II. The Underlying Cause of Chronic Pain

4. You stated that these are not generally life-threatening conditions, are there painful conditions that can be dangerous or life-threatening?

Great question! That's why anyone who has pain, acute or chronic, must have a proper physical exam and work-up by a qualified physician to rule out any 'red flags' in these conditions. Red Fags that may indicate fractures, tumors, or infections that may be at the source of their pain.

It has been estimated that less then 5% musculoskeletal pain arises from fractures, tumors, and infection, while another 5% of musculoskeletal pain cases are caused by nerve root problems such as disc herniations. If you are in this 10% of musculoskeletal cases you must find out the actual cause and have it properly treated. However, this leaves over 90% of musculoskeletal pain arising from a mechanical origin, that of a myofascial (muscle and tendon) and joint (ligamentus) dysfunction.

5. What then is the cause of this myofascial dysfunction that accounts for 90% of the musculoskeletal pain and suffering in the U.S.?

Physical, chemical, and emotional distress overtime causes specific changes in muscle and tendons known a myofascial trigger points; these myofascial lesions are commonly known as "muscle knots." Myofascial trigger points are hyperirritable tissues in muscles and tendons that cause three things to happen. First, the tissue becomes painful and/or tender, second they cause the myofascial tissues to shorten, and third they cause the muscle to weaken. These three changes cause alteration in our patterns of movement causing more stress to our muscles, tendons, and ligaments causing more myofascial trigger points. This leads to a vicious cycle of more and more recurrent pain in an individual, until all the active and latent trigger points are released and removed.

6. What then is the difference between an active and a latent trigger point?

Let's get our terms established here for a better understanding. As previously mentioned, any severe acute or chronic recurrent physical, stress, such as an injury, chemical stress, such as toxin exposure or nutritional deficiency, or emotional stress can lead to the formation of taut bands in muscle tissue. These at first are painless, but eventually they will begin to shorten muscles and alter our movement patterns. Further physical, chemical or emotions stress will cause these taut bands to begin to form pain-causing trigger points.

An active trigger points is myofascial trigger point that spontaneously causes local pain and/or pain referred to a distal area, for example pain down the arm, leg or into the head. Patients who have experienced pain due to a heart attacks, broken bones, or kidney stones, have reported that their myofascial pain from trigger points can be just as severe these ailments. So we should never underestimate the suffering someone is going through with Myofascial Pain Syndrome or Fibromyalgia.

Now a latent trigger point is defined as a focus of hyperirritability in muscle or its fascia, that does not cause spontaneous pain, it is only painful when it is pressured or distressed. However, it will cause the other characteristics of TPs such as a shortening and weakening of the muscle.

Another important distinction to be made, and the reason will come clear soon, is that of satellite trigger points. By definition satellite trigger points are those that form in muscles that are in the referral pain zone of primary active trigger points. Remember a primary active trigger points are usually where the problem began, they produce spontaneous pain tenderness and restriction of movement, and they produce referral pain. This referral pain is felt at a distance, often entirely remote from its source, and usually happens in a pattern that can be seen in books and TP charts. For example TPs in the Quadratus Lumborum muscle of the low back will refer pain into the hip and buttocks. The muscles in this referral pain zone, such as the Gluteus Medius and Minimus, will then form numerous satellite trigger points, which may be latent or quiet TPs, or active TP causing severe pain in the low back and legs.

8. Many individuals with chronic pain know about their active trigger points, but why is it helpful for then to know about and identify latent and satellite TPs?

Many times an individual with chronic myofascial pain will be lucky enough to find a doctor or therapist who knows something about trigger point therapy. However, usually only a few of the primary active trigger points get treated. Why? First, of all primary TPs are very easy to identify, the patient is usually pointing right to them. Secondly, many clinicians do not realize the importance of finding all satellite and latent trigger points and releasing them.

In the previous example of the low back, if only the primary trigger points in Quadratus lumborum muscle of were released, the low back the pain would return. If satellite TPs of the Quadratus lumborum which are usually found in the Gluteus Medius, remain in the buttock, these satellite TPs would reactivate the Quadratus Lumborum and subsequently the low back pain would return. Individuals then think that trigger point therapy didn't work.

Also surrounding primary TPs there are usually many nested latent TPs or quiet "muscle knots" that many times go untreated. When a clinician finds a painful primary TP there are, many latent trigger points in that muscle or in surrounding muscles close by. Time must be taken to release all these nested latent TPs in the region of the primary active TPs. If they are not released, just as with satellite TPs, these regional latent or quiet TPs will reactivate the primary TPs and the chronic pain will eventually return through a neurological reflex. This is why it is so important to perform a comprehensive "search and destroy mission" of all the myofascial trigger points in the region.

Next: Proper Treatment of Pain