Trigger Points: What Are They?

Massage Therapy is a very confusing field now. Not being covered under insurance leaves the door wide open to what falls under the heading. A given massage therapist practices anything from spa relaxation to physical therapy type work.

To clarify what I do, the type of massage therapy modality I specialize in is “Neuromuscular Therapy” or “Trigger Point Myotherapy.”

What’s a Trigger Point & Why Work It?

“Trigger points” (TrPs) are tender points in soft tissue that radiate or refer pain to distant areas. These are found all over the human body usually in the belly of a muscle. Once formed, they radiate pain out from the belly similar to a wrinkle in a sheet or a ripple on the water, this is the referred pain felt. Trigger points are produced by muscle stress, such as overwork, repetitive motion, or sudden excessive stretch.

There are four types of trigger points:

  1. Active TrP – one that is spontaneously producing referred pain.
  2. Latent TrP – one that produces pain when pressure is applied during palpation.
  3. Primary TrP – one that is caused by muscle stress.
  4. Satellite TrP – one that is produced secondarily by a primary trigger point.

How Do They Go Away?

Trigger points generally stay inside the muscle until manipulated away. Get rid of them today with medical massage therapy in Des Moines Iowa.Trigger points generally stay inside the muscle until manipulated away. In layman’s terms, when a muscle is over-stressed it feels compromised and immediately protects itself. This tightening process forms TrPs within the muscle. Muscles are very stubborn and don’t forget experiences easily, hence the term “muscle memory”. Muscles will hold on to this protection until a manual process occurs which tells the brain to send a signal to the muscle that it’s safe to relax and return to a normal resting length. This is what I do.

Pressure is placed directly into a tight or sensitive trigger point area, which often causes radiating pain, and held until the tenderness disappears. This process repeats running along the rippled path of the TrPs. There is a delicate balance between applying enough pressure to release it and applying so much pressure that the TrP worsens. Releasing the points encourages increased circulation to the area allowing the underlying tissue to soften. This is the point when clients say, “I didn’t even know that hurt until you found it! How did you know that was there?”

What Is Neuromuscular Therapy?

Neuromuscular Therapy is also called Trigger Point Myotherapy. This technique alters the length muscles to teach them how to operate correctly. Muscles are manipulated back into the shape originally intended. Less is more during this treatment session to avoid bruising and soreness. This type of therapy consists of alternating levels of concentrated pressure on the areas of muscle spasm to release the lactic acid from the muscle, resulting in increased blood flow and oxygen. Fascia is also stretched to keep the body loose. If the shell of the body is loose, the muscles can loosen and relax back into their natural form.

Causes of Trigger Points

The common cause of trigger points results from various forms of trauma, ranging from a direct injury, excessive stretching, heavy lifting and twisting, or even emotional stress. These sensitive regions will often activate pain in referring areas. Once we eliminate the trigger point, massage aids in removing the waste products and restore circulation to the area.

Some trigger points will be more severe than others and patience is the key factor during the session. Less severe TrPs will release almost immediatley. More severe ones need worked longer. The reason the experience is so worth it, however, is that there is an immediate relief as soon as the TrP dissipates. There’s no waiting 3-5 days to see if the session was a success. You know right away.

Some severe trigger points can reform after a session. I always recommend icing the area worked after a session. The ice will increase circulation to the area and decrease inflammation, minimizing the odds of the TrP reforming.

Carmen Satre, LMT, CMMT, CMLDT, OMTDr. Janet Travell is the person most often associated with trigger point therapy. She’s quoted as saying, “Active trigger points cause pain. Normal muscles do not contain trigger points. Individuals of either gender and of any age can develop trigger points.” Simple enough. Another great reminder that you don’t have to live with the pain. Come in and get those stinkers gone so you can feel good in your skin again.

See you on the table!

