When people first encounter trigger point therapy and pain referral charts, it's common to feel a sense of excitement. I certainly did when I first opened Clair Davies' Trigger Point Workbook over 20 years ago.
All of a sudden, I felt that I had encountered a lost secret treasure map, where X marks the spot that causes pain Y.
I had learned hundreds of Thai massage techniques in my training, but was becoming very disillusioned with being able to reliably treat pain in my clients using the Thai sequences I had been taught.
Trigger point therapy provided a lovely map, where I could find the source of common pain complaints by working backward from the sites where pain was felt.
Pain felt in the front of the shoulder, for example, was most often caused by the infraspinatus muscle in the back of the shoulder.
I would invariably find taut fibers and tender trigger points in the infraspinatus in clients with anterior shoulder pain.
Compressing those points would produce referred pain in the front, just as the chart said it would, and it often felt very similar to the type of pain the person reported.
However, while this seemed very promising, I was crestfallen when my diligent work on the infra failed to have much impact, or the pain would quickly return.
There are 13 muscles that refer pain to the anterior shoulder, so I thought perhaps I had just missed one farther down on the list.
I quickly learned that it was a terribly inefficient and ultimately misguided strategy to just go down the list, trying all of them.
I had wandered into what I now call the "Direct Referral Trap". It is an easy and obvious mistake that I believe has hindered the acceptance of trigger point therapy. I describe this situation extensively in my book, ENDING PAIN.
It isn't that the referral charts researched so extensively by Dr. Travell are wrong. They are just a small piece of a more complex puzzle.
The pain patterns are accurate, but they don't capture how each muscle operates (and misbehaves) as part of a system. it would be like trying to predict the weather based on the conditions in a single neighborhood.
The unfortunate consequence of this mistake is that it makes it seem that trigger point therapy doesn't work.
After a few tries, therapists are likely to relegate the approach to the dustbin of other tools that have limited use.
Why A Narrow Focus On Individual Muscles Doesn't Solve Most Pain Conditions
As I developed Coaching The Body®, I discovered why this "Trigger Point 1.0" approach is so hit-or-miss.
Focusing on the direct referral of a single muscle is rarely effective because a) muscles are very often the target of satellite referral from other muscles and b) all muscles are neurologically linked to a network of related muscles.
While anatomy books describe the action of the infraspinatus as external rotation, its function is very different.
The infra is a primary stabilizer of the arm in the shoulder joint during virtually any arm motion. If there is any degree of residual pain or instability in the shoulder, its stabilizer role becomes amplified and it will likely develop trigger points from excessive demand.
This explains why so many therapists spend a lot of time treating the infra, without getting anywhere. They haven't addressed and balanced the other muscles in the complex system around the shoulder.
It comes down to protection and safety. As long as the central nervous system detects a need to protect a joint due to trauma, excess mobility or even minor pain, there will be a tendency for trigger points to develop and persist around a joint.
In the case of the shoulder, we have a joint that is designed for great mobility and relatively low stability. As bipeds, we no longer need to bear weight on our shoulders, but we do need a mobile joint to facilitate movement of the arm and our grasping ability for manipulation of our environment.
Muscles work in an orchestrated performance with their functional unit - both agonists and antagonists for the muscle's actions as well as muscles that are related to the muscle's function.
In the case of the infraspinatus, the functional unit is very large. All of the muscles that move and stabilize the scapula, all of the glenohumeral muscles attaching the arm to the scapula, and some of the arm-to-torso muscles (such as pectoralis major) are potential contributors.
How Do I Treat So Many Muscles in a Reasonable Amount of Time?
It's pretty much impossible trying to treat such a vast collection of muscles in any kind of useful way without a sophisticated plan.
You need to have an intelligently designed treatment order that works agonist/antagonist pairs, because a muscle's antagonists very often perpetuate its dysfunction.
You'll benefit from an ongoing triage approach, so you aren't spending time on muscles that aren't troubled.
Its important to understand how and when to repeat part of the sequence, perhaps after uncovering and resolving some hidden perpetuating muscles.
And you must deal with muscles that are throwing satellite referral into the shoulder, particularly the muscles in trouble.
If it sounds like a lot, it is. When I was starting out, I desperately needed someone to tell me what muscles to treat in what order, considering the points above.
Nothing like that existed anywhere, so I had to create it myself.
It took many years, but it was so worth the effort. Now I can offer it to you, and that makes me very happy. What I care most about is changing the way that pain is understood and treated in our very broken medical system.
Over the course of the last 20 years, we've developed CTB Protocols for treating pain conditions in all of the major body areas.
Our protocols are intelligent sequences, taking into account the likely functional relationships and satellite referral patterns that must be addressed to get to the root of pain.
As an example, our Core Upper Body Protocol covers all of the relationships that are likely to keep the infraspinatus activated, so you aren't wasting your time trying to hammer away on one intransigent muscle at the end of a chain.
All of these protocols are covered in our Coaching The Body Membership training. The Membership is our flagship training program for practitioners, and it incorporates hundreds of hours of trainings that we used to do exclusively in person.
Now it's available online, in a format that you can use as a reference for the rest of your career.
These ideas were developed over 20+ years of clinical experience, and have been tested in thousands of sessions.
Recently, I was gratified to be able to restore full shoulder range to an athlete who was attempting to return to pro sports after a disastrous surgery left him without enough range to play at a pro level.
Before seeing me, he had been failed by 40 different PTs, none of whom could restore his pain-free range in a lasting way.
Please see the video for an example of working with some of the essential muscular relationships behind shoulder pain. It's a great example of how to work with functional pairs and make dynamic treatment decisions.
Changing the course of someone's life in this way is immeasurably satisfying. You can help them realize their dreams, and you can achieve some of yours as well.
I hope that you can join our community of Pain Hackers.
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