The Trigger Point Therapy Workbook YOUR SELF-TREATMENT GUIDE FOR PAIN RELIEF Clair Davies, N.C.T.M.B. Foreword by David G. Simons, M.D. New Harbinger Publications, Inc.Publisher's Note "This publication is designed to provide accurate and authoritative information in regard to the subject matter covered. Iti sold with the wx- derstanding that the publisher is not engaged in rendering medical, psychological, financial, legal, or other professional services. f expert as- sistance or counseling is needed, the services of a competent profesional should be sought Care has been taken to confirm the accuracy of the information presented and to describe generally accepted practices. However, the authors, editors, and publisher are not responsible for errors or omissions or for any consequences from application of the information in this book ‘and make no warranty, express or implied, with respect to the contents of the publication. Some drugs and metioal devices presented in this publication may have Food and Drug Administration (FDA) clearance for limited use in restricted research settings. Its the responsibilty ofthe healthcare provider to ascertain the FDA status of each drug or device planned for use in their clinical practic Distributed in the U.S.A. by Publishers Group West; in Canada by Raincoast Books; in Great Britain by Aislift Book Company, tds in South Africa by Real Books, Ltd.; in Australia by Boobook; and in New Zealand by Tandem Press. Copyright © 2001 by Clair Davies New Harbinger Publications, Inc. 5674 Shattuck Avenue ‘Oakland, CA 94609 Cover design by SHELBY DESIGNS AND ILLUSTRATES ustrations by Clair Davies Eaited by Clancy Drake Text design by Michele Waters ISBN 1-57224-250-7 Paperback All Rights Reserved Printed in the United States of America New Harbinger Publications’ Web site address: www.newharbinger.com eB 2 oO wo 9 8 7 6 5 £ 3 2This book is dedicated to my daughter Amber Davies. I could not have written it without her steady faith in me. Her patience, constant encouragement, tactful criticism, and undying enthusiasm for trigger point therapy continually renewed my faith in myself and in the value of this project. Amber has been my number-one disciple. As a longtime sufferer of debilitating chronic pain, she was highly motivated to test and validate every new idea regarding self-treatment. My greatest reward has been in seeing her become relatively pain free and self-reliant due to our combined efforts. Amber has gone on to become a skilled massage therapist and is now devoted to helping bring the benefits of trigger point therapy to others.CHAPTER 1 CHAPTER 2 CHAPTER 3 CHAPTER 4 CHAPTER 5 CHAPTER 6 CHAPTER 7 CHAPTER 8 CHAPTER 9 CHAPTER 10 Contents Ilustrations Foreword Acknowledgments Introduction A New Life All about Trigger Points Massage Guidelines Head and Neck Pain Shoulder, Upper Back, and Upper Arm Pain Elbow, Forearm, and Hand Pain Chest and Abdominal Pain Midback, Low Back, and Buttocks Pain Hip, Thigh, and Knee Pain Lower Leg, Ankle, and Foot Pain Epilogue Resources Bibliography References Index vii xvii xix 15 35 7 125 154 177 209 247 251 253 257FIGURE 2.1 FIGURE 2.2 FIGURE 3.1 FIGURE 3.3 FIGURE 3.4 FIGURE 3.2 FIGURE 3.5 FIGURE 3.6 FIGURE 4.1 FIGURE 4.2 FIGURE 4.3 FIGURE 4.4-4.6 FIGURE 4.7 FIGURE 4.8 FIGURE 4.9 Ficure 4.10 FIGURE 4.11 FIGURE 4.12 FIGURE 4.13 FIGURE 4.14 FIGURE 4.15 FIGURE 4.16 FIGURE 4.17 FIGURE 4.18 Figure 4.19 Tliustrations Magnified contraction knots (trigger points) in muscle fibers Orientation of muscle fibers: (A) parallel; (B) parallel with tendinous inscriptions; (C) bipennate; (D) unipennate Key to pictorial devices Supported fingers Supported fingers nearly perpendicular to skin Supported thumb Thera Cane The Knobble massage tool Stemocleidomastoid muscles Stemocleidomastoid, sternal branch: trigger points and referred pain pattern Sternocleidomastoid, clavicular branch: trigger points and referred pain pattern Sternocleidomastoid massage between fingers and thumb ‘Trapezius number 1 trigger point and referred pain pattern: front view Trapezius number 1 trigger point and referred pain pattern: side view Trapezius number 2 trigger point and referred pain pattern ‘Trapezius number 3 trigger points and referred pain patiern Trapezius number 4 trigger points and referred pain pattern Massage of number 1 trigger point with fingers and thumb Trapezius massage with supported thumb against ball on the wall or bed Upper trapezius massage with Thera Cane Middle trapezius massage with Thera Cane over the opposite shoulder Lower trapezius massage with Thera Cane Lower trapezius massage with ball against wall Levator scapulee trigger points and referred pain pattern Suboccipital muscles’ trigger points 21 37 40 a ai 49 50 52 53 SRSRRRL88 56 59viii The Trigger Point Therapy Workhook FiguRE 4.20 FIGURE 4.21 FIGURE 4.22 FIGURE 4.23 FIGURE 4.24 FIGURE 4.25 FIGURE 4.26 FIGURE 4.27 FIGURE 4.28 FIGURE 4.29 FIGURE 4.30 FIGURE 4.31 FIGURE 4.32 FIGURE 4.33 FIGURE 4.34 FIGURE 4.35 FIGURE 4.36 FIGURE 4.37 FIGURE 4.38 FIGURE 4.39 FIGURE 4.40 Figure 4.41 FIGURE 4.42 FIGURE 4.43 FIGURE 4.44 FIGURE 4.45 FIGURE 4.46 FiGuRE 4.47 FIGURE 5.1 Figure 5.2 Figure 5.3 Figure 5.4 Figure 5.5 FIGURE 5.6 FIGURE 5.7 FIGURE 5.8 g, FIGURE 5.9 FIGURE 5.10 Suboccipitals’ referred pain pattern 59 Posterior neck massage with Thera Cane 59 Position of hands for posterior neck massage with ball or Knobble in hand. 60 Use this position while lying down First hand in place for posterior neck massage with supported fingers 60 Second hand in place for posterior neck massage with supported fingers 60 Splenius capitis trigger point and referred pain pattern 61 Splenius cervicis trigger point number 1 and referred pain pattern: through the 64 hhead to the back of the eye Splenius cervicis trigger point number 2 and referred pain pattern 61 Semispinalis capitis number 1 trigger points and referred pain pattern 61 Semispinalis capitis number 2 trigger points and referred pain. pattern 62 ‘Multifidi and rotatores trigger points and referred pain pattern 62 Masseter trigger points and referred pain pattern 63 Masseter massage with thumb and fingers (thumb inside the mouth) Medial pterygoid trigger points and referred pain pattern 65 Medial pterygoid massage with thumb 85 Lateral pterygoid trigger points and referred pain pattem 65 Lateral pterygoid massage with index finger in mouth Buccinator trigger point and referred pain pattern Obicularis oculi trigger points and referred pain pattern 67 Zygomaticus and levator labii trigger point and referred pain pattern 67 Zygomaticus and levator labii massage with fingertips 67 Kneading the zygomaticus between fingers and thumb 67 Diagastric trigger points and referred pain pattem 68 Posterior digastric massage with fingertips 68 Anterior digastric massage with fingertips 68 Longus colli massage with fingertips 69 Temporalis trigger points and referred pain pattern 69 Temporalis massage with supported fingers 70 Scalene trigger points 75 Scalene referred pain patter, front view 75 Scalene referred pain pattern, back view 75 Location of scalene muscles behind the stemocleidomastoid 76 Scalene massage behind the sternocleidomastoid with fingertips 7 Scalene massage behind the sternocleidomastoid attachment to the collarbone 78 Posterior scalene massage at the junction of the trapezius and the collarbone 78 Bones of the shoulder, front view 79 Bones of the shoulder, back view 79 Locating the superior angle of the shoulder blade 80Figure 5.11 FIGURE 5.12 FIGURE 5.13 FIGURE 5.14 Figure 5.15 FicurE 5.16 Ficure 5.17 FIGURE 5.18 FIGURE 5.19 FIGURE 5.20 FIGURE 5.21 FIGURE 5.22 Figure 5.23 FIGURE 5.24 FIGURE 5.25 FIGURE 5.26 FIGURE 5.27 FIGURE 5.28 FIGURE 5.29 FIGURE 5.30 FIGURE 5.31 FIGURE 5.32 Figure 5.33 FiGuRE 5.34 FiGuRE 5.35 FIGURE 5.36 FIGURE 5.37 FIGURE 5.38 FIGURE 5.39 FIGURE 5.40 FIGURE 5.41 FIGURE 5.42 FIGURE 5.43 FIGURE 5.44 FIGURE 6.1 FIGURE 6.2 FIGURE 6.3 Mustrations ix Rhomboid trigger points and referred pain pattern 81 Serratus posterior superior trigger points 82 Serratus posterior superior referred pain pattern 82 Serratus posterior superior massage with Thera Cane (hand at opposite 82 shoulder) Supraspinatus trigger points and referred pain pattern 84 Supraspinatus massage with the Thera Cane 85 Infraspinatus trigger points 86 Infraspinatus referred pain pattern 86 Axrow shows outward rotation for locating infraspinatus with isolated 87 contraction Infraspinatus massage with Thera Cane 88 Teres minor trigger points and referred pain pattern 88 Subscapularis trigger points and referred pain pattern 89 Position of the fingers for the subscapularis massage ot Position of the thumb for the subscapularis massage o Position of the arms for the subscapularis massage 91 Subscapularis massage with arm hanging down between legs 4 Deltoid trigger points 92 Posterior deltoid pain pattem 92 Lateral deltoid pain pattern 92 Anterior deltoid pain pattern 92 Teres major trigger points and referred pain pattern 94 Latissimus dorsi trigger points and referred pain pattern 94 Latissimus dorsi and teres major massage between fingers and thumb 94 Coracobrachialis trigger points and anterior referred pain pattern 95 Coracobrachialis posterior referred pain pattern 95 Coracobrachialis massage with thumb 95 Biceps trigger points and referred pain patter 96 Biceps massage with knuckles 96 ‘Triceps number 1 trigger point and referred pain pattern 97 Triceps number 2 trigger point and referred pain pattern 97 ‘Triceps number 3 trigger point and referred pain pattern 97 ‘Triceps number 4 trigger point and referred pain pattern 98 ‘Triceps number 5 trigger point and referred pain pattern 98 ‘Triceps massage with knuckles and ball 