Use Trigger Point Manual Therapy for Plantar Heel Pain…It Works!!!

Once TPs are released we can begin working to gain control of the dysfunction that is part of running injury that lead to TPs.

It may show a relationship between trigger points and heel pain; but likely a relationship between a tight/dysfunctional gastrocnemius leading to increased stress to plantar fascia or pressure on plantar nerve through the Windlass mechanism; fascial restrictions – particularly the superficial back line according to Myers. No telling really….

Agreed to both above comments…Hunter you are likely correct and there is likely a biomechanical issue from a tight gastroc that is causing increased pressure on the medial aspect of the calcaneous which is causing this pain…That stated, we should focus time in addressing the issues in the gastrocnemius because by doing so, you will help reduce the pain occuring in the heel…

I agree with the comments that myofascial hypertonicity of the gastrocnemius is likely contributing to increased biomechanical strain on the plantar fascia. Another thing to consider is that the referred pain pattern of the gastrocnemius and soleus partly in the area of the plantar surface of the calcaneous and sole of the foot. So releasing trigger points is likely the reason for the improvement of the pain pressure thresholds and possibly even the symptomatic complaints. I agree with Bruce that one needs to figure out the underlying contributing factor to the persistence of the trigger points in the calf, whether it be a spinal influence or some other biomechanical influence along the kinematic chain.

Would someone please define for me what a “trigger point release” means? I am aware of various soft tissue techniques targeting trigger points, but do not understand where or how we “release” them. Are you finding the palpable taut band dissapears following being released?

When are clinicians going to learn how to properly stretch??? I would like to pull my hair out but I’m bald already! I do like the focus of this article, however, and I’d like to commend you Joe for taking the time to write this post as trigger points are an underappreciated player in orthopedic medicine outside of physical therapy.

With all of the emphasis on EBP, JOSPT still classifies heelpain as plantar fasciitis. These are not one in the same!! And treatment consisting of stretching and triggerpoint soft tissue techniques to the calf mm. Say what?! What about identifying the underlying movement dysfunction that is the cause of the wear and tear on the plantar fascia. This is the same old passive modality base treatment we have been touting for years. We need to see beyond just the localized region of pain and find “The cause of the cause”.

I’m pretty sure we never said that was the ONLY treatment for these patients. This is a treatment used concurrently with other exercises, stretching and manual techniques. Patient education about activity level and proactive self treatments is important when dealing with plantar/heel pain. Think about trigger point release and fascial work more as a modality utilized to allow easier movements and ability to exercise.

Articles like this really frustrate me. The authors cited the excellent and comprehensive Lucas et al systematic review from 2009, which concluded the following:
“No study to date has reported the reliability of trigger point diagnosis according to the currently proposed criteria. On the basis of the limited number of studies available, and significant problems with their design, reporting, statistical integrity, and clinical applicability, physical examination cannot currently be recommended as a reliable test for the diagnosis of trigger points. The reliability of trigger point diagnosis needs to be further investigated with studies of high quality that use current diagnostic criteria in clinically relevant patients.”

Despite this, the authors of this study hardly even question whether the trigger point construct is valid. They then go on to describe an aging concept developed by Travell and Simons that has simply not withstood any scientific rigor whatsoever.

When is this hoarding of ideas by PTs going to stop? Are we ever going to discard anything from our dubious past that hasn’t met evidence- or science-based muster? When are peer reviewers going to start holding authors accountable for the articles they cite and start differentiating the level of evidence themselves when deciding what gets published?

Worst of all, are we going to continue to propagate the trigger point myth in the general consciousness by providing these “Perspectives for Patients” propaganda leaflets in the name of “educating the public” (read: “using tooth fairy science to market PT”).

I just can’t wait until my next patient comes in and asks me to treat the “trigger points” (which no one has been able to prove actually exist) in their calf.

Welcome back John!!! Do you mind giving a neurophysiology perspective on the diagnosis of plantar heel pain and how you would approach the treatment of a patient with the diagnosis???

Joe, since you seem so impressed with this study, can you explain what it is you find so impressive?

