Clinical Note: Get Triggered! The role of Trigger Points in Sport Medicine

By Jonathan Maister CAT (C), RMT, Sport Fellow csmta.ca

Trigger points are a massage therapist’s constant companion. The budding student knows it from early on in their RMT journey as a tiny rigidity in the muscle. It may refer pain peripherally as well as elicit an exquisite discomfort on site. Ischemic pressure, ice massage, fascial work, massage, stretching and even acupuncture needles are all known strategies to address them.

But therein lies the mystery of these physiological phenomena. There is much more to them and they also play a role with athletes since they can cause pain, confusion and possibly affect performance. Physiologically these are areas of focused hyperactivity of the muscle spindle. The common causes may be strenuous activity (as in the gastrocnemius lateral head) or prolonged lengthening (such as the rhomboid and levator scapula). I would also hazard to suggest that chronic holding in a muscle due to an actual injury, will also result in trigger points. The vicious cycle of pain, tension and compensation will precipitate trigger points.

In terms of detailed mechanics in a sport environment:

Think of the pounding of the lower extremity with all running sports, often on a firm surface. The concentric-eccentric rebounding on the lower leg with the gastrocnemius acting across 2 joints puts an extraordinary amount of stress on this muscle. Coupled with this, it’s a consideration that the movement of the fibula compounds this further. Hence this area, posterior to the fibula head is a hotbed of trigger points. Even swimming, with the foot forced into planterflexion with the kicking motion, may have a similar response. Chronic intense holding of the foot into plantarflexion.

Throwing sports and racquet sports subject the scapula retractors into extreme eccentric loading. Think of a tennis player or baseball pitcher hammering their arm anteriorly at incredible speed. That rhomboid must decelerate the scapula as it barrels laterally with the pitching/racquet arm. The sedentary scenario involves the scapula retractors hanging onto the abducted scapula, chronic lengthening which stimulates the muscle spindle to respond.

A further curve ball in this situation (no pun intended) is the subluxation of the

costotransverse joint. This manifests similarly to the trigger point – hypersensitivity in the inter spinal/scapula region. The difference is that ischemic pressure on the subluxed joint will not bring relief. Pain will remain the same or even increase. Knowing the precise region of the costotransverse joint will also facilitate accuracy in assessing the situation. Being Cross- Checked into the boards during ice hockey, falling onto the ground in rugby, or vigorous pulling movements (powerlifting, gymnastics) may pull the rib out of position. Strenuous breathing may also be a cause (from personal experience). With the passage of time, ligaments become looser which predisposes the athlete to rib subluxation.

The levator scapula boasts one of the RMT’s favourite trigger point site. Favourite, because it is so common and often so uncomfortable. With the protracted shoulder, the muscle is stretched and torsioned stressing the muscle spindle. The tenderness manifest on the muscle attachment on the superior angle of the scapula. In the case of the scapula retractors and the levator scapula, simply reversing the scapula position should be enough to remedy the situation. Introducing a strength program for the rhomboids and middle trapezius will also obviate the problem. The strengthened muscles will be better equipped to handle the stresses placed on them, and it is also hoped that the stronger muscle, ipso facto, will ensure the scapula rests closer to the spine. One further consideration is this. The protracted scapula may tweak the suprascapular nerve in the suprascapular notch. This manifests as a deep burning in the upper back (the region of the suprascapular notch). To the uninitiated, this may be mistaken for a levator scapular trigger point. By normalizing the scapular position, the stress on this nerve will abate and the symptoms disappear.

The scalenes. Here's a muscle integrally involved with respiration. The innate habit of the tired athlete to hold onto a fence or place their hands on their neck is an attempt to stabilize the upper body, hence facilitating a more effective elevation of the rib by the scalenes. Without knowing the anatomy, the athlete’s actions reflect the anatomical characteristics of the scalene muscles. When hypertonic it may shift the associated rib into a “stuck” elevated position. This can be palpated as a firmness (not to be mistaken for muscle) adjacent to the lateral base of the cervical spine. Muscle holding of the muscle can also affect the athlete’s ability to breath optimally, just as muscle holding in the extremities may affect swimming or running optimally. But the scalenes are notorious for referring pain to the chest. To the uninformed, chest pain may be worrisome. But looking at the individual case, i.e. the patient is a well conditioned athlete with anterior head carriage and an elevated rib and a hypertonic scalene on the involved side. Give that consideration, treat the muscle (and rib if you can and if necessary) and see if the chest pain remains. It’s common enough that I have seen this phenomenon a number of times. An elderly patient with inherent cardiovascular history of illness will require referral. But be advised of what to look for.

Clearly there is more to trigger points than meets the eye, or should we say the fingertip. By understanding how they evolve not only will be reduce their pathophysiology, but we could also enhance the athlete’s performance.

References:

https://www.physio-pedia.com/Trigger_Points

Janet Travell, David Simons: Myofascial Pain and Dysfunction: The Trigger Point Manual

Reid. David C. Sports injury assessment and rehabilitation