98 Avoid grasping with thumb and fingers 105 Bones of the forearm and hand: (A) radius; (B) ulna; (C) carpals; (D) 106 metacarpals; (E) phalanges ' ‘7 Brachialis ‘rigger points and referred pain patternx The Trigger Point Therapy Workbook Figure 6.4 FIGURE 6.5 FIGURE 6.6 FIGURE 6.7 FIGURE 6.8 FIGURE 6.9 FIGURE 6.10 FiGuRE 6.17 FIGURE 6.12 FIGURE 6.13 FIGURE 6.14 FicurE 6.15 FIGURE 6.16 FIGURE 6.17 FIGURE 6.18 FIGURE 6.19 FIGURE 6.20 FIGURE 6.24 FIGURE 6.22 FIGURE 6.23 FIGURE 6.24 FIGURE 6.25 FIGURE 6.26 FIGURE 6.27 FIGURE 6.28 FIGURE 6.29 FIGURE 6.30 Figure 6.34 FIGURE 6.32 FIGURE 6.33 FIGURE 6.34 FIGURE 6.35 FIGURE 6.36 FicuRE 6.37 i, FIGURE 6.38 , FIGURE 6.39 Brachialis massage with supported thumb Extensor carpi radialis longus trigger point and referred pain patter (the drawings show the outer side of the forearm and hand) Locating the extensor carpi radialis longus by isolated contraction Extensor carpi radialis longus massage with supported thumb Extensor carpi radialis longus massage with ball against a wall (the ball is between the arm and the wall, which is not shown here) Brachioradialis trigger point and referred pain patter Supinator trigger point and referred pain pattern Extensor carpi radialis brevis trigger point and referred pain pattern. Locating extensor carpi radialis brevis by isolated contraction Extensor carpi radialis brevis massage with ball against the wall Extensor carpi ulnaris trigger point and referred pain pattem Locating extensor carpi ulnaris by isolated contraction Extensor carpi ulnaris massage with ball against the wall Anconeus trigger point and referred pain pation Locating the anconeus by isolated contraction. Extensor igitorum trigger point and referred pain pattem Extensor indicis trigger point and referred pain pattern Locating extensor digitorum by isolated contraction Locating the extensor indicis Extensor digitorum massage with ball against the wall Flexor carpi radialis trigger point and referred pain pattern Locating flexor carpi radialis by isolated contraction Flexor carpi radialis massage with supported thumb Flexor carpi radialis massage with ball against the wall Flexor carpi ulnaris trigger point and referred pain pattern Locating flexor carpi ulnaris by isolated. contraction Palmaris longus trigger point and xeferred pain. pattern Locating palmaris longus by isolated contraction Flexor digitorum trigger points and referred pain pattern Pronator teres and pronator quadratus trigger points and referred pain pattern Locating pronator teres by isolated contraction Locating pronator quadratus by isolated contraction Hlexor pollicis longus trigger point and referred pain pattern Locating flexor pollicis by isolated contraction Opponens pollicis trigger points and referred pain pattern Opponens pollicis massage with supported thumb Adductor pollicis trigger points and referred pain pattern 108 109 109 110 110 110 111 a1 114 112 112 112 113, 113 13 “114 114 114 115 115 116 116 116 116 7 117 17 118 118 119 119 19 120 120 3 121 121Ilustrations xi FIGURE 6.41 Locating the abductor pollicis. To feel the muscle contract, press the thumb — 121 against the side of the hand. FIGURE 6.42 Adductor pollicis massage with supported thumb 122 FIGURE 6.43 Dorsal interosseous trigger points and referred pain pattern 122 FIGURE 6.44 First dorsal interosseous trigger points and referred pain pattern 122 FIGURE 6.45 ——_Locating first dorsal interosseous by isolated contraction 123 FIGURE 6.46 Dorsal interosseous massage with supported thumb 123 FIGURE 6.47 Eraser massage of interosseous 124 FIGURE 6.48 Spring clamps and erasers for massage of interosseous muscles * 124 FIGURE 6.49 First dorsal interosseous massage with supported thumb 124 FIGURE 7.1 Pectoralis major, clavicular section: trigger points and referred pain pattern 130 FIGURE 7.2 Pectoralis majot, sternal section: trigger points and referred pain pattern 130 FIGURE 7.3 Pectoralis major, costal section: trigger points and referred pain pattern 130 FIGURE 7.4 Pectoralis major, arrhythmia trigger point 130 FIGURE 7.5 Pectoralis major massage with ball against the wall 131 FIGURE 7.6 Pectoralis major massage with supported fingers 131 FIGURE 7.7 Pectoralis major massage of lateral border 134 FIGURE 7.8 Subclavius trigger points and referred pain pattem 132 FIGURE 7.9 Stemnalis trigger points and referred pain pattern 132 FiGuRE 7.10 Pectoralis minor trigger points and referred pain pattern 134 FIGURE 7.11 Locating pectoralis minor: the hand behind the back is pushing against the 135 wall FIGURE 7.12 Serratus anterior trigger point (trigger points may be found in any of the 136 muscle’s bellies) FIGURE 7.13 Serratus anterior referred pain pattern in the side 136 FIGURE 7.14 Serratus anterior referred pain pattem in the back 136 FIGURE 7.15 — Serratus anterior massage with ball against the wall 137 FIGURE 7.16 Upper abdominal trigger points and referred pain pattern 141 FIGURE 7.17 Midabdominal trigger points and referred pain pattern 141 FIGURE 7.18 Pseudoappendicitis trigger point and referred pain pattern 141 FIGURE 7.19 Lower abdominal trigger points and referred pain pattern 144 FIGURE 7.20 Abdominal trigger points and referred pain patterns in the back 142 FIGURE 7.21 Supported fingers for upper abdominal massage 143 FiGuRE 7.22 Supported fingers for lower abdominal massage 143 FIGURE 7.23 Supported thumbs in opposition for midabdominal massage 143 FIGURE 7.24 ‘Massage of midabdomen. 144 FIGURE 7.25 Psoas trigger points and referred pain pattern in the back 145 FIGURE 7.26 Psoas trigger points and referred pain pattern in the groin and thigh 145 FIGURE 7.27 Supported fingers for psoas massage 146 FIGURE 7.28 —Psoas massage with supported fingers 147xii The Trigger Point Therapy Workbook FIGURE 8.1 Deep spinal muscles: sample trigger points and pain patterns 155 FIGURE 8.2 (A) Semispinalis; (B) multifidi; (C) rotatores; (D) levator costae muscles 155 FIGURE 8.3 Massage of deep spinal muscles with Thera Cane 157 FIGURE 8.4 Longissimus sample trigger points and referred pain pattem. 159 FIGURE 8.5 Miocostalis sample trigger points and referred pain patterns 159 FIGURE 8.6 Serratus posterior inferior trigger points and referred pain pattern 160 FIGURE 8.7 Serratus posterior inferior massage with ball in a sock against the wall 161 FIGURE 8.8 Quadratus lumborum: superficial trigger points and referred pain pattem 162 FIGURE 8.9 Quadratus lumborum: deep trigger points and referred pain pattern 162 FIGURE 8.10 Locating quadratus lumborum by isolated contraction with hip hike 163 FIGURE 8.11 Quadratus lumborum massage with ball against the wall 163 FIGURE 8.12 Quadratus Jumborum massage with Thera Cane 163 FIGURE 8.13 Gluteus maximus number 1 trigger point and referred pain pattem 164 FIGURE 8.14 luteus maximus number 2 trigger point and referred pain patter 164 FIGURE 8.15 Gluteus maximus number 3 trigger point and referred pain pattern 164 FIGURE 8.16 Massage of gluteal muscles with ball against the wall FIGURE 8.17 Massage of gluteal muscles with ball on the floor or the bed FIGURE 8.18 Massage of gluteal muscles with Thera Cane - FIGURE 8.19 luteus medius number 1 trigger point and referred pain pattern FIGURE 8.20 luteus medius number 2 trigger point and referted pain pattern FIGURE 8.21 luteus medius number 3 trigger point and referred pain pattern FIGURE 8.22 Feeling the greater trochanter (A) and the top of the hipbone (B) FIGURE 8.23 Locating gluteus medius by isolated contraction with weight shift to right foot 169 FIGURE 8.24 luteus medius massage with ball against the wall 169 FIGURE 8,25 Gluteus minimus number 1 trigger point and referred pain pattern 170 FIGURE 8.26 — Gluteus minimus number 2 trigger point and referred pain pattern 170 FIGURE 8.27 Locating sluteus minimus by isolated contraction with weight shift to right 174 foot FIGURE 8.28 — Gluteus minimus massage with ball against the wall 171 FIGURE 8.29 Piriformis number 1 trigger point and referred pain pattern 172 FIGURE 8.30 ——_Piriformis number 2 trigger point and referred pain pattern 172 FIGURE 8.31 (A) pitiformis; (B) the other short hip rotators; (C) the sciatic nerve 173 FIGURE 8.32 Locating piriformis by isolated contraction 174 FIGURE 8.33 Piriformis massage with ball against wall 174 FIGURE 8.34 Piriformis stretch 175 Figure 9.1 Tensor fasciae latae trigger point and referred pain pattern 181 FiGure 9.2 Locating tensor fasciae latae by isolated contraction with weight shift 182 FiGuRE 9.3 Tensor fasciae latae massage with Thera Cane 182 FIGURE 9.4 Tensor fasciae latae massage with ball against wall 182FIGURE 9.5 FIGURE 9.6 FIGURE 9.7 FIGURE 9.8 FIGURE 9.9 FIGURE 9.10 Figure 9.11 Figure 9.12 Figure 9.13 FIGURE 9.14 FIGURE 9.15 FIGURE 9.16 FIGURE 9.17 FIGURE 9.18 FIGURE 9.19 FIGURE 9.20 FIGURE 9.21 FIGURE 9.22 FIGURE 9.23 FIGURE 9.24 FIGURE 9.25 Ficure 9.26 FIGURE 9.27 FicurE 9.28 FIGURE 9.29 FIGURE 9.30 FIGURE 9,31 FIGURE 9.32 FIGURE 9.33 FIGURE 9.34 FIGURE 9.35 FIGURE 9.36 FIGURE 9.37 FIGURE 9.38 FIGURE 9.39 FIGURE 9.40 FIGURE 9.41 FIGURE 9.42 Ilustrations Sartorius trigger points and referred pain pattern Sartorfus referred pain pattern near the knee Locating sartorius by isolated contraction, by raising the leg forward Sartorius massage with supported fingers Quadriceps muscle Rectus femoris number 1 tigger point and refered pain pattern Rectus femoris number 2 trigger point and referred pain pattern Locating rectus femoris by isolated contraction Rectus femoris massage with paired thumbs Rectus femoris massage with Thera Cane Rectus femoris massage with ball against the wall Vastus intermedius trigger point and referred pain pattern Vastus medialis number 1 trigger point and referred