Is it the long term improvement in heel pain? – oh wait, we don’t know if this intervention provides long term relief for heel pain- it only went out 4 weeks.

Is it the incisive and deep explanation of the mechanisms involved in the maintenance of this persistent pain state? -oh wait, they cite a SLR which essentially concludes that there’s no evidence that trigger points exist despite the authors assertion: “We found active TrPs in all patients within the Str-ST group, suggesting a possible role of TrPs in plantar heel pain…” So much for an incisive and deep explanatory model.

Is it the huge effect size in outcomes?- oh wait, the authors felt compelled to recognize that the 95% CI contained the MCID for the primary outcomes, so maybe there wasn’t much difference between groups after all. I guess we’ll have to see if someone can replicate this study and improve the power a bit to get those CI’s a little tighter. A few more subjects or, hey, a tighter operational definition of “trigger point” ought to do it.

It must be the fancy, glossy, “Perspective for Patients” information attached at the end- oh wait, now we’ll have a bunch of patients coming to PT to get their trigger points “released” or electrified or poked with needles or whatever else we can imagine doing to patients, since we’re licensed professionals and all and there’s a charge code to submit for our learned and well-reasoned interventions. We’ll be inundated with more “sick” people with “trigger points”.

If this is what passes now for the kind of clinical research to get excited about, then I think our profession has gone further off the tracks then I thought.

I wouldn’t waste my time with a neurophysiological perspective for this tripe- it doesn’t pass a common sense perspective.

http://free-loops.com/2889-crickets-chirping.html

John,
Lets say I am a patient that comes to see you with complaints of plantar heel pain…Give me some insight…some wisdom…on how you would approach a differential diagnosis followed by treatment…Nice loop but I wasn’t to a computer until now to respond your comment

Hey, before I answer your question, which I think is irrelevant to my critique of this article, why don’t you answer mine?

Are you satisfied with the duplicitous nature of this study, i.e. acknowledging the research showing MTrPs to be a dubious construct, yet then identifying them as a potential source of heel pain? Is that a logical and valid leap to make in a peer-reviewed research article?

Here’s the authors’ justification for using the trigger point construct in this interventional study:
“As muscle TrPs have been advocated as a potential source of plantar heel pain, (34) a clinical intervention approach including TrP treatment should also be considered in the management of plantar heel pain.” (p 48)

Interesting that they would use the term “advocated” as opposed to “proposed” or “suggested” or “hypothesized”. A Freudian slip, perhaps? That citation is Simons and Travell, and certainly no one advocated more for MTrPs than those two. So, I at least have to commend them for the accuracy of their referencing in this case.

Should we advocate for interventions that presume a mechanism that has not withstood scientific scrutiny? Is this ultimately helpful to the health of society?

The explanation here is the problem, primarily, not the intervention (although I have issues with that as well).

John,
While I do agree that the term “advocated” is a poorly chosen word, I do not think the word-choice was intential of the authors. To be honest, it may have been lost in translation from Spanish to English. You can disagree but neither of us know…could be a Freudian slip.

I do not understand how the term “trigger point” is questionable. By definition of Simmons and the authors of the study, a trigger point is “a hyperirritible area associated with a taut band of a skeletal muscle that are painful on compression, contraction, or stretching of the muscles and elicit a referred pain distant to it”. Have you never assessed a patient and found a hyperirritible region within a muscle which was also taut? Couldn’t this be an example of peripheral sensitization in which a sensitization of nociceptors occurs as a protective mechanism by the body in order to prevent further use of a damaged structures (which if used, could further damage the tissue as well as surrounding tissues)?

The results of the study, despite possible low power , im my opinion, are clinically relevant in which patients had a statistically significantly better outcome when they had the manual TrP techniques. The appropriate statistics were used to analyze this and there was a difference in PPTs and the patients perception, which is most important.