Say No To Scar Tissue

I admit it, not everyone is as excited about scars as I am. I collect and count them as badges of honor. Much like tattoos, scars are visual stories leaving their marks on our physical bodies reminding us how we survive and strengthen. However, some scare are viewed as unsightly and distracting and some might not want the reminder of the experience. Good news! Scars can easily be broken up and minimized.

Scar Tissue Overview

What is it?
Scar tissue is the growth of new tissue: skin or fascia, after injury.

How is it recognized?
Scar tissue on the skin often lacks pigmentation and hair follicles.

Is massage indicated or contraindicated?
Massage is contraindicated during the acute stage of any injury in which the skin has been damaged. In the subacute stage massage may improve the quality of the healing process.

What Is Scar Tissue?

Scar tissue is a special kind of fibrous connective tissue that forms when tissues are injured. It is unique because, unlike those in tendons and ligaments, the collagen fibers are not arranged in a parallel pattern. Because of the abundance of dense and irregular collagen fibers, scar tissue is strong but not as pliable as normal, healthy tissue. Serving as a replacement for other injured tissue, it cannot perform the functions of tissue it replaces, and its blood supply is minimal.

Extensive scarring can restrict normal movement, reduce or prevent normal circulation of blood and lymph, and impede or even prevent injured tissue from functioning properly. The structure of scar tissue depends upon where the injury occurs, but it usually has the same components as the original tissue, accompanied by an abundance of extra collagen fibers.

Types of Scar Tissue

There are two types of scar tissue, internal and external.

When soft tissues are compromised or injured, the body automatically responds to repair the damage. In phase II of the healing mechanism, collagen fibers are produced to splint the area and prevent further damage. New collagen fibers are relatively easy to align with the fibers of the original tissue, given gentle movement throughout phase III. Collagen fibers continue to be produced during phase III, and without enough movement, they become sticky and hard. As a result, the collagen fibers are difficult to realign and they easily develop into connective tissue adhesions, or scars, with far-reaching effects.

  1. External – the scars are visible when the integument (skin) is injured,
  2. Internal – but tissues beneath the surface of the skin can also develop scars. Invisible scars are equally capable of affecting structures in other areas of the body.

What Does Massage Do?

Once a scar or adhesion is created in one area, it begins to pull on the fascia throughout the body. Remember – it’s all connected!

In the subacute and chronic stages of a skin injury, massage is indicated and can be very beneficial. Soft tissue work is the recommended treatment for superficial scar tissue and may be initially applied.

The quicker the adhesion is treated, the less likely it is to affect the rest of the body. Because of its patchlike nature, there is a tendency for all other tissues to pull in the direction of the scar, which can lead to more compensation patterns and fascial restrictions.

Once the scar has formed, massage on and around the scar tissue can increase the speed of healing by increasing circulation to the area, which prevents fascial restriction and increases mobility of the tissue. Scar tissue may have reduced sensation, so providing the therapist with regular feedback throughout the session is extremely helpful.

Methods to Release Scar Tissue

Releasing scar tissue is a very specific technique, both for internal and external scarring. I use a few methods to breakup both kinds of tissues including cross fiber friction, massage cupping, and Gua Sha tools.

Client Study: LH, External Scar

Last year LH had skin cancer removed just under her right nostril. Obviously she wanted that scarring diminished. The raw, untouched before/after photos below shows our progress in only 3 sessions of 15 minutes within a five-day period.

Massage therapy is effective in releasing scar tissue.

LH’s scar tissue before session 2.


Massage therapy is effective in releasing scar tissue.

LH’s scar tissue after 3 sessions.

LH Testimonial:

“I had a basal cell carcinoma removed on my face that required 14 stitches. As I am in my 60’s, I was concerned about healing time and permanent scarring. Carmen has a scar treatment that gave me impressive results. With a small number of 15-minute sessions, Carmen was able to achieve rapidly discernable results. Carmen is competent, calm and gentle. In her hands the treatments were enjoyable and soothing, with no discomfort.”