pain pattern Vastus medialis number 2 trigger point and referred pain pattern Vastus medialis massage with paired thumbs Vastus medialis massage with supported fingers Vastus medialis massage with elbow Vastus lateralis number 1 trigger point and referred pain pattern Vastus lateralis number 2 trigger point and referred pain pattern Vastus lateralis number 3 trigger point and referred pain pattern Vastus lateralis number 4 trigger points and referred pain pattern Vastus lateralis number 5 trigger point and referred pain pattern ‘Vastus lateralis massage with supported fingers ‘Vastus lateralis massage with Thera Cane Vastus lateralis massage with ball against the wall Inner thigh muscles Pectineus trigger point and referred pain pattern Locating pectineus by isolated contraction, raising the inner leg forward Pectineus massage with paired fingers Adductors longus and brevis trigger points and referred pain pattern 183 183 184 184 185 186 186 187 187 188 188 188 189 189 190 190 190 191 191 191 191 191 192 192 193 193 194 195 195 196 Locating adductor longus (A) and abductor magnus (B) by isolated contraction, 197 raising right leg from bed Grasping adductor longus between fingers and thumb Grasping adductor magnus between fingers and thumb Adductor massage with supported fingers Adductor magnus number 1 trigger points and referred pain pattern Adductor magnus number 2 trigger points and referred pain pattern ‘Adductor magnus number 1 massage near the sit bone with Thera Cane Position of ball for adductor magnus number 1 trigger point massage on ‘wooden chair 198 198 198 199 199 200 200xio The Trigger Point Therapy Workbook FIGURE 9.43 —Gracilis trigger points and referred pain pattern 201 FIGURE 9.44 (A) hamstrings; (B) sit bone; (C) femur; (D) tibia; (B) fibula 201 FIGURE 9.45 Biceps femoris trigger point and referred pain pattern 202 FIGURE 9.46 Hamstring massage with ball on wooden bench or chair 203 FIGURE 9.47 Semitendinosus and semimembranosus trigger point and referred pain patiem 204 FIGURE 9.48 —_Popliiteus trigger point and referred pain pattern 205 FiguRE 9.49 ——_Popliiteus massage with fingers of both hands 206 FIGURE 9.50 Popliteus massage with thumbs 206 FIGURE 9.51 —_—_Plantaris irigger point and referred pain pattern 207 FIGURE 10.1 (A) shin muscles; (B) tibia; (C) fibula 214 FIGURE 10.2 Tibialis anterior trigger point and referred pain pattem 216 FIGURE 10.3 Locating tibialis anterior by isolated contraction 217 FIGURE 10.4 Tibialis anterior massage with supported fingers or Knobble 217 FIGURE 10.5 —Tibialis anterior massage with Thera Cane 217 FIGURE 10.6 —_Tibialis anterior massage with the heel as the tool 218 FIGURE 10.7 Tibialis anterior massage with heel 218 FIGURE 10.8 Extensor digitorum longus trigger point and referred pain pattern 219 FiGURE 10.9 Extensor hallucis longus trigger point and referred pain pattern __ 219 FIGURE 10.10 Locating extensor digitorum longus by isolated contraction 220 FIGURE 10.11 ‘Locating extensor hallucis longus by isolated contraction 220 FIGURE 10.12 (A) peroneus muscles; (B) tibia; (C) fibula; (D) fifth metatarsal 224 FIGURE 10.13 Peroneus longus trigger point and referred pain pattern 222 FIGURE 10.14 Locating peroneus longus by isolated contraction 223 FIGURE 10.15 Peroneus longus massage with paired thumbs 223 FIGURE 10.16 —_Peroneus brevis trigger point and referred pain pattern 224 FIGURE 10.17 Locating peroneus brevis by isolated contraction 224 FIGURE 10.18 —Peroneus tertius trigger point and referred pain pattern 225 FIGURE 10.19 Locating peroneus tertius by isolated contraction 225 FIGURE 10.20 Peroneus tertius massage with paired thumbs 225 FIGURE 10.21 Peroneus tertius massage with ball on the edge of the bed 226 FiGuRE 10.22 — Gastrocnemius number 1 trigger point and referred pain pattern in the instep 227 FiGure 10.23 Other gastrocnemius trigger points and local pain pattern 227 FiGURE 10.24 — Gastrocnemius massage with supported fingers 228 FIGURE 10.25 — Gastrocnemius massage with opposite knee 228 FIGURE 10.26 Gastrocnemius massage with opposite knee 228 FIGURE 10.27 Soleus number 1 trigger point and referred pain paterrn 230 FIGURE 10.28 Soleus number 2 trigger point and referred pain pattern 230 FIGURE 10.29 Soleus number 3 trigger point and referred pain pattern in the low back 230 FIGURE 10.30 Tibialis posterior trigger points and referred pain pattern 232FIGURE 10.31 Figure 10.32 Figure 10.33 Figure 10.34 Figure 10.35 FIGURE 10.36 FIGURE 10.37 FIGURE 10.38 FIGURE 10.39 FiGURE 10.40 Figure 10.41 FiGuRE 10.42 FIGURE 10.43 FIGURE 10.44 FIGURE 10.45 FIGURE 10.46 FIGURE 10.47 FIGURE 10.48 FIGURE 10.49 FIGURE 10.50 FIGURE 10.51 FIGURE 10.52 FiGuRE 10.53 Figure 10.54 Figure 10.55 FIGURE 10.56 FIGURE 10.57 Mlustrations Flexor digitorum longus trigger point and referred pain pattern Flexor hallucis longus trigger point and referred pain pattem. Flexor digitorum longus massage with paired thumbs Locating flexor hallucis longus by isolated contraction ‘Morton's foot: (A) second metatarsal; (B) first metatarsal; (C) calluses Locating the metatarsal heads Pads under the first metatarsal heads Extensor digitorum brevis and. extensor hallucis brevis trigger points referred pain pattern . Sample interosseous trigger point and referred pain pattern Locating the short extensors by isolated contraction Inierosseous massage with supported thumb Abductor hallucis trigger points and referred pain pattern Locating abductor hallucis by isolated contraction Abductor hallucis massage with supported thumb Massaging the bottom of the foot with small nipple on the Thera Cane ‘Massaging the bottom of the foot with the Knobble Massaging the bottom of the foot with a small hard rubber ball on the floor Abductor digiti minimi trigger points and referred pain pattern Locating abductor digiti minimi by isolated contraction Flexor digitorum brevis trigger points and referred pain pattern Locating flexor digitorum brevis by isolated contraction Quadratus plantae trigger point and referred pain pattern Adductor hallucis trigger points and referred pain pattern Flexor hallucis brevis trigger points and referred pain pattern Locating adductor hallucis and flexor hallucis brevis by isolated contraction ‘Adductor hallucis and flexor hallucis brevis massage with supported thumb Flexor digiti minimi brevis tigger point and referred pain pattern x0 233 233 234 234 235 236 236 237 238 239 239 240 240 241 241 241 244 242 242 243 244 244 245Foreword By David G. Simons, M.D. Clair Davies possesses a fortunate combination of attributes: He is a skilled practitioner, has good writing skills, and: shows a remarkable determination to help relieve mankind of unnecessary suffering. The message of this book is a voice in a wilderness of neglect. Muscle is an orphan organ. No medical specialty claims it. As a consequence, no medical specialty is concerned with promoting funded research into the muscular causes of pain, and medical students and physical therapists rarely receive adequate primary training in how to recog- nize and treat myofascial trigger points. Fortunately, massage therapists, although rarely well trained medically, are trained in how to find myofascial trigger points and frequently become skilled in their treatment. Since there is no well-established body of research on this subject, there is no well- recognized etiology. Nevertheless, a credible hypothesis based on solid scientific research is available to serve as a model for further research to clarify the nature of myofascial trigger points. Much research needs to be done on this neglected subject. It is becoming increasingly clear that nearly all fibromyalgia patients have myofascial trigger points that are contributing significantly to their total pain problem. Some patients are diagnosed as having fibromyalgia when in fact they only have much more treatable mul- tiple trigger points. Inactivation of the trigger points of fibromyalgia patients requires espe- cially delicate and skilled treatment. Skilled clinicians recognize myofascial trigger points as the most common cause of ubiquitous enigmatic musculoskeletal pain, but finding a truly skilled practitioner can be frustratingly difficult. The guidance in this book can serve practitioners who have yet to understand the nature of their own musculoskeletal pain and can also benefit patients who are unable to find a practitioner adequately skilled in this neglected subject. There is no substitute for learning how to control your own musculoskeletal pain. Treating myofascial trigger points yourself addresses the source of that kind of common pain and is not just a way of temporarily relieving itAcknowledgments I’m fortunate to have been influenced by so many good people during the development of this book and throughout my own evolution. The following deserve special notice: ‘Ann Luray Bailey of Lubbock, Texas (formerly Ann Gyor of Lexington, Kentucky), my first massage therapist, “the one I liked so much,” the wondrous woman who introduced me to trigger points and then moved away, making it necessary for me to draw on my own. resources and ultimately produce this method of self-treatment. If all healthcare practitioners had Ann’s mind, hands, and heart, there would be very little pain in the world. Barbara G. Cummings, the illustrator for Travell and Simons’ Myofascial Pain and Dys- function, The Trigger Point Manual, whose insight, imagination, and graphic skills made it possible to comprehend the reality of trigger points for the first time. The complex medical innovations of Janet Travell and David Simons would have been virtually incomprehensible without Barbara’s drawings. She made the Trigger Point