itself and the small muscles that enable those vertebras to move in three-dimensional space.
Trigger points are best managed by directing care to the underlying issues, primarily involving loss of full mobility of spinal vertebras and resultant inflammation in spinal muscles. As with many other biomechanical problems, chiropractic care is often the best solution. By utilizing a specific, highly targeted, noninvasive approach, chiropractic care helps alleviate the factors that have led to the painful muscle spasms known as trigger points. As the underlying biomechanics improve, the trigger points themselves begin to resolve, all without the need for injections or medications.
1Fernández-de-las-Peñas C, Dommerholt J: Myofascial trigger points: peripheral or central phenomenon? Curr Rheumatol Rep 16(1):395, 2014
2Kim SA, et al: Ischemic compression after trigger point injection affect the treatment of myofascial trigger points. Ann Rehabil Med 37(4):541-546, 2013
3Zhou JY, Wang D: An update on botulinum toxin a injections of trigger points for myofascial pain. Curr Pain Headache Rep 18(1):386, 2014
Many people experience radiating pain as a component of neck pain or low back pain. A person with neck pain might have pain that radiates down her arm, possibly into the hand.1 A person with low back pain might have accompanying leg pain, possibly traveling into the foot. Such arm/hand pain or leg/foot pain can represent a serious underlying health problem. However, not all types of radiating pain are of equal importance. The key is to be able to identify which patterns require prompt attention and which merely appear to be significant but are not.
Authentic radiating pain is most often caused by pressure and/or irritation of a spinal nerve root.2 The spinal nerve becomes inflamed and sends pain signals to the brain that are interpreted as pain in the region of the body supplied by that nerve. Inflammation of a certain spinal nerve in the neck region will result in the experience of pain down the outside of the arm and forearm and into the thumb and possibly index finger. Inflammation of a certain spinal nerve in the low back causes the person to feel pain traveling along the back of the thigh and calf and into the fifth toe.
Specific patterns of radiating pain are associated with inflammation of specific spinal nerves. Such inflammation may be typically caused by pressure from a herniated intervertebral disc. Other disorders which may create local space-occupying pressure need to be considered as well. A thorough history and physical examination will help to identify the cause of the problem. X-ray studies may be needed, as well as an MRI scan. The underlying problem, including the pattern of pain radiation, may be termed a radiculopathy or radiculitis.
But most cases of what appears to be radiating pain are not, in fact, related to pressure on a spinal nerve. Most patterns of radiating pain are not associated with a radiculopathy or radiculitis. Rather, the large majority of pain patterns involving the arm/hand or leg/foot are caused by normal, everyday aches and pains. Our run-of-the-mill physical problems involve relatively large muscles such as the trapezius (overlying the upper back, shoulder, and mid back) and relatively small muscles such as those that overlay the spinal bones themselves and help move the spinal column. Ligaments that hold bones together and tendons that attach muscles to bones may also be involved in these everyday ailments.
Irritation and inflammation of muscles, ligaments, and tendons may cause more difficulty than mere soreness and tightness. Such inflammation may also cause radiating pain, but in broader, more diffuse patterns than those caused by inflammation of a nerve root. A person might experience neck pain with arm and hand pain, or back pain with leg and foot pain, but in a broad pattern not associated with a spinal nerve. This is actually good news for the patient, as such forms of radiating pain (known as scleratogenous patterns), are usually more easily treated than those associated with a radiculopathy or radiculitis.
The bottom line is that your chiropractor is experienced in the diagnosis and care of such problems. Your chiropractor will be able to determine if your radiating pain is associated with muscles, ligaments, and tendons or if it is related to pressure on a spinal nerve.3 Your chiropractor will make specific recommendations for care of your specific health problem and help guide you in the process of returning to good health.
1Caridi JM, et al: Cervical radiculopathy: a review. HSS J 7(3):265-272, 2011
2Magrinelli F, et al: Neuropathic pain: diagnosis and treatment. Pract Neurol 2013 Apr 16 [Epub ahead of print]
3Mena J, Sherman AL: Imaging in radiculopathy. Phys Med Rehabil Clin North Am 22(1):42-57, 2011
Out of the blue, your back starts to hurt. At first, it's just an annoyance. You can live with it. You've had lower back pain before and it went away on its own.
