How Using Trigger Point Phenomena Can Make You a Pain Hacking Hero
Most people don't think of the feet and ankles as potent instigators of pain elsewhere in the body. I know I didn't when I started out. But 15 years of clinical observation have made it abundantly clear to me.
Many of my conclusions in this area have sprung from my study of “trigger point phenomena.” Trigger point phenomena (and related concepts like “satellite referral”) can help lead you to the real source of your patients’ pain.
Without a knowledge of these concepts, you may make serious errors in pain diagnosis.
The Myth of Muscle “Weakness”
In the following illustration, the original label for the Gluteus Medius was "Gluteus Medius Weakness".
Traditional wisdom taught us that weak muscles are responsible for many types of pain. Is the patient shuffling along with severe hyperpronation and severe sciatic pain? Let’s put them on the abduction machine and strengthen those "weak" glutes!
Unfortunately, this approach often makes their pain worse.
Why? Because we failed to ask why the gluteal muscles became so weak. To answer that question, you need to know something about how trigger points influence muscle function.
Often, their glutes are so dense that you can't even generate enough compression for them to feel anything! Why would we think a muscle like that is weak? Why would we think that further torture and overwork would improve the situation?
What were we missing in this equation? Trigger point knowledge.
Trigger points can make muscles weak, even though they have plenty of mass and capacity. And when you release the trigger points…voila!... strength returns.
But if you follow the “weak muscle myth,” and further challenge those already overloaded muscles, the pain gets worse.
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Example: A Typical Trigger Point Mistake
The illustration above seems to suggest that the knee pain is caused by...
- The mechanical stresses of poor alignment
- Femoral rotation
- Valgus knee associated with severe hyperpronation
The "weak glutes" make it impossible for the patient to resist these forces. So, the "cure" is to strengthen the glutes so they can abduct the leg and counter the hyperpronation.
There are several errors in this analysis. And we see the disastrous results of these errors every day.
Error: Assuming that the knee pain comes from the knee joint itself. This is another example of the injury model of pain. It's a fancy explanation for how mechanical distortion causes the injury. See my other articles for more background on this.
Most pain comes from referral, and the knee is no exception.
If you do know something about trigger points, it would be equally incorrect to assume the pain comes only from direct referral originating in the quads. And that’s where your logic comes in. Does the patient regularly overwork their quads? Why are the quads so disturbed? Do they bike, run, squat a lot?
If the answers are NO, then satellite referral is a much better explanation. In fact, in almost all situations, referral is a huge contributor to pain.
The gluteus minimus and adductors are very sensitive to disturbances in gait. These disturbances can trigger pain in (and weaken) the quads and over the knee joint.
This is a more logical explanation for why someone (who isn't burning out their quads) might have knee pain.
Satellite referral and trigger points can seem pretty mystical to the uninitiated. And it may be years before science fully explains these strange phenomena.
But my real world, clinical experience, has proven their “logic” over and over.
My approach: Propose a theory, try it in the clinic and use what works.
How Anatomical Irregularities Set Up Trigger Points
On to the next question: Why is their gait disturbed?
The answer is often related to hyperpronation. Hyperpronators have excess mobility in the ankle and foot, leading to an appearance of flattened arches (but the arch is intact, it just collapses on to the floor).
When the foot collapses medially, the glutes have to work extra hard to abduct and stabilize the leg. This extra work causes them to develop trigger points. This in turn causes them refer pain into the quads and the knee.
And when the gluteal muscles get weak the body will recruit other muscles (like the TFL) to pick up the slack. And then those muscles become troubled.
This explanation of knee pain is actually quite simple and logical. But it only works if you understand the trigger point principles. Without these keys, it's easy to assume the joints cause all pain.
I've seen this domino reaction (from gait problems to pain), so many times. And it's why I place so much importance on correcting foot and ankle alignment. When you can remove that "domino" where the foot hits the ground, you can stop this reaction. And stop it from causing so many types of pain.
And then your patient can walk, play tennis, even strengthen their glutes - without pain.
And you become the "Pain Hacker." After enduring therapists after therapist who failed them, you become their hero!
(The illustration at the top illustrates these circular functional and referral relationships I've been discussing. The ones that lead to so many kinds of pain. See our Pain Hacker's Guide courses for more information like this.)
And if you really want to be a Pain Hacking Hero, check out our courses and trainings here.
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