Manual work. Her illustrations were a constant inspiration while I was struggling to create my own illustrations for this book. All my friends in the Piano Technicians Guild, who fostered my growth, not only as a piano technician, but also as a writer and illustrator in the Piano Technicians Journal. I con- tinue to feel their support, even after leaving the fold and taking on this disconcerting new identity. ‘My instructors and classmates at the Utah College of Massage Therapy, who helped bear the “old man” into a new world of caring and healing. So many new experiences! What a trip! “My daughter Maria, my son-in-law (and former apprentice) Wayne Worley, my former wife (and best friend) Janice Lipuma, her son Will Drane, my mother-inlaw Ruth Quigley Smith, and my grandsons Michael and Adam, who were all always in my corner, even when I was too preoccupied to notice. ‘The editors and staff at New Harbinger Publications, who know exactly what they’re doing in putting a book together and caring for an ignorant and apprehensive new author. Special thanks to Clancy Drake, Heather Gamos, Kasey Pfaff, Spencer Smith, Amy Shoup, and Michele Waters. To avoid the disgrace of forgetting someone, I won't try to name the numerous clients and personal friends who have given me so much of their confidence and trust as I rediscov- ered myself in the transition from piano mechanic to massage therapist and teacher of self-care.Introduction Jennifer, twenty-eight, who loved to run for her health every day in the fresh morning air, has had to stop running and is reluctant even to walk any distance because of relentless pain in her knees and heels. Larry, fifty-two, can think of little else but the constant pain in his back. It’s hard to get in and out of bed. His back hurts whether he’s sitting, standing, or lying down. Tt makes him hate his job and has ruined his love life. ‘Melanie, thirty-six, spends her days at a computer keyboard and her nights worrying about her future and the unremitting pain in her arms and hands, As a single mother, she has to keep working no matter what. Jack, forty-five, has shoulder pain that wakes him up at night. He can’t raise his arm to comb his hair. Reaching up to scratch his back is impossible. A sudden movement brings a jolt of pain that feels like an electric shack and doubles him over, grimacing and breathless, Is this the start of the inevitable decline into old age, disability, and death? Howard, twenty-three, is a gifted violin student. After years of hard work under some of the best teachers in the country, he now fears a professional career is out of reach because of constant pain and an unexplained, increasing stiffness in his fingers. Do you know anybody like these people? They’re everywhere—on every job, in every office, in every home. The thing all these people have in common, other than chronic pain, is that they aren't getting the help they need. It’s not that they haven't looked. They've gone the rounds. They've seen doctors, had tests, done physical therapy, and filled out insurance forms, or—sick at heart—have paid the exorbitant bills themselves. They've tried chiropractic, acupuncture, magnets, pain diets, and herbal therapy. They take their pain medicine and dutifully do their stretching exercises. Sometimes they feel better for a while, but the pain always comes back. Nothing really seems to get to the bottom2 The Trigger Point Therapy Workbook of the problem. They fear surgery may be the only solution, despite being told there are no guarantees of success. They’re beginning to wonder if anybody really knows anything about ain. If all this describes your own situation or that of someone you care about, this book may provide the help you've been seeking, It proposes to give you a sensible explanation of what's wrong and help you find the real cause of your pain. Even better, it may well show you how to get rid of the pain yourself, hands-on. No doctors. No pills. No bills. There is growing evidence that most of our common aches and pains—and many other puzzling physical complaints—are actually caused by trigger points, or small contraction knots, in the muscles of the body. Pain clinic doctors skilled at detecting and treating trigger points have found that they’re the primary cause of pain roughly 75 percent of the time and are at least a part of virtually every pain problem. Even fibromyalgia, which is known to afflict millions of people, is thought in many instances to have its beginning with trigger points. (Travell and Simons 1999: 12-19; Gerwin 121; Fishbain 181-197). Trigger points are known to cause headaches, neck and jaw pain, low back pain, the symptoms of carpal tunnel syndrome, and many kinds of joint pain mistakenly ascribed to arthritis, tendonitis, bursitis, or ligament injury. Trigger points cause problems as diverse as earaches, dizziness, nausea, heartburn, false heart pain, heart arrhythmia, tennis elbow, and genital pain. Trigger points can also cause colic in babies and bed-wetting in older children, and may be a contributing cause of scoliosis. They are a cause of sinus pain and congestion. They may play a part in chronic fatigue and lowered resistance to infection. And because trigger points can be responsible for long-term pain and disability. that seem to-have no means of relief, they can cause depression. The problems trigger points cause can be surprisingly easy to fix; in fact most people can do it themselves if they have the right information. That’s good, because the time has come for ordinary people to take things into their own hands. The reason this is so is that an appallingly high percentage of doctors and other practitioners are still pretty much out of the loop regarding trigger points, despite their having been written about in medical jour- nals for over sixty years. There has been, and continues to be, great resistance to the whole idea. Why has the medical profession not embraced the idea of trigger points? Partly it’s because trigger points are commonly confused with acupressure points. Acupressure, which has come down to us from ancient Chinese medicine, is alleged to have a positive effect on supposed flows of energy throughout the body. Although acupressure and other Eastern methods of healing do seem to have a beneficial effect, they’re very resistant to solid scien- tific investigation and are viewed by many doctors and a large segment of the public as quack medicine with no proven results. If you don’t know the difference, the claims about trigger points sound like quack medicine too. Our knowledge of trigger points, however, comes right out of Western medical research. Trigger points are real. They can be felt with the fingers. They emit distinctive elec- trical signals that can be measured by sensitive electronic equipment. Trigger points have also been photographed in muscle tissue with the aid of the electron microscope. (Travell and Simons 1999: 57-67) Most of what is known about trigger points is very well documented in the two-volume medical text Myofascial Pain and Dysfunction: The Trigger Point Manual, by Janet Travell and David Simons, These books tell virtually all that is known about trigger points, and the ‘pros- Pects for pain relief are very exciting. Much of the information in The Trigger Point Manual isIntroduction — 3 couched in difficult scientific terms, but basic trigger point science isn’t hard to grasp if it’s put into everyday language. Travell and Simons describe a trigger point as simply a small contraction knot in mus- cle tissue. It often feels like a partly cooked piece of macaroni, or like a pea buried deep in the muscle. A trigger point affects a muscle by keeping it both tight and weak. At the same time, a trigger point maintains a hard contraction on the muscle fibers that are directly con- nected to it. In turn, these taut bands of muscle fiber keep constant tension on the muscle’s attachments, often producing symptoms in adjacent joints. The constant tension in the fibers of the trigger point itself restricts circulation in its immediate area. The resulting accumula- tion of the by-products of metabolism, as well as deprivation of the oxygen and nutrients needed for metabolism, can perpetuate trigger points for months or even years unless some intervention occurs. It’s this self-sustaining vicious cycle that needs to be broken (Travell and Simons 1999: 71-75). The difficulty in treating trigger points is that they typically send pain to some other site, Most conventional treatment of pain is based on the assumption that the cause of pain will be found at the site of the pain. But trigger points almost always send their pain else- where. This referred pain is what has always thrown everybody off, including most doctors and much of the rest of the health-care community. According to Travell and Simons, con- ventional treatments for pain so often fail because they focus on the pain itself, treating the site of the pain while overlooking and failing to treat the cause, which may be some distance away. Even worse than routinely treating the site of the pain is the pharmaceutical treatment of the whole body for what is usually a local problem. Painkilling drugs, the increasingly expensive treatment of choice these days, give us the illusion that something good is hap- pening, when in reality they only mask the problem. Most common pain, like headaches, muscle aches, and joint pain, is a warning—a protective response to muscle overuse or trauma. Pain is telling you that something is wrong and needs correction. It’s not good med- icine to kill the messenger and ignore the message. When pain is seen in its true role as the messenger and not the