Testimonial: Kim W., Internal Scarring

“Carmen is fantastic! After years of going to whatever massage therapist had an opening and always feeling underwhelmed I’ve finally found a keeper! Carmen believes in treating the cause of the problem rather than providing short-term relief and thank goodness she does. I have scar tissue and knots that have been around for half my life and have always caused me problems. Carmen worked with me to create a treatment plan that would address my problem areas and ultimately lead to an overall reduction in my scar tissue and muscle congestion. After only a handful of visits I’m already feeling relief where I’ve never felt relief before and am feeling better overall. Also, she doesn’t ask that you come in for an hour each time. She can spot treat your problem areas in 15-30 min if that’s all that’s necessary. The flexibility is key. I still have a long ways to go in my treatment but I feel I’m making great progress.”

Scars are just like pain, you don’t have to live with it and their effects can be greatly minimized.

See you on the table!

Introduction to Massage Therapy, second edition, Mary Beth Braun, BA, MT, NCTMB & Stephanie J. Simonson, BS, MT

Neck & Shoulder Pain: Why Won’t It Go Away?

Massage provides relief for first rib fixation syndrome.There are those of you suffering from chronic pain or spasms in your neck, shoulder(s), or mid-back. You’re beyond frustration. You’ve tried several healthcare providers, including chiropractors and physical therapists, all issuing different treatment plans but nothing has helped. You’ve even tried massage but that provided nothing more than temporary relaxation. X-rays and MRI results are normal. What is going on and why can’t you find relief? The answer could be First Rib Fixation Syndrome. A lot of people haven’t heard of this and don’t realize they have it.

What Is First Rib Fixation Syndrome?

Doctors tend to overlook this syndrome as part of their first examination and diagnosis. It’s easy to miss, which is too bad because an elevated first rib can cause a plethora of symptoms and complications, leaving someone to suffer unnecessarily for years. This syndrome can be a long-held issue developed over time. Common causes include bad posture, long hours at the desk, over exercising, moving heavy objects, having a physical job, or possibly sustaining an injury.

Massage provides relief for Upper Crossed Syndrome symptoms.Over time, a muscular imbalance occurs known as The Upper Crossed Syndrome which elevates the first rib. When this happens, shoulder muscles (the subscapularis and infraspinatus) load up with trigger points, resulting in weakness and pain. With muscles now compromised, the shoulder is unable to move normally. People then tend to compensate for the pain by rounding the shoulders forward and jutting the head out further from the neck. The neck muscles (scalenes, serratus anterior, and sternocleidomastoid) overcompensate and develop more active trigger points. Referred pain from these new trigger points manifests as what may seem like random, erratic symptoms. Since these muscles attach to the first rib, even more elevation occurs. The trapezius muscle in the back then goes into immediate self-protection mode, resulting in tightness and spasm. This has a tendency to compress the brachial plexus and subclavian artery to eventually throw the person into a possible state of Thoracic Outlet Syndrome. Vicious, isn’t it?!

Sleeping habits play a large part in the development and treatment of this syndrome. Elevated first ribs typically occur in stomach sleepers. Some sleep with one arm tucked under their head, or sleep with minimal or multiple pillows. These now compromised muscles work extra hard if the person spends long hours working in front of computers using a mouse or has an intense job with repetitive movements. Changes in sleep style post treatment speed recovery and help prevent trigger points from reforming.

Also, all athletes should be evaluated as an elevated first rib is common in that type of lifestyle, particularly tennis players and weight lifters.


  • Shoulder pain
  • Neck pain
  • A heavy hurting feeling or throbbing in the arm
  • Dull achy pain and tightness in upper back and shoulders
  • Headaches
  • Trapezius spasm
  • Radiculopathy (a neuropathy)
  • Jaw pain
  • Mid-back pain
  • Paraesthesia (tingling, prickling, or burning)
  • Chest & sternal pain

Treatment: Can It Go Away?

