Knots-that-Aren't, or Are They?: Thoughts on Trigger Point Expression
In the last few months, I have seen a number is clients whose pain stems from trigger points. Lots of them. While it is common for trigger points to be a pain source, I have started to notice an interesting pattern as to when they illicit pain.
Trigger points carry a few points of debate because they are difficult to study. Imaging techniques such as X Ray and MRI cannot see them leaving the mechanisms behind trigger point pain obscure. And direct palliation, the most reliable method of detection, often produces varying findings in research. (This lead to a discrepancy as to whether or not they even exist for the longest time, though the physiological community now largely agrees that they do.) Reasons for why tactile definiteness is elusive include 1) examiner/practitioner palliation skill level, 2) qualities of touch, like pain, are subjective, and 3) some things that feel like knots to those doing the touching do not induce pain in the touched ruling them out as trigger points.
It is the last point on which I make my observational hypothesis. Currently, it is accepted that trigger points can be ”active” and produce pain constantly, or “latent” and only cause pain when directly agitated. But as I have worked with people who have severe causes of trigger points (which I am classifying here as having more than ten knots in a given muscle group that are contributing to dysfunction), I noticed that many of those feel-like-but-aren't trigger points - the ones that do not create pain even when compressed - will become either active or latent as other knots are released.
For example, I have been working with a client for several months who came in with the worst presentation of trigger points I have seen thus far in my career. The pain they caused radiated through the thigh, into the groin, and affected low back so much so that the client's primary doctor was preparing to help file for permanent disability. We released more than 23 distinct knots within the thigh throughout the course of our sessions. During our work, I also noted a fair amount of feel-like-trigger-points in the client's left calf, but only two sent pain signals. I dismissed the rest as congestion since trigger points, by definition, must cause pain.
Massage combined with trigger point injections (done by a different medical specialist) has almost completely rid this client of the low back, groin, and thigh pain several months sooner than the usual prognosis with trigger point injections alone! But now something interesting is happening. All of those feel-like-trigger-points in the client's calf are now producing pain. There is active pain in the form of soreness in the lower leg when walking and sharp, latent pain upon contact with the knots.
So how can not-trigger-points suddenly become trigger points? And what does that mean for all other feel-like-but-aren't trigger points?
I believe it all has to do with order of operations. In bodywork, we are taught if a muscle does not release, something else needs to be corrected first. Example: tight rhomboids will not relax if the shoulders are rounded forward due to joint misalignment or overactive pectoralis major muscles - soothe pecs or correct joint displacement and rhombs will chill out. In energy work, we also learn the body will only reveal to release what is most appropriate or needed at any given time. Imagine wearing several coats and wanting to remove the T-shirt underneath. It's going to be easiest to remove each layer starting with the outermost, the one readily seen and accessed first than to try to go straight to the bottom layers, right? That's a bit how energetic obstacle clearing works. We also believe the brain can process a limited amount of input at once. This means that of all the kinks the body may have, only a few will be felt. Usually the biggest problem or the area that is most ready to head. (For more on that last note, check out this article.)
Combine these principles, apply them to our understanding of trigger points, and we now have a possible explanation for why knots may not produce pain even if they are legitimate trigger points. The brain has not prioritized that particular knot as worthy of attention at the time it is found, instead processing pain signals in other areas that must be addressed before any other layers of the problem can be removed. This is my own educated guess. What research develops to confirm or refute any part remains be seen. But until then, my hypothesis is at least functional for practical application.
What do you think? Is it possible to have pain you do not feel? What injuries have you experienced where you should have felt pain but did not, or felt less pain than expected? Let me know in the comments!