Prolotherapy and Trigger Points
Robert Filice, M.D.

Soon after becoming a trained active prolotherapist here at Caring Medical, I noticed that injections at certain spots in some patients would trigger a very noticeable involuntary twitching of muscle fibers. Usually this would happen upon entering a spot with significant ligament tenderness underneath. What I had discovered was that deep ligament pain induces instability in muscle and nerve tissue above the injury, and that both the ligament and the muscle “trigger point” contributed to the patient’s pain and dysfunction. A trigger point is a spot of excess muscle excitability wherein there is exquisite tenderness to palpation, and the production of local as well as referred pain in adjacent areas.

According to Doctors Janet Travell and David Simons in their widely acclaimed medical textbook, Myofascial Pain and Dysfunction: The Trigger Point Manual, Myofascial trigger points are tiny knots that develop in a muscle when it is injured or overworked. The defining symptom of a trigger point is referred pain; that is, trigger points usually send their pain to some other site.

This is the reason conventional treatments for pain so often fail. It's a mistake to assume that the problem is at the place that hurts! Travell and Simons' research has shown that trigger points are the primary cause of pain seventy-five percent of the time and are at least a part of nearly every pain problem. The two main components of a trigger point are a localized area of maximum contraction of the individual muscle cells (sarcomeres) called a knot, and the overstretched “Z” bands that result between the knot and the muscle’s attachment to a nearby bone.  

Normally, when a muscle is working, its sarcomeres act like tiny pumps, contracting and relaxing to circulate blood through the capillaries that supply their metabolic needs. When sarcomeres in a trigger point hold their contraction, blood flow essentially stops in the immediate area. The resulting oxygen starvation and accumulation of the acidic waste products of metabolism irritates the trigger point. The trigger point responds to this emergency by sending out pain signals.

Trigger points are associated with headaches, neck pain and jaw pain, low back pain, tennis elbow, and Carpal Tunnel Syndrome. They are the source of the pain in such joints as the shoulder, wrist, hip, knee, and ankle that is so often mistaken for arthritis, tendinitis, bursitis, or ligament injury. Trigger points also cause symptoms as diverse as dizziness, earaches, sinusitis, nausea, heartburn, false heart pain, heart arrhythmia, genital pain, and numbness in the hands and feet. Even fibromyalgia may have its beginnings with trigger points.

The management of trigger points depends on a careful physical exam, an understanding of referred pain patterns, various physical therapy modalities, including special massage techniques, and often Prolotherapy to strained and painful ligaments in the area. Massage of the trigger point flushes the tissue and helps the trigger point's contracted sarcomeres begin to release. In dealing directly with the trigger point, massage is the safest, most natural and least invasive and inexpensive form of pain therapy. But it is often not permanently successful. A second stage of intervention might be what we call “Neural Therapy” injections directly into the trigger points. The injected procaine (a local anesthetic) wipes out the nerve cell’s memory of the irritation (like clearing the memory in your computer by hitting the reset button), and can provide temporary to complete resolution of the trigger point in acute conditions. However, muscles will always tend to spasm and strain whenever the underlying ligaments are lax or injured (as is often the case in chronic conditions), and it will be impossible to get rid of a trigger point permanently if such underlying tissue pathology is not addressed with Prolotherapy.

Therefore our guideline is that if a trigger point has been stubbornly painful and refuses to clear up or constantly recurs despite massage, muscle stretch, and local anesthetic injection techniques, the patient should have a Prolotherapy evaluation. Prolo patients who are getting better lose the muscle twitching they may have demonstrated earlier in the course of their treatment, and the trigger points will disappear along with their painful condition. This is especially valuable in fibromyalgia patients who often have a large number of very severe trigger points, and who also do well with Prolotherapy. Prolotherapy is often required for a permanent solution to the trigger point problem.