In the first line of the discussion, the authors state the results of the study indicate the techniques used resulted in better “short-term” outcomes…at no point did they define this study as a long-term fix for plantar-heel pain…that stated, if the technique causes a decreased output of pain in this region, it will allow for an improved ability to perform other interventions…

I want to hear your differential diagnosis and best evidence-based approach in treating plantar heel pain…You can critique the literature, problem and intervention but please give us insight into a better researched approach…

Here’s the important part of my post, which you failed to address:
“Should we advocate for interventions that presume a mechanism that has not withstood scientific scrutiny? Is this ultimately helpful to the health of society?”

Just because there’s a longstanding “definition” of a trigger point, doesn’t mean it exists as such. There once was a longstanding definition of reflex sympathetic dystrophy that was subsequently abandoned when investigators were unable to provide adequate evidence that it was a reflexive condition mediated by the sympathetic nervous system. Now a more general and accurate term, Complex Regional Pain Syndrome, is being used. The Lucas et al systematic review demonstrated that the definition of MTrPs, in fact, has not withstood any attempt to validate it to date (as recent as 2009). Perhaps we should adopt a more accurate term since words actually mean things.

If that doesn’t make the term “trigger point” questionable to you, then I guess we’re just going to have to finish this discussion.

John,
How about we use the term “localized tight-muscle tenderness” in place of “trigger point”. If we replaced this verbage, would the study make sense to you? You cannot argue that you have never found localized tenderness within a muscle which was also tight.

And say the examiners were pushing into a tight, tender muscle which facilitated a “deep pressure”, neurological inhibition, does the verbage really matter (deep pressure vs. trigger point release)?

The patients in this study fit a subgroup of individuals we see clinically. There were statistically significant responses following the interventions as compared to a control group. If we see patients that present like the experimental group, and the intervention for this subgroup is effective, then who cares what is truly happening under the skin as long as it alleviates the patients chief complaint and isn’t causing tissue damage.

I know your a manual therapist and I am Maitland trained myself and the big thing that Maitland taught, was to look for that chief complaint or “comparable sign”. He didn’t care about a diagnosis or verbage, he simply said treat the patients signs and symptoms, which in his thought-process were always related to pain or stiffness. So who cares about the term “trigger point” … if a patient comes into my office with plantar heel pain and tenderness and tautness in the calf, I am going to apply deep pressure to that region which I expect will decrease pain output in the heel.

There is my answer to your question…now please entice me with your differential diagnosis and better evidence-based treatment approach to this problem

Here’s a direct quote you apparently wouldn’t recognize:
“”To speak or write in wrong terms means to think in wrong terms.”
- GD Maitland (1924-2010)

I think you’ve grievously misstated an important philosophical tenet of Maitland’s that may have just caused him to roll over in his grave.

Geoff Maitland knew the limitations of our knowledge of pain, so he was cautious and used descriptions of processes and, as you accurately described, phrased these in terms of signs and symptoms. To presume that he wouldn’t care about mis-identifying the source of the patient’s comparable sign in the face of scientific data which fails to support its existence diminishes the man’s significant contribution to critical and analytical thinking in our field.

“If we see patients that present like the experimental group, and the intervention for this subgroup is effective, then who cares what is truly happening under the skin as long as it alleviates the patients chief complaint and isn’t causing tissue damage.”

Have you considered what is going on *in* the skin itself as soon as you touch the patient? If you haven’t, then you may be missing something that would preclude needing to knead the patient’s muscles.

How am I misstating his teaching John? Yes, he did have limited language so he did not mistakingly give an inaccurate diagnosis but did Maitland really care about a diagnosis? Maitland emphasized listening to the patient, treating the comparable sign and continuously reassessing the effectiveness of treatment. He emphasized to not treat a condition; but instead the individual presentation. He didn’t care about labeling a diagnosis or verbiage but instead focused on the patients presentation. That said, if the patients comparable sign is heel pain and pressing into the calf decreases this, wouldn’t this decreasing the comparable sign? Who cares if its a a result of releasing a trigger point, neurological inhibition, cutaneous sensation or placebic…if it decreases the patients perception of pain, the patient is happy. That said, this study demonstrated, applying pressure in the calf decreased plantar heel pain as measured by a PPT indicating that something physiological is going on with the technique which subjectively also resulted in decreased pain.