affliction itself, treatment can be directed to the cause of pain. Luckily, referred pain is now known to occur in predictable patterns. The valuable medical advance made by Travell and Simons and their brilliant illustrator, Barbara Cummings, has been in delineating these very patterns. Once you know where to look, trig- ger points are easily located by touch and deactivated by any of several methods. Unfortunately, the two clinically oriented methods put forth in The Trigger Point Manual don’t lend themselves to self-treatment. The goal of this book is to build on the work of Travell and Simons and provide a more practical and cost-effective approach to pain ther- apy: a classic do-it-yourself approach, rather than a reliance on multiple professional office visits. This new approach is a system of self-applied massage directed specifically at trigger points. Significant relief of symptoms often comes in just minutes. Most problems can be eliminated within three to ten days. Even long-standing chronic conditions can be cleared up in as little as six weeks. Results may be longer in coming for those who suffer from fibromyalgia, chronic fatigue, or widespread myofascial pain syndrome, but even they can experience continuing progress and can have genuine hope of significant improvement in their condition. Self-applied trigger point massage works by accomplishing three things: it breaks into the chemical and neurological feedback loop that maintains the muscle contraction; it increases circulation that has been restricted by the contracted tissue; and it directly stretches the trigger point’s knotted muscle fibers. The illustrations in this book show you how to find4 ‘The Trigger Point Therapy Workbook the trigger points that are generating your specific problems, as well as the exact hands-on techniques for deactivating them. Special attention has been given to designing methods of massage that do no damage to hands that may already be in trouble from overuse. This book’s primary use is as a self-instruction manual, but it can also be used as a text- book for classroom use. This simplified and direct approach to treating pain with self-applied massage can constitute a foundational course in trigger point therapy in any professional training curriculum. Students in chiropractic colleges, physical therapy depart- ments, and massage schools will derive particular benefit. If they can learn how to interpret their own referred pain and how to find and treat their own trigger points, they will know exactly what to do when they encounter similar problems in their future clients. A class in self-applied trigger point massage would be a boon in medical schools for exactly the same reasons. When new doctors can learn how to fix their own pain with self-applied massage, they are in better touch with the realities of pain and with the great potential in the treatment of trigger points. Such an addition to medical education would profoundly improve the treatment of pain and lower much of its cost. And it’s not too late for physicians already in practice to learn about trigger points and myofascial pain and put the knowledge to good use. They will find this book a quick and practical introduction to the magnificent work of Travell and Simons and this neglected branch of medicine. Hopefully, many will be encouraged to go to Travel and Simons’ Trig- ger Point Manual for a deeper scientific understanding and for even greater benefit to their practice. A large segment of the public needs help and encouragement in learning how to deal with their trigger point-induced pain. No one is better positioned to provide this help than the medical community. The medical profession is not unaware of the deficiencies of current methods of treating pain. Doctors hurt too. Many of them worry like the rest of us about the relentless popping of pills, and many experience frustration with their inability to offer better solutions to their patients. Trigger point therapy, whether self-applied or administered by a professional, has the potential to truly revolutionize pain treatment throughout the world.CHAPTER 1 A New Life Iwas sixty years old when, at the height of my success in a business I'd pursued for almost four decades, I decided to dump it all and start at the bottom in a completely new field. Piano rebuilding had been my trade and it had been a good one. My income had exceeded one hundred thousand dollars in some years; as a massage therapist, I knew I'd be lucky to make twenty thousand. The old life was full of rewards, not the least of which was intense satisfaction in the work itself, great prestige in my community, and unquestioned status among my peers. The new life would be full of anxieties and uncertainties, with little likelihood of ever equalling the success I'd enjoyed in the old one. What was my motive for making such a wrenching change? In a word, the motive was pain. Through a difficult personal struggle with pain, I believed I had learned something worth sharing with the world. I believed I’d discovered something new in the treatment of pain that could change lives as it had changed mine. I couldn't be content with keeping it to myself. ‘You wouldn’t be reading this book if you weren’t in the midst of your own unresolved struggle with pain—or if you weren't motivated to help those who are in pain. I hope my story will show you what can be done when nobody is able to help you—when you hurt so bad you'd sometimes almost rather die than live. ‘Vladimir Horowitz's piano tuner taught me to tune pianos. It was 1960 and I was an apprentice at Steinway & Sons in New York. It was a great start, After I left Steinway, I had my own business in New York for several years, tuning in homes, churches, concert halls, recording studios, and theaters all over town. New York was cheap, a lot of really famous people knew my name, I rode a motorcycle, I had girlfriends—life was good. In the late sixties, I moved to Kentucky, seeking cleaner air and a place to park my new car. I settled down, got married, and started raising two spunky daughters. In succeeding years, I rebuilt and refinished hundreds of grand pianos and tuned tens of thousands of pianos of all kinds. The business was full of rewards for a restless, creative spirit: I invented dozens of new tools for the piano trade, and through the many articles I wrote for the Piano Technicians Journal, piano tuners all over the world became acquainted with my tools, my6 The Trigger Point Therapy Workbook methods, my name. I gained a reputation as someone who was good at finding simple solu- tions for difficult problems. But during my time in the piano business I had a lot of trouble with pain—neck pain, back pain, every kind of pain you'd expect to get from hard physical work. As time went by, I grew increasingly concerned about how long I could continue. I had gradually become aware that the happiness and the very livelihood of virtually every piano technician I’d ever known had been threatened at one time or another by work-related pain. I remembered one of my teachers at Steinway had once been so crippled by a bad shoulder that he could hardly do his work. When I eventually came down with a bad shoulder of my own, I had to face the fact that there really weren't any good solutions for pain. Basically, you popped a pill and tried to live through it. I discovered that the worst thing about pain was that doctors and others who were supposed to help didn’t really help: many almost seemed to be faking an understanding. And they all charged an arm and a leg whether they helped you or not. The situation made me so mad and desperate that I made up my mind to fix my shoulder myself, if there was any possible way. Before I was done, had not only gotten rid of my shoulder pain, but I had retired from my work with pianos and had graduated from massage school. Instead of tuning pianos I ‘was now tuning people. I had discovered the most important work of my life. Nobody Understood Shoulders Ironically, my life-changing crisis with pain wasn’t caused directly by piano work—though Tm sure my job set me up for it. The trouble began one January morning when I came in from shoveling snow in my driveway with an oppressive little pain in my shoulder. As I went on with my shop work that day and in the days that followed, I favored the shoulder more and more. Everything I did irritated my condition—whatever that condition was. Before long, I could hardly raise my arm. Soon, I couldn’t pick up my grandson, reach across to get my seat belt, or crawl under a grand piano to do a repair without excruciating pain. It got so bad that a sudden move would give me a jolt of pain that felt like an electric shock, doubling me over, grimacing and breathless, for several minutes. I couldn’t sleep. I’d get up in the night seeking relief with ice rubs and hot showers, but nothing I did had any lasting effect. The ice would dull the pain long enough to let me get back to sleep, but in the momn- ing the pain was back in full force. Some years earlier, I had gone to a massage therapist for a back spasm. I had gone as a last resort, not really hoping for or expecting much. But she fixed me, and then went on to fix the chronic pain I had in my arms and hands. I couldn’t have been more pleased—or sur- prised. I had barely been aware that massage therapy existed, let alone having any notion that it actually worked. I had figured the pain in my arms and hands was just the inevitable and all-too-precipitous decline of old age. But in only three sessions, my massage therapist succeeded in ridding me of an affliction that had possessed me for as long as I could remem- ber. Unfortunately, I