Massage therapy provides relief for thoracic outlet syndrome, first rib fixation syndrome, and frozen shoulder.So what do I do that’s different than others? When someone presents a certain set of physical complaints that resemble this syndrome, I palpate effected areas for tenderness, spasm, and edema. A person will automatically jump or pull away when an elevated first rib is touched. Through various soft tissue mobilization techniques (MFR, PNF, ART, TPT, Gua Sha, Massage Cupping) active and latent trigger points in almost all of the muscles listed above are manipulated until pain ceases. This can take as little as one treatment for someone to experience immediate relief but can take up to a handful of sessions for more aggressive cases (those with repetitive work related movements that reform trigger points). These sessions are different than “typical” massages as the entire time can be spent on removing and breaking up the trigger points. This is aggressive and intense so I am sure to only work within the person’s tolerance level.

If this sounds familiar, please contact me. I also strongly recommend visiting your chiropractor for them to adjust the first rib(s) back in place. Again, this is a great example of the kind of pain you don’t have to live with. Let’s knock it out so you can feel good in your skin again.

See you on the table!

Why Stretch?

Stretching daily after massage sessions keeps muscles in a constant state of their natural resting length, happy and healthy.I am a nag about people’s daily stretching routine. More times than not I learn that people have good intentions to include stretching in their day but “don’t get around to it.” We are all guilty of this! But why is stretching so important? There is a science to it.

What Exactly Does Stretching Do?

Stretching your muscles on a regular basis can improve the range of motion and flexibility. Keeping muscles at a proper length takes unnecessary tension off tendons, which lessens damage and helps recover from injury. Stretching also allows for more muscle tone; muscle will be larger in volume without becoming bulky.

Stretching allows the body’s muscles to gently loosen. Increased flexibility of the neck, shoulders, and upper back improve respiratory function. Keeping upper and lower legs as well as the glutes stretched prevents plantar fasciitis and loose fluid movement in the lower back.

Without stretching, the body becomes stiff and tight. Stretching helps to push fluids and oxygenated blood throughout the entire body, increasing range of motion and improving posture. Remember, stretching is not relaxation (although that is a natural side effect); stretching is elongation!

Even if you do not have a regular exercise routine, stretching daily has many benefits. As our bodies age our muscles tighten and we lose some of the range of motion that we once enjoyed. Stretching can reverse these signs of aging by continuing to allow you to do the tasks that you expect. It doesn’t take a large time commitment, and the benefits far outweigh the effort. Start small and work your way into more stretches.

So What’s Stretching Have To Do With Massage?

Stretching is very important following a massage session. During the massage I am removing/releasing trigger points, or areas of built-up tension, within the muscles. Tension builds by: repetitive movements, gravity, moving around within our environment with a compromised gait pattern, exercising without stretching, the list goes on. Muscles kneaded and worked during the massage remove trigger points. When this happens, the brain sends a signal to the muscles to return to their natural resting states. The body does not feel tight any longer and fluids and chemicals flow freely inside the body.

So the person leaves the massage and returns to their daily life, right? Exactly, and then two weeks later they’re back in the same situation of pain and tightness. Stretching daily after massage sessions keeps muscles in a constant state of their natural resting length, happy and healthy!

The other important result of daily stretching in regards to massage sessions is Less Pain! An inflexible and tight body experiences a more painful session with slower progress. Better muscle tone + increased flexibility = less painful massage sessions. This is now when the person receives regular monthly massage sessions as maintenance to enjoy a “well-aging” body vs. someone who can’t seem to “kick the pain,” having massage sessions only last them a week or two. Make sense?

Ok, Then What Is the Proper Way To Stretch?