Still waiting on your answer to my question….

OK. why exactly are we arguing over semantics in this thread? The study was just trying to state that there may be a causal relationship between a found comparable sign and/or a palpated tightness in the area of the gastroc and the patient’s heel pain. This was tested to see if there was a change in the patient’s pain. Therefore, the most important take home point of this article is to have this as another assessment during the initial examination of the patient.

And on the topic of Maitland:

You have to remember his main concept of the “permeable brick wall”. This encourages the therapist to balance information from questioning and physical testing, with research evidence and past experience, to come up with an individualized and specific plan of care for each patient. The main idea driving this concept is for the therapist to break free and be innovative. Therefore, regardless of what the trigger point is or isn’t I will continue to use soft tissue mobilization in my treatment of heel or foot pain is this is evident in the initial examination.

John, If you could possibly tell us WHAT the “trigger point” is then we would be eternally grateful, but until that time comes all you had to say was that you disagreed with the term “trigger point”.

All I know is that I am glad to have this in my bag of tricks instead of using “good ole ultrasound and heat now give me some money”.

hunterstark,
You’re asking *me* to tell you what a “trigger point” is? Well, that’s strange.

The term is “myofascial trigger point”. I heartily encourage you to read the review by Lucas et al, which was cited in the article in question. I’m not going to write an annotation for you. Read the article yourself.

Joe,
The quote from Maitland is authentic. He said what he said. I don’t know if he himself ever uttered the words “myofascial trigger point”. Again, if your thinking brings you to believe that you can influence taut bands in muscle directly without knowing what is happening at the interface between your and the patient’s skin, then there’s really nothing more for me to say about the issue.

I would recommend, however, that you take a look at Joel Bialosky’s excellent article which describes a model of manual therapy mechanisms that incorporates current knowledge of neurophysiology (Bialosky JE, Bishop MD, Price DD, Robinson ME, George SZ. The mechanisms ofmanual therapy in the treatment of musculoskeletal pain: a comprehensive model.Man Ther. 2009 Oct;14(5):531-8.)

I’ll finish by saying that I don’t have anything against developing effective treatments and publishing them in the literature. However, I do have a big problem with unfettered empericism driving clinical practice. If I wanted to have a “bag of tricks” I would’ve become a magician or a comedian like Carrot Top.

I’m not particularly interested in making my patients happy by telling them a story they want to hear but I know to be inaccurate. There’s another profession that does that on a regular basis. Do we want to be more like them?

John,
I’ll check out that article. And I guess your saying that I should take ultrasound, whirlpool, paraffin and MFR out of my bag-of-tricks? I thought John Barnes was a “therapist of the highest caliber” (title is per his website)…jk… You do make a good point in that the practice needs to move away from magicians to clinicians so that we don’t become like the our DC friends. Im sure we’ll be talking again…

Hunter, I found an article that you may enjoy on ultracrap for the treatment of spinal stenosis…The abstract is here: http://cre.sagepub.com/content/24/7/623.short ….If you need the full article Ill forward it to you….

Oh I am truly sorry John. I heartily meant for you to give me YOUR idea or definition of a “trigger point”. That’s all I was saying. I didn’t mean to give you flashbacks to your childhood about carrot top or magicians. You don’t have to be a smartass about anything. I know what I would refer to as a trigger point as I like to read literature also.

Joe,
THANK YOU SO MUCH FOR THE ARTICLE! ha! you have to look people that continue to use ultrasound for anything!

Who’s being the smartass? I just spent several posts questioning the validity of trigger points and expressing my doubt that they can be reliable identified, and then you ask me to define something that I suggest lacks any scientific evidence of its existence.

I suppose I could take a stab at describing unicorns, too. Would that make them any more real?

I DO NOT KNOW what a myofascial trigger point is other than the mythology that’s been written about. So I guess in addition to being a smartass, I’m also a dumbass.

What i’m trying to say is that you cannot say something is mythology without giving another option or definition of a definite physical phenomenon. We see points of tenderness in our patients daily; therefore, how can you say something is a complete myth without giving a better or another definition of that phenomenon.