was at a loss with the new shoulder problem. This wondrous woman had moved away and I had no choice but to try to find someone else with a similar gift for healing. It was a fruitless search. Variations on the theme of “exercise and stretch” were all I heard, despite my protests that stretching made my pain worse, not better. At one point, I realized that the physical therapist who was treating me for my frozen shoulder was herselfChapter 1A New Life 7 secretly suffering from exactly the same affliction! She couldn’t fix herself and she couldn’t fix me, but she expected payment just the same. Thad a sense that nobody really understood shoulders. I tried a series of massage thera- pists, looking for the grand resullts I’d had before, but they all just seemed to tinker with my shoulder problem. From previous experience, I had no faith in chiropractic for this problem. Talso had no reason to think doctors would offer me anything but painkillers, or worse, sur- gery. You also hear about doctors forcibly manipulating frozen shoulders. Not in this life- time, I thought; thanks just the same. In the midst of my frustrating search for effective treatment, I decided to go to the annual convention of the Piano Technicians Guild. There were classes all week on various aspects of piano technology, and I had always felt revitalized by the dynamic exchange of ideas there. I was determined to go despite my disability, and was hoping a break from work would help. But sitting all day in classes holding my arm defensively and motionless at my side only seemed to aggravate the problem. I rubbed at my shoulder continuously; I squeezed it; I tried to relax it; I tentatively and cautiously flexed it. The only result was an ache that rose in intensity throughout the week. My every thought was of pain. On the last night, the pain was so unremitting that not even the ice treatments had any effect. I lay in bed in my hotel room at two o’clock in the morning and cried like a baby. Evi- dently, all I could hope for was to somehow outlive the problem. I had heard that it took about a year for a shoulder to heal itself—if it did heal itself. Lying there in my misery, I happened to remember a pair of medical books I had seen years earlier on the desk of that first massage therapist I'd liked so much. She told me she teferred to those books constantly, and she had been the only person who really seemed to know what she was doing in regard to pain. I realized I was going to have to find a way to take care of this problem myself and those medical books might at least be a place to start. It was a spark of hope. A New Technology When I got home from the convention, I ordered the books: volumes I and II of Myofascial Pain and Dysfunction: The Trigger Point Manual, by Janet Travell and David Simons. The price of medical books was a shock and I bridled a bit, but I finally had to ask myself: What is this knowledge worth? My shoulder answered the question for me. When the books came, I entered a world I hadn't known existed. As soon as I began to zead, the mystery of my shoulder problem began to clear. In the Trigger Point Manual, 1 found hundreds of beautifully executed illustrations of the muscles of the body. They showed the likely trigger points for every muscle and the patterns of pain they predictably touched off. I found that, although the physiology of a trigger point was extremely complex, a trig- ger point for practical purposes could be viewed as what most people call a “knot”: a wad of muscle fibers staying in a hard contraction, never relaxing. A trigger point in a muscle could be actively painful or it could manifest no pain at all unless touched. More often, though, it would sneakily send its pain somewhere else. I gathered that much of my pain, perhaps all of it, was probably this mysterious displaced pain, this referred pain. I had never been able to figure out why all the rubbing I had been doing had never done any good. Jt was a mis- take to assume the problem was at the place that hurt!8 — The Trigger Point Therapy Workbook The pain in the front of my shoulder was actually coming from behind it, from trigger points in the infraspinatus, a muscle that covered part of the outside of my shoulder blade. The deep aching behind my shoulder was coming from trigger points in the subscapularis, a muscle on the underside of my shoulder blade, sandwiched between the shoulder blade and the ribs. The unrelenting pain at the inner edge of my shoulder blade was being sent by trig- ger points in the scalene muscles, in the front and sides of my neck. It was no wonder nobody knew what to do for me! It was clear to me that all I had was a massive number of trigger points in the muscles in my shoulder—trigger points in over twenty muscles, as it turned out. That first massage therapist, the one I liked so much, had treated me very successfully with ordinary massage techniques and I understood now that it was trigger points she was dealing with. Perhaps I could deal with the trigger points myself using massage. ] began to think that this might be a job for someone with a technician’s mentality—maybe someone who was smart enough to take on the complexities of a piano would be well equipped to fix trigger points. Driven by my misery and by my excitement about these new ideas, I studied Travell and Simons night and day. I found that my trigger points would yield under the touch of my own hands if I persisted. After only about a month of assiduously applying what I was learning chapter by chapter, I had succeeded in fixing my shoulder ... my own shoulder! 1 was astounded. The pain was gone. I could raise my arm. I could sleep through the night. This stuff really worked! Given the innately optimistic cast of my mind, | immediately took a larger view. I saw that I had in my hands the tools to take effective care-of myself, at-least-when-it came-to-any Kind of myofascial pain. I supposed that I might be able to treat any trigger point I could reach and extinguish virtually any pain I might have. I could develop a complete system, a kind of new technology, and maybe other people would be helped by it Mechanical Ingenuity Travell and Simons had done a wonderful thing in giving the science of myofascial pain to the medical community. The illustrations by Barbara Cummings brilliantly clarified every aspect of the subject. Without these dedicated people, the science of trigger points and referred pain would still be an impossible jumble, largely unknown and inaccessible. Unfortunately, Travell and Simons’ two main methods for deactivating trigger points weren't oriented toward self-treatment. They were designed specifically for the doctor's office or the physical therapy clinic: a doctor could inject trigger points with procaine, a local anesthetic; and a physical therapist could presumably stretch trigger points out of existence. It bothered me, however, that the physical therapy protocol, which Travell and Simons called their “workhorse” method, involved. the muscle stretching that I had found so ineffec- tive and even dangerous, in that it had made my shoulder problem dramatically worse. To be sure, Travell and Simons had made stretching safer by using a refrigerant spray on the skin. “Distracting” the nervous system with the spray meant the underlying muscles were less likely to tighten up in defense. Nevertheless, safe or not, I felt that the spray and stretch method was too elaboarte to be practical for self-treatment, and that it would be impossible to use on areas that were hard to reach. Trying to get at the relatively small trigger points by stretching whole groups of recalci- trant muscles seemed unnecessarily indirect and inefficient. The problem was not with the generalized tension in the muscle, but rather with the trigger point, a very specific,Chapter 1—A New Life 9 circumscribed place within the muscle. The trigger points knotted up muscle fibers obvi- ously needed to relax and let go, but why not go straight to the trouble spot and deal with it directly? Massage seemed to me the natural approach, and it obviously worked with trigger points—that good massage therapist had proven that much to me. I wanted to find simple ways to use massage for self-treatment. I wanted to develop a comprehensive method for dealing with trigger points anywhere in the body. I wanted something that a regular person like me could immediately understand and use. I was sure all this could be done. Among the old-time piano men at Steinway, the highest compliment was to be called “a pretty good mechanic.” A good mechanic cared about the details and he stuck with the job until he got it right; he could find the solution to a problem even if it wasn’t in the book. My life up to that point had been built around being a good mechanic, and being able to find the simple solution. That's certainly what I had to do in devising ways to self-treat trigger points. For the purposes of treating trigger points, I felt the body was best thought of as a machine, a mechanical system of levers, fulcrums and forces, especially in regard to the ‘bones and muscles. I could understand such a system. A lifetime of working with my hands was about to begin to pay off in a new and unexpected way. My first challenge was to learn the exact location of each muscle, to visualize how it attached to the bones, and to understand the job the muscle did. Finding the precise massage technique that a trigger point would respond to was where the art would come in. The difficulty here was in figuring out how to reach unreachable places and get effective lever- age in awkward positions without hurting my hands and fingers, which were already