  • Strengthen Then Stretch – I come from a ballet conditioning background, ballet being the most efficient way to strengthen the human body, and learned immediately that the fastest and healthiest result of balanced muscle tone is to first strengthen the muscle, then stretch it. Football players and professional athletes can attest to this – yes, they’re doing secret ballet conditioning, shhh! DO NOT STRETCH A COLD MUSCLE! This causes injury, tears, and frustration as flexibility is not found. Walk first, do a few movements first, then stretch. I stretch multiple times during the workout to constantly elongate the muscles. When you do this, you will not be sore the next day after workouts! The key to knowing when your body has achieved a healthy state of strength and flexibility is when you can get out of bed in the morning and immediately reach the same level of flexibility you have after a workout, be it touching your knees, ankles, or toes.
  • Form, Form, Form – every stretch performed must have proper form to avoid injury and hyper-flexion. If you are unsure of proper form, look it up on the internet or have me demo the stretch for you.
  • Stretching daily after massage sessions keeps muscles in a constant state of their natural resting length, happy and healthy.Protect the Lower Back – for any stretch done standing it is crucial to keep knees slightly bent and pelvis tilted forward to protect the lower back. Otherwise, as you’re getting a wonderful stretch in the target muscle, you compromise the lower back and scratch your head why your back feels like it’s “ready to go out” a few days later.
  • BREATHE – it is a natural reaction to hold in our breath when we feel tension. This is the opposite of what the muscles need. While holding each stretch, breathe deeply! The science to this breathing mechanism is the pump. As we breathe deeply during our stretches, oxygen is physically being pumped into the muscles, allowing our bodies to extend, relax, and as a result, gain flexibility.

I do believe there are good stretches and bad stretches for the body. For more information, talk with me during your next session. I will help you choose the right stretches for your troubled area and create a customized protocol for you.

See you on the table!

Heat or Ice – Which Is It?

I hear a lot of confusion in the massage room about when to use heat over ice. Of course heat feels amazing but sometimes icing an injury feels good too. The use of heat and ice are equally important in the self-care process of muscle management. They each have specific uses but need applied at the right time or they could exacerbate an issue.

Heat vs. Ice

Icing, or cryotherapy – is for injuries except for low back pain
Heat, or thermotherapy – is for muscles

Icing, or cryotherapy, is for injuries except for low back pain.Choosing ice over heat for injuries is very important as icing calms damaged and inflamed tissues. These tissues are already swollen and carrying heat, a normal process for the body, although painful. Adding heat during this time feels great initially but only creates increased pain
and swelling. Not what you need in a time of trying to resume daily activities.

Choosing heat for muscles is great for muscle spasms or pain from knots and trigger points. Icing muscle spasms or trigger points can actually make them worse. Picture being surprised with someone splashing cold water on you or someone coming in from the cold outside and putting their hands directly on your skin – the entire body contracts. This is what happens when icing trigger points and spasms, both already in a state of contraction. Severe spasms and trigger points can feel like knife blades and it’s a common mistake to run for an ice pack. But icing these tissue issues causes the muscles to contract even harder, and the trigger points to burn more intensely. Trigger points and muscle spasms calm down with heat.

Heat also relieves psychological stress, which is a major factor in pain issues. At the end of a hard day’s work it’s a great idea to throw heat on tight neck and shoulder muscles or on leg muscles after a work-out.

What About A Muscle Strain or Tear?

This one is debatable but ice is generally preferred. If the muscle is truly injured, ice only for the first few days. Use ice to bring down the initial inflammation and help numb the severe pain. Once this phase is over replace with heat.

Always Cold or Over Heated?

Icing, or cryotherapy, is for injuries except for low back pain.It’s not a good idea to use heat if you’re already sweating or overheated. And ice will only make you feel worse if you’re shivering. The brain may misinterpret these situations as an excess and a threat. Shake things up to help out the brain. If you experience an injury but you’re already freezing, warm up in a hot shower and then throw an ice pack on the injury afterward. Or bundle up in a robe and blankets during cryotherapy. Same with heat. If your legs are cramping and you’re overheated from the work-out, jump in a cool shower then slowly turn up the heat to help relax the muscles.