Now it's a few weeks later. You've got a low-grade pain that's not getting any better. You're actually worse, in fact, because your back hurts most of the time.
What to do?
You don't want to run to a doctor. After all, it's just back pain. Everybody has back pain. So you begin to solicit advice from your friends. And, of course, your friends have plenty of advice. "Do these exercises my doctor gave me." "Do these stretches - they worked for me." "Go to yoga class." "I know a great Pilates instructor. She'll get you in shape and your back will stop hurting." "Take vitamins and drink more water." "Meditate."
Your friends mean well and it's all very good advice. But none of it seems to work. Another month goes by and now the pain is increasing. It's even affecting your sleep.
It's time to see a doctor. But which one? For the most part, medical physicians are not experts on back pain. Typical recommendations include rest, moist heat, and anti-inflammatory medication.1,2 But, really, you've done all that. You need more specific advice.
Choices might include doctors of chiropractic, orthopedic surgeons, and physical therapists.
Many orthopedic surgeons are spinal specialists, but what they do is surgery. This would be a last resort, typically, after other treatment options have failed.
Physical therapists are highly skilled practitioners who focus on exercise, rehabilitation, and re-training. They are not primary care providers, and typically patients are referred to physical therapists by family physicians, chiropractors, and orthopedic surgeons.
Doctors of chiropractic are spinal specialists, too, and what chiropractors have to offer is expert conservative therapy.3 Chiropractors treat back-related problems all day, every day, and are the right doctor to see first.
As spinal specialists, chiropractors receive extensive training in evaluating patients with back pain. Chiropractors consider all aspects of the problem, and develop sound treatment plans based on the facts. If a person does not respond as anticipated, their chiropractor has a "Plan B" in place for further evaluation and possible referral.
When choosing a doctor, you're allowed to ask questions and participate in the process. The strategy for follow-up is critically important.
First, if you're improving and doing well, how will can you help keep the problem from recurring? Will your chiropractor prescribe stretches, exercises, and other self-care action steps to help you keep yourself well?
And, what steps will be taken if your problem and pain are not improving? Where might you be referred for further tests and evaluation? Chiropractic treatment is a powerful tool in most cases of back pain. Symptoms should begin to improve quickly. Have your chiropractor outline the "Plan B" if you are, in fact, not getting better.
Your doctor of chiropractic will be able to answer these questions.
1Zuhosky JP, et al: Industrial medicine and acute musculoskeletal rehabilitation. Arch Phys Med Rehabil 88(3 Suppl 1):S34-39, 2007.
2Cayea D, et al: Chronic low back pain in older adults. What physicians know, what they think they know, and what they should be taught. J Am Geriatr Soc 54(11):1772-1777, 2006.
3DeVocht JW: History and overview of theories and methods of chiropractic. Clin Orthop Relat Res 444:243-249, 2006.
What's going on? Is this mechanical failure people seem to be experiencing in their joints a new phenomenon? Or are more diagnoses being made now owing to the ready availability of CAT scans and MRI units? Are more surgeries being done owing to the abundance (at least in urban areas) of surgeons wanting to perform these procedures?
Regardless, deeper questions point to lifestyle patterns that may predispose a person to developing knee osteoarthritis. A comparison with earlier times may be useful in this context. For example, it's not well-known that people in the Middle Ages - the 11th and 12th centuries - lived into their 80s. They managed to get along without ibuprofen, without arthroscopy, and without major surgical procedures. But we live in the 21st century. What is our problem?
Are there risk factors for back pain? And, if there are, what can I do to keep myself healthy and well? Your chiropractor can help answer these questions and more.
One primary risk factor relates to exercise. Everyone has heard, "if you don't use it, you lose it". If you're not exercising regularly, your back muscles are deconditioned and much more susceptible to injury - the strains and sprains we're accustomed to calling "back pain".