being overused in the course of an ordinary workday. The project became an obsession. I studied Travell and Simons the first thing in the morning and the last thing at night. I studied in the parking lot at McDonald’s. Using my own body as the laboratory, I discovered something new every day. I found trigger points everywhere and became aware of pain that I didn’t know I had. I only wanted to talk about trigger points and often greeted family members excitedly with the exclamation, “I found another one! I found another one!” Over a period of three years, I learned how to find and deactivate trigger points in 120 pairs of muscles, which enabled me to cope with every trig- ger point that Travell and Simons dealt with in their books except those inside the pelvis. A World of Pain The misdiagnosis of pain is the most important issue taken up by Travell and Simons. Referred pain from trigger points mimics the symptoms of a very long list of common mala- dies; physicians, in weighing all the possible causes for a given condition, have rarely even conceived of there being a myofascial source. The study of trigger points has not historically been a part of medical education. Travell and Simons hold that most of common everyday pain is caused by myofascial trigger points and that ignorance of that basic concept could inevitably lead to false diagnoses and the ultimate failure to deal effectively with pain. (Travell and Simons 1999: 12-14) From the beginning, I had a sense that for some reason the great work of Janet Travell and David Simons had fallen into a deep pit and was in danger of being buried and forgot- ten. Surely by now Travell’s discoveries about pain should have swept the country and changed the world of health care. The first volume of the Trigger Point Manual had been pub- lished in 1983, but I couldn’t find anything about trigger points in the public library. None of10 The Trigger Point Therapy Workbook the popular family medical guides even mentioned trigger points. Nothing truly informative was to be found. in bookstores. Doctors were still using drugs as the primary treatment for pain. Many were actively hostile to the concept of trigger points, discounting the idea as just more bogus medicine, something purely imaginary. Only massage therapists seemed to be informed about trigger points and referred pain, and only exceptional individuals among them (in my own experience at least) were treating trigger points effectively. What's more, the burgeoning variety of unproven modalities offered by massage therapists gave the profession such an aura of flakiness that the elegant science of myofascial pain treatment got unfairly confused with treatments whose results could easily be attributed to the placebo effect. With such an identity, how could the medical profession or the public at large ever take it seriously? Clearly, there was a world of pain out there in need of the simple and genuine solutions I felt I had in hand. I despaired of doctors ever listening to me about trigger point therapy. Taking the facts about myofascial pain directly to the public seemed the more logical tack. I began to think about leaving the piano business behind. There was something more impor- tant for me to do. The first thing I wanted to do was to write about the self-treatment of pain for all my ailing friends in the Piano Technicians Guild. Previous articles in the Piano Technicians Jour- nal had given me a following. I guessed that my ideas about pain had a better chance of pub- lication in this journal than almost anywhere else. I also conceived of giving seminars and workshops about the self-treatment of pain, and I thought that getting a massage school diploma might give me more credibility-But I had an even better motive for going to massage school. My daughter Amber had had chronic back pain ever since lifting a heavy chair during a scene change while she was work- ing in summer theater. Employing my new knowledge about trigger points, I'd been trying to give her massage, but I just wasn’t very good. I didn’t know the time-tested manual tech- niques used by massage therapists. It would be worth learning to do massage right, if only to help my daughter; and anything I learned that benefited my method of self-treatment would be a plus. I applied to the biggest massage school I could find, one with a busy, well-managed student clinic where I could get a great deal of experience in the shortest time possible. At that moment, I couldn’t imagine becoming a professional therapist, but I definitely wanted the skills. With the help of my son-in-law, who I had trained to take over my piano business, I plowed through a backlog of half a dozen rebuilding jobs. We cleared my calendar in time for me to start a six-month clinical course at the Utah College of Massage Therapy. Massage School There were forty-nine of us in the class: thirty-six women and thirteen men. We were a greatly varied group of all backgrounds, from many states and foreign counties, and ranging in age from. seventeen to sixty. It soon became apparent that, although I was the oldest in the class (and possibly prejudged by most of the others to be a creaking fuddy-duddy), I was the only one who could claim to be free of pain. All the others—young and old, male and female—had some kind of enduring problem with pain. I found that it was almost a cliché that people go to massage school because they have chronic pain and they’re looking for the solution they haven't found elsewhere.Chapter I-A New Life 12 Jt seemed ironic to me that I arrived in Utah having read both volumes of Travell and Simons’ Trigger Point Manual and having gone a long way toward developing my method of self-healing, yet I couldn’t get anyone to listen. I had just left a business where my word was taken as gospel. I had disciples. In the role of student, my accustomed authority was reduced to nil. Nobody wanted to hear what I knew about trigger points. I could only stand and watch as a fellow student would have a pain crisis, usually bad neck pain or a back spasm, and run off to a chiropractor or to the emergency room. I kept offering help and being turned down. Tt was even harder to approach the instructors about do-it-yourself massage, but the anatomy teacher apparently felt less threatened than the others. He was a big, self-confident guy with a great sense of humor, who didn’t fear losing his authority with the students. During a break one day, he heard me talking to a classmate about trigger points and asked if I knew how to fix pain. He said he often had pain that shot diagonally across one side of his chest. He was having it again just that morning. It wasn’t his heart, he said; he'd had it checked. While he explained, I reached up and began pressing on his neck just above his col- larbone. He suddenly stopped talking and winced, then exclaimed, “Hey, that's it! That's my pain! How did you do that?” A trigger point in a scalene muscle was causing the pain in his chest. I showed him how to work the trigger point himself and he told me later that the pain had gone away and hadn’t come back. T couldn't get over it. This man was a registered nurse and a gifted teacher of anatomy, who knew his muscles but didn’t know about his own trigger points. He was a product of the same system that turns out physicians with the same astounding gap in their knowledge. ‘After my classmates saw me go hands-on with our anatomy teacher's trigger points, they began letting me show them some of my tricks. I showed one student how to kill her sinus pain by working on her jaw mwuscles, another how to stop his feet from hurting by massaging his calves, and another how to get rid of her dizzy spells with attention to trigger points in the front of her neck. Several eventually came to me for back pain of various kinds. Near the end of the course, I got to show the whole class my techniques for getting rid of arm and hand pain, something we all experienced working in the clinic. Several classes of budding massage therapists worked in the weekend clinic where it was not unusual for us to give 1200 massages on a Saturday and Sunday. Isaw the same pain patterns in the clinic that I had seen with my fellow students: lots of back trouble, plus a broad selection of every other kind of pain you could think of. I saw pain in every part of the body and every joint: shoulders, elbows, wrists, knuckles, hips, knees, and ankles. Typically, the client had already been the rounds of doctors, chiroprac- tors, physical therapists, and so on, looking for the magician in the white coat: They'd tried yoga, magnets, pain diets, herbal therapies, and acupuncture. Some had had their problem for ten years and more, Many guessed they were just getting arthritis and so were habitually popping pills. They felt older than their years, handicapped by pain. They felt their careers in danger. Depression due to constant pain was a prevailing theme. It was exasperating to hear the same stories repeatedly, to know both how simple theix problems were and just what to do for them, and to know many clients were coming for massage only as a last resort. In my view, massage is the only thing that works for these kinds of pain, and should be the first thing tried, not the last. I consistently found trigger points to be the cause of my clients” problems, and clients nearly always got off my table feeling better. Many left my booth feeling they'd finally found something that worked. I felt more and more that I also had found something that worked. I liked giving massage a great12 The Trigger Point Therapy Workbook deal—I was surprised at how much. I asked for extra shifts and accumulated twice