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!

The Importance Of Water

Drinking plenty of water daily is important, especially during the first 24 hours before and after a massage.Surprising to most people, water is the only fluid that properly hydrates the body. Everything else that comes into the body registers as food and files accordingly. Drinking plenty of water daily is important, especially during the first 24 hours before and after a massage. But why is it so important?

Water Before A Session

Massage actually dehydrates muscles by moving fluid out of the muscle to the spaces between. Drinking water before a massage creates hydrated muscles, providing an easier session for the therapist to perform deep work and the client to receive deep work. Hydrated muscles are easily manipulated. Beginning a session in a state of dehydration causes muscle cramping during the session. This is not only painful to experience but time is lost working the cramp out vs. achieving smarter work around the body.

Water After A Session

Massage stimulates circulation in the body while flushing water, salt, and other minerals from muscles. Our circulatory system carries away waste materials generated by cells. Massage also pushes out a high amount of toxins into the system. Drinking water post-session forces released toxins to move and be carried out of the body. Without the follow-up of water, toxins can pool within the system, causing muscles aches, soreness, swelling, and discomfort.

What’s With The Warm Water?

Why do I insist on handing out room temperature water after a massage session? Drinking water right after a session helps bring people back to alertness. After a massage it is typical to feel “spacey” and disoriented. Having a glass of water helps to bring the body and mind back to the present and allows the brain and mind time to slowly return to the real world. Warm water, specifically, performs this action in a soothing way. Cold water is shocking and causes an immediate reaction inside the body. Warm water goes down smoothly and effortlessly, causing the least trauma in the system, thereby helping to acquaint the client to the present.

See you on the table!

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!

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!

Beat The Heat

Those of us living in four season states have a comedic annual ritual. The long winter drones on day after day… A break in the cold finally happens… The shorts and flip-flops come out of the closet and we take full advantage of the first weeks of hot weather and full on sun! It’s a fun tradition. What’s not so fun is overdoing it and feeling the awful effects of heat exhaustion, or worse, heat stroke. Whether you spend long hours in the garden or run more miles outside than you’ve been used to during the Winter there are a few tips to survive the heat wave outside. The key is to analyze the symptoms and then learn how to respond or better yet, prevent.

Heat Syncope
Symptoms include fainting and light-headedness that usually occurs at the end of the exercise.

  1. If you begin to feel faint, get out of the heat and rest in a cool place drinking cold water.
  2. Elevate your legs.
  3. Most likely you will experience “heat cramps” – tight muscles or spasms after intense exercise. To relieve these, massage and stretch the cramped muscle and drink more cold water.

Heat Exhaustion
Heat Exhaustion is similar to heat syncope but accompanied with nausea, vomiting, headache, fast breathing, and poor coordination. Most people in this state still try to get through their current activity but Don’t!

  1. Find a cool, shaded place to cool down.
  2. Remove as much of your sweat-soaked clothing as possible and use cold, wet towels to cool the skin.
  3. Elevate your legs and drink water or a sports drink to replenish lost electrolytes.
  4. DON’T jump into an icy bath as this cooling method is too rapid for the body to adjust.

Heat Stroke
Heat Stroke is the second leading cause of death in athletes yet totally preventable.  It’s a small step from heat exhaustion to full-blown heat stroke with symptoms being hysterical behavior, delirium, blacking out, and weakness.  It’s a myth that dry skin signals heat stroke – the sweating mechanism is still working.  If you see someone displaying this behavior do the following to help them:

  1. Cool the body as quickly as possible and call 911.
  2. While waiting for EMS, move the person to a cooler place and swap their clothing with ice packs, cold towels, etc.
  3. Massage in this instance is very effective in increasing circulation in the extremities.
  4. If the person starts to shiver, remove all cooling devices as shivering is our natural way to increase core temperature, which needs lowering in this moment.

Follow good prevention during the hot Summer by staying well hydrated, increasing consumption of good food made up of mostly fruits and vegetables, and exercising in moderation.

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