Muscles get stronger when they're required to do work. Also exercise helps "train" the soft tissues around a joint - the ligaments and tendons - these supporting structures "learn" how to withstand mechanical stresses and loads without becoming injured. Basically, when you exercise - when you do any kind of exercise - your body gets "smarter" and you're less likely to get those annoying back problems.1
A related risk factor is weak abdominal muscles. When you were a kid, at some point one of your gym teachers probably told you to "suck in your stomach". Actually, it turns out that was pretty good advice. Your abdominal muscles support the muscles of your lower back. If your abdominals are weak or if you're not using them - letting them hang out and droop instead of keeping them activated - your body weight has to be held up by the muscles of your lower back. They're not designed to do that - they're designed to move your spine around. And eventually, these lower back muscles will give way under the excess strain. The result is a very painful lower back injury.
There are many easy-to-do exercises for your abdominal muscles. The key is to actually do them - and do them after you're finished doing the rest of whatever exercises you've scheduled for that day. How often? Three times a week is plenty. Abdominal routines are quick - no more than 10 minutes. And, remember to use your abdominal muscles throughout the day. Imagine your abdominals are being pulled in and lifted up. This is not a "tightening" - your thought should be "activate". Your body will know what to do, once you've started adding consistent abdominal training to your exercise routine.
Risk factors for back pain may also be found in your personal and family medical history.2,3 During your initial visit your chiropractor will ask you about accidents and surgeries you've experienced, and discuss any important elements in your family history. For example, surgery to remove an inflamed galllbladder or appendix or to repair a hernia may result in weakened abdominal muscles. A motor vehicle accident or a fall from a height may have caused injuries that healed with soft tissue scarring.
Learning about potential risk factors and taking appropriate action will help ensure a stronger, more flexible, and healthier lower back.
1Jones MA, et al. Recurrent non-specific low-back pain in adolescents: the role of exercise. Ergonomics 50(10):1680-1688, 2007
2Cherniack M, et al. Clinical and psychological correlates of lumbar motion abnormalities in low back disorders. Spine J 1)4):290-298, 2001
3Plouvier S, et al. Biomechanical strains and low back disorders. Occup Environ Med 2007 (in press)
A 30-year-old mom bends over to pick up her four-year-old and feels a sharp stabbing pain in her lower back. A 60-year-old man bends over to pick up his five-year-old grandchild and feels an electrical shooting pain in his lower back. For both, the pain is so severe they need to sit down.
The next day, both the mom and the grandfather notice they now have pain and numbness radiating down one leg, and they are having trouble walking.
What's going on, how did it happen, and what can be done about it?
First of all, a little basic anatomy is useful. Spinal discs are weight-bearing shock absorbers. They contain a gel-like ball-bearing center, which is surrounded by tough fibrous cartilage, arranged in concentric, criss-crossing circles.1
As a person gets older, the discs naturally lose some of their water content, and cracks and fissures naturally develop in the fibrous cartilage. If a weight-bearing stress is unusual and unexpected, the gel-like material in the center of the disc can push through one of the fissures and possibly irritate a spinal nerve.
If enough of this material pushes through, the nerve can become inflamed and cause symptoms such as radiating pain and/or numbness, and possibly weakness, in one leg.
Typically, such pain and/or numbness radiates down the leg, traveling below the knee and possibly into the foot.
Such symptoms, with or without back pain, are highly suggestive of an inflamed spinal nerve. In fact, the person will usually say the leg symptoms are much worse and of greater concern than any back pain that may be present.
If the MRI confirms the disc herniation and suggests an inflamed nerve, the diagnosis is complete. What's next?
In the best scenario, conservative treatment may be sufficient and the nerve inflammation improves with time.2,3 Anti-inflammatory medication may be helpful. Chiropractic conservative therapy may include physical therapeutic modalities and gentle trigger point therapy to relieve associated muscle spasms.
A spinal surgeon should be consulted to provide an additional opinion and input. If pain is severe and there is neurologic loss, surgery may be the best option.
Of course, the best management, as always, is prevention. Pay attention to safe lifting procedures. Exercise regularly and get sufficient rest. Your chiropractor will be able to provide guidance and recommend effective protocols to help you achieve and maintain good health and wellness.
1Postacchini F: Lumbar Disc Herniation. Springer, 2004, Chapter 2.
2Rothoerl RD, et al: When should conservative treatment for lumbar disc herniation be ceased and surgery considered? Neurosurg Rev 25(3):162-165, 2002.
3Lumbar Disc Herniation. New Engl J Med 347(21):1728-1729, 2002.