as many hours as were required. Until I was working regulatly in clinic, I hadn’t seen that giving massage to others was a way of taking care of myself. I'd only been thinking of getting a diploma from a good school so I would have a bit of credibility when I went on to teach self-massage. Unex- pectedly, I got as much from the massages as my clients did, maybe more. I felt myself becoming kinder and more empathic. Knowing how to take care of my own pain had made me more fit for taking care of others, which made me more fit for taking care of myself. My six months at the Utah College of Massage Therapy was transformational. I regretted I hadn’t done it sooner. Recurrent Themes While in massage school I finished writing my series of eight articles on self-applied trigger point massage for the Piano Technicians Journal. Publication began two months after I gradu- ated. When the first article appeared, desperate piano tuners began calling me for advice from all over the United States and Canada. They didn’t want to wait until the article on their particular problem came out. Many were on the verge of quitting piano work because of chronic pain. Some had been in pain for as long as twenty years, repeatedly going the rounds of the health-care community just like I had, with the same frustrating result One tuner from New England had been afflicted with severe recurrent pain in both knees since climbing Mount Katahdin, the highest point in Maine, twelve years earlier. The pain had started as he descended the mountain and his friends had had to carry him most of the way to the bottom. Now he couldn’t even go out and mow his lawn without being crip- pled for days by the effort. Working with me over the phone, he was able to find and mas- sage the horribly painful trigger points in his thigh muscles that were causing the pain in his knees. Before we hung up, the pain was gone. There had been no way for him to know that his trouble was not in his knees but in his thigh muscles, strained by the unaccustomed mountain climbing: his doctors, physical therapists, and chiropractors hadn’t known. At the Piano Technicians Guild National Convention a couple of months later, he happily told me he'd continued working on his trigger points and hadn't had any more trouble with his knees. I was as pleased as he was. Iwas scheduled to give a workshop on the self-treatment of pain at that convention and was worried that nobody would come. From the number of sufferers who had called me on the phone, I should’ve known better. One hundred and ten people showed up, and it was standing room only in the modest-sized meeting room. I knew at least one thing about every petson in the room before we even began: they all hurt. Piano technicians are the most diverse, intelligent, creative group of people I’ve ever had the privilege to know, and at the same time they’re the most assertively independent. Some literally would rather die than ask for help. if I could tell them something about the treatment of pain that they could do themselves, they wanted to hear it. They were all in such need that no one so much as looked away throughout the whole program. I was very’ encouraged. ‘That was the first convention I went to not as a piano tuner, but as a massage therapist. I didn’t go to classes at all that week. I didn’t go to committee meetings. J didn’t even party at night. Thad something better to do. I spent every day, from eight in the morning until ten at night, troubleshooting trigger points and giving massage, only leaving my room to get aChapter 1—A New Life 13 quick meal. They weren't all piano tuners who came to me; spouses needed help too. Although there were some recurrent themes, like shoulder pain, they brought me all kinds of problems—back pain, neck pain, headaches, numb hands—just like in the massage school clinic. People at the convention had come from all over North America, even from several foreign countries. No matter where these people lived, they all had the same story: they'd had trouble getting effective treatment. Nobody seemed to know what caused their pain and nobody could help. Back in Kentucky, as I began my private practice, again I saw all the by now familiar patterns. All the people who came for massage had already been to a physician or a pain clinic. Almost all had experimented with chiropractic. Many had been to the emergency room for their pain. Most had been through physical therapy. They had, tried everything, including various forms of alternative medicine. Some hhad even tried massage but hadn’t been impressed. It had been “feel-good” massage: it had been relaxing but hadn’t put a dent in their pain. Interestingly, almost all the people who came to me had some kind of back pain along with whatever other pain complaint they had. Their previous treatments for back pain had always focused on the spine. I heard about injections of papaya or cortisone. People had usually been told they had arthritis or bad disks, or that their cartilage had been worn away. ‘They'd been shown X-rays that purported to prove it. One woman was on her doctor's schedule to have her vertebrae fused. Some had already had surgery, and frequently had as much pain after surgery as before. Typically, the surgeon’ last word. was always that he was sorry but he’d done all he could. Then he'd renew their prescription for rs and. dump them off on a physical therapist. I heard these stories over and over again. And over and over, I found that trigger point therapy gave them the relief they’d been seeking for so long. Had trigger points been the problem in the first place? Arthritis? Bad disks? In Travell and Simons’ Trigger Point Manual, I had read that you can have herniated disks and arthritis of the spine and still find that myofascial trigger points are the primary cause of your back pain. One client said her doctor confided sympathetically that he had back pain too. He wore magnets under his clothing just like she did. Many of my clients had tried magnets and were often a little embarrassed to say so. Yes, the magnets did seem to help, they said, but the pain always came back, It was the same with TENS units: when you took them off, you still had your problem. (A transcutaneous electrical nerve stimulation {TENS] unit gives you lit- tle shocks that interfere with pain signals, but has no effect on the cause of the pain.) Nearly everyone I treated was on pain medication of some kind, although few had the illusion that painkillers were a real cure. People seem to know intuitively that throwing a doak over the pain only keeps you from seeing the real problem. When you hide the prob- Jem, you never get the opportunity to address it. Looked at in this way, painkillers actually perpetuate pain. People want real solutions; they don’t want to dope the problem away. ‘Another common theme among the people who came to me was numbness and pain in the hands and fingers. I began to get the impression that the computer keyboard was crip- pling the country. I saw wrist braces of all kinds. A doctor had wanted to put one woman’s wrists in casts to heal her numb hands. While many clients feared they had carpal tunnel syndrome or had even been given the diagnosis, massage of trigger point in the forearms, shoulder, and neck always took the pain and numbness away. This outcome was usually a surprise to the client. It soon ceased to be a surprise to me. Good results were so consistent with “carpal tunnel” symptoms that I began to wonder whether true carpal tunnel syn- drome really existed.14 ‘The Trigger Point Therapy Workbook ‘What did all this mean for me? I knew how to help myself and it was clear I could help other people, but what was the best use of my newfound skills? There was indeed a world of pain out there, but I’d started too late as a massage therapist to hope to help very many peo- ple one on one. At my age I wasn’t going to have a Jong career as a healer. What could I do for the world of pain with the time and energy I had left? It became increasingly clear that I had to write a book about trigger point therapy and get this information out to as many peo- ple as possible. Casting a Wider Net A doctor should have written this book. It should’ve been written by a bona fide, credentialed expert in a white coat with years and years of experience and scores of articles published in medical journals. If “M.D.” followed my name on the cover of this book, 1 wouldn’t have had to write this chapter. This chapter is meant to give you some reason to trust what I have to say about pain, some reason to suspend your disbelief long enough to give my methods a fair try. The best evidence of whether my method is a good one for you will come from your own personal experience with it. Trying it is the only way you can truly validate my claims about its success. I don’t claim to be an authority on pain. Travell and Simons are the pain experts. In writing this book, my job has primarily been to put their vast knowledge into more under- standable form and transmit it to you. Having figtired out how to fx my own pain counts for something, though. Being a massage therapist counts too, because I’ve proven to myself and to my clients that I know how to fix pain for other people. I thought you might be interested in my shoulder story. I thought you might be inter- ested in how the wisdom of Janet Travell and David Simons got me through my difficulties and how they truly gave me a new life. From my success in defeating pain, I thought you might gain a smidgen of hope: my new life offering the possibility of a new life for you. My own hope is that this book will be a useful one. It’s you who will prove me right or wrong.