Do Not Ice Low Back Pain!

Except for a direct injury from whiplash or a muscle tear where inflammation is definitely present, do not ice a low back injury. This is a common point of confusion even within the healthcare industry. Common low back pain, the feeling as if the back “is out”, is not from an injury or trauma causing inflammation. Painful trigger points, knots/adhesions, and the low back muscles being weak are the common causes of low back pain. When the low back feels like it’s out, icing will only make that feeling worse. Always Heat.

Hopefully this clears up some confusion. Using the above information as a guideline, choose the therapy that feels right for your body at the time and help speed up the healing process.

See you on the table!

Golfer’s / Baseball Elbow

Medical massage can provide relief for golfer's elbow.Because of the twisting and flexing motion in the arm and hand necessary for certain sports, especially golf and baseball, and the grasping motions required in some occupations, you may have tenderness and pain at the tendon attachments on the inside portion of the elbow. This is called Medial Epicondylitis. Like other therapists, I do not believe people have to live with pain. So let’s look into this nagging condition.

What exactly is golf elbow? Turn your thumb away from your body. There is a muscle that starts above the elbow on the inside and runs across the top of your lower arm. It hooks to the hand on the first and second fingers. This muscle is the flexor carpi radialis. You can also feel it if you squeeze your hand and many times the muscle will pop up. When the tendon of this muscle becomes aggravated or over used a person can develop “golf elbow”.

Medical massage can provide relief for golfer's elbow.

What is a tendon? Tendons hold the muscle to the bone and are very strong. However, when they tear, scar tissue forms, weakening the muscle’s integrity. Tendons do not heal well because of limited blood supply.

Signs & Symptoms

  • Severe, burning pain on the outside part of the elbow
  • Possible Swelling
  • Point tenderness along the origin of the pronators teres, FCR, Palmaris longus, and FCU
  • Pain can radiate to the forearm.
  • Possible pain radiation to medial forearm and fingers caused by ulnar nerve compression

What causes this particular tendon to become aggravated? Most of the time, “golf elbow” is caused by stress, overuse, or form (the way you swing the club). Many times the grip on the club can cause stress, ask your Golf Pro for any recommendations.

What can you do about it? You have several ways to take care of this situation.

Rest is the best step to take first, but do not stop there. Use Ice as often as possible.

Why use ice? Ice helps release metabolites (waste products). When you use ice there are four sensations you will feel – cold, burning, aching, and numbness. When your arm reaches the numbness stage (10-20 minutes), take the ice off. Ice cups are good to use.

To make an ice cup: freeze water in a paper cup, then peel away the paper moving the ice up and down your arm until the you reach the four stages. After your arm is numb, get a tennis ball and squeeze 6 to 10 time for three sets, keep the arm slightly bent and the wrist straight. Then repeat the ice and the exercise. If possible, do this 2 to 3 times each night. There are several other exercises in addition to the tennis ball squeeze; however, this one is very effective.

Can you alternate heat and ice? Yes. This can sometimes be very effective in the healing process. When alternating, always let your skin go to normal body temperature before switching methods.

How long should this be continued? You should see some positive results within 4 to 6 weeks. If you are continuing to play golf while you are still having discomfort, realize the tendon will take longer to heal and may never fully recover. If you have had chronic or long-term “golf elbow” it may take even longer to heal.

What other alternatives are there? Massage is wonderful for “golf elbow,” especially when incorporating the ice routine above. Stretching is also very effective, especially before and after playing golf. If the pain still persists, see a qualified Orthopedic physician. They may have other options including injections with a corticosteroid which is another form of treatment; however, realize many times injections can deteriorate the muscle grouping.

Remember, you do not have to live with pain!

Terry Cross, HHP, LMT
Laurel J. Freeman, BA, LMT