What condition do you think of when a patient presents with pain, numbness, tingling, stiffness, burning or swelling in the hands and fingers? The universal response is carpal tunnel syndrome (CPS), with little consideration of other possible causes. But it's important to remember that trigger points can provoke these same sensations.

Treating pain and numbness of the hands and wrists with trigger point work, such as myofascial release, ischemic compression, static pressure and deep muscle massage therapy on the forearm, shoulder, neck and back, results from research by Janet Travell, MD, and David Simons, MD. Their work established that trigger points are the cause of most common myofascial pain problems.¹Drs. Travell and Simons describe a trigger point as a small contraction knot in muscle tissue.¹It often feels like a pea buried deep in the muscle, which keeps the muscle tight and weak. Trigger points also maintain a hard contraction on the muscle fibers that are directly connected to them. These taut bands of muscle fiber keep constant tension on the muscle's attachments, often producing symptoms in adjacent joints.

In addition to the aforementioned effects, trigger points can also cause hypersensitivity, muscle weakness, joint stiffness and a variety of autonomic symptoms. When these symptoms occur in the hands, patients and physicians often mistakenly assume that arthritis, bursitis, tendinitis, CPS or a neurological defect is the culprit. Clinicians can fall into the same trap when they don't recognize myofascial symptoms.

Trigger points in the scalene, brachialis and forearm muscles are the most common cause of symptoms in the hands. Other muscles in the upper back, shoulders, arms and hands may sometimes be involved. Because of the displacement of symptoms, treatment that focuses on the hands may only provide partial or temporary relief. Similarly, the benefits of pharmaceutical interventions are usually transitory because they don't address the cause of pain.

Traditionally, massage therapists have treated trigger points with ischemic compression, which requires pressing and holding the point for a specific amount of time. This concept originated with fitness expert Bonnie Prudden, who employed myotherapy for pain control.²At the time, it was a stimulating idea that ushered the development of several new massage methods.

However, a more effective way to treat trigger points involves combining compression and slow, deep massage strokes. By applying a series of strokes directly to the trigger point nodule, you can achieve results faster than using the static pressure of ischemic compression alone. This technique results in less irritation to the trigger point and less referred pain to the patient.

You're creating a repeated milking action to flush out the blood and lymph fluid, comparable to rinsing out a dirty cloth. Wetting and wringing it out only once doesn't get it clean. You need to repeatedly run fresh water through the cloth and wring it until the water runs clear. The same process works with a trigger point.

Move slowly over the trigger point, about one stroke every 2 seconds. Each stroke needs to be about an inch long-enough to move from one side of the trigger point to the other. Instead of sliding your finger across the skin, move the skin with the fingers. Release at the end of the stroke, go back to where you started, reset and repeat.

Each time you release the pressure fresh blood flows into the spot and brings a renewing charge of oxygen and nutrients. This action is important because the knotted muscle fibers have been strangling the surrounding capillaries and depriving the area of these essential substances.

The level of pain caused by massage is a useful measure of safety and effectiveness. For maximum benefits, exert pressure to make it hurt a little. Aim for a pain level of 7 on a scale of 1 to 10. Pressure greater than 7 risks causing the muscles to tighten. Trigger points in the following muscles can cause symptoms.

Brachialis. The brachialis muscle is the workhorse of the elbow, and performs much of the work that's credited to the biceps. Trigger points in a brachialis muscle make it difficult to straighten the elbow, but pain is felt at the base of the thumb. There may also be an oppressive ache or tightness on the outside of the forearm and upper arm near the elbow. Trigger point tightness in the brachialis can compress the radial nerve and cause numbness in the thumb and back of the forearm.

Brachialis trigger points are found under the outer edge of the biceps, just above the crease of the elbow. Push the biceps aside to access the trigger points and massage against the bone.

Forearm muscles. Trigger points in the hand and finger extensors cause pain in the outer elbow and in the back of the forearm, hand, wrist and fingers. They also cause hand weakness, finger stiffness, numbness, tingling, knuckle tenderness and clumsiness.

Trigger points in the extensor carpi radialis longus are a frequent cause of lateral epicondylitis or tennis elbow. They also provoke a burning pain in the outer side of the forearm and on the back of the wrist and hand. Tension in the extensor carpi radialis brevis causes pain in the back of the wrists and hands, and a sense of tightness, burning or aching in the forearm. Tightness in this short extensor can trap the radial nerve and cause numbness and tingling in the hand.

Extensor carpi ulnaris trigger points send pain to the ulnar side of the wrist and reproduce the feeling of a sprain. In addition, trigger points in the pronator teres and palmaris longus cause forearm and hand symptoms that may be mistakenly diagnosed as CPS.

For optimal outcomes, suspect trigger points as a primary cause of pain when a patient enters therapy for CPS. If trigger points are present, rehabilitate the hand, wrist, forearm, shoulder, neck and back of the injured side and incorporate physical therapy for the weakened, opposing muscles. Working just the hand and wrist won't yield the best results.

By combining massage therapy with stretching and strengthening exercises, you can get a handle on trigger points and allow the body to heal itself from this common source of pain.

References

1. Travell, J.G., & Simons, D.G. (1992). Myofascial pain and dysfunction: The trigger point manual. Baltimore: Lippincott Williams & Wilkins.

2. Prudden, B. (2002). Pain Erasure. New York: M. Evans & Co.

Morgan E. Miller is a certified massage therapist and licensed skin therapist. She's the owner of Elements to Wellness, a massage therapy and skin center in Reading, Pa.

Applying the right protocol

The efficient treatment of trigger points (TrPs) requires a thorough understanding of the signs, symptoms and pain patterns, and then applying several important skills and devices.

When you encounter TrPs, you must decide how to approach treatment. It's important to know that many perpetuating factors may exist and they should be addressed. These mechanical, nutritional or systemic factors can be anything that sustains the formation and existence of TrPs. For mechanical factors, look into workstation ergonomics, sporting activities and sleep positions for poor body mechanics that can place undue stress on the musculoskeletal system.

Once a history and evaluation are complete, you can begin treatment. The idea is to deactivate the TrP through mechanical disruption of the nodule and restore range of motion (ROM) to affected muscles. Use deactivation techniques based on the patient's presentation of symptoms and current pain. Conservative treatments include direct compression or active myofascial release techniques.

Another technique is called the spray and stretch technique. This method works by spraying a stream of vapocoolant spray over the skin from the muscle origin over the TrP to the insertion and over the referred pain zone, while passively stretching the targeted muscle. The spray bombards the central nervous system with cold to block the reflex muscle spasm and allow a full stretch. Stretch the muscle by taking up slack, which appears as the spray is passed over the muscle.

With this approach, there's less discomfort for the patient. The technique may also be used in conjunction with other manual therapies, including TrP dry needling techniques (TDN), to reduce muscle spasms and increase ROM. When used with TDN, many patients report the experience of cold to be soothing after the needling procedure. After treating with a vapocoolant, a patient's tissues should be re-warmed with a moist heating pack. Take treated muscles through three ROM cycles, from fully contracted to fully lengthened, to retrain the muscle. Also, instruct patients about stretching techniques and at-home TrP care with a self treatment tool. By following this basic protocol, patients can achieve results and you'll be able to expand your clinical experience with pain treatment.

Jeffrey A. Lutz, CMTPT, is a myofascial trigger point therapist at The Pain Treatment & Wellness Center, with offices in Greensburg and Pittsburgh, Pa. He can be reached at jeff@musclepainhelp.com.