Thus, we must rely on the best supporting evidence for this phenomena. I don’t really care what you call it at all unless you have better evidence to support your idea.

But I would like to hear about unicorns if you are an expert on that also.
Thanks!

First of all let’s agree that the tissue of interest is that which carries nociceptive messages to the CNS and this can only include nervous tissue since it’s the only tissue that can depolarize, which imbeds into muscle, tendon, vascular and skin in the region of the tender point. And yes, I suppose we must include fascia as well. Another tissue that is innervated in the region is the nervous tissue itself. The nervi nervorum ensure that nociceptive signals can be transmitted from the nerve to the spinal cord and potentially the brain, which is the *only* place where a pain experience can be constructed.

Do we agree on all that?

So if we refer to a tender spot that is covered in skin as a “myofascial trigger point” we have already made a potentially inaccurate assumption that the problem is occurring in the nervous tissue that imbeds into the muscle and fascia. How have we ruled out the cutis and subcutis layers, the vascular tissues and the nerves themselves?

If you look closely at the Lucas et al review of the two studies that used 3-D analysis to determine the reliability of locating a trigger point the range of error between examiners was 3.3 to 6.6cm (not mm, cm). That’s over 1.5 to 2.5 inches! One of the studies showed only a 21% agreement on location. Certainly we have to question the ability to reliably locate one of these things.

Then, of the one study that actually reported on the presence or absence of a trigger point, the highest reliability estimate for a taut band had a kappa of 0.46. Not exactly anything to write home about. Lucas et al also noted that in this single study that attempted to determine the existence of trigger points in actual patients, the examiners were expertly trained in trigger point diagnosis and had training prior to the study in order to improve their reliability. Obviously, we have to question whether these meager results were inflated.

I’ve already quoted the conclusion of the study above so no need to be redundant.

Well there’s your annotation, Hunter. Don’t bother thanking me. The next time you think you have your hand on the horn of a unicorn, you may want to open your eyes, back up a little and see if you don’t in fact have you hand on a sharpened broom handle- or some other long, rigid object with a point on it’s end.

After that, look up the word pareidolia.

Thanks. All I wanted. Not so hard was it john ?

You know what really grinds my gears?
http://www.somasimple.com/forums/showthread.php?t=9438&highlight=grinds+gears

What John’s approach is or isn’t has little relevance to the article. I find tender spots in my patients all the time. I don’t poke them though. I don’t create fancy names or stories about them either. Why don’t the people defending the “MTrp” construct just call them “subluxations” and get it over with?

Comparable sign /= Chief complaint

As I said, no need to thank me.

Guys,
The intention of this site is to not only educate other PTs and provide articles of interest relating to PT, but also to engage in professional discussion regarding the topics which are written…

As a contributor not only to this site, but to other PT forums, I open myself up for criticism on my clinical analysis of research as well as my practice patterns. That stated, all discussions should remain professional, as we all share the same goal which is to get our patients better. There are alot of clinicians who treat (probably with much out-dated methods) and take off their “PT hat” the minute they leave the clinic. By engaging in this site, as well as other professional blogs and forums, we are all attempting to better ourselves as clinicians. And despite our differences in approaches to treatment, I am sure those who engage in sites like this are getting better treatment outcomes vs. those who don’t (possible study idea…anyone interested in putting something together, let me know…I have the resources to get it approved)

Even though I don’t always agree with your thoughts John, I do appreciate the discussions that you provoke bc it does lead me to read some fantastic literature such as the Bialosky piece you referenced earlier.

I think this is a good ending point for the discussion on this piece. Whether the pain in the heel referenced in this article is related to mesodermal, fascial, muscular or neurological tissue, we do know that something physiological is occurring which improves short-term outcomes of reducing heel pain when you put your hands on patient.

Jason says: “Why don’t the people defending the “MTrp” construct just call them ’subluxations’ and get it over with?”

I hadn’t thought of that, Jason. Very good then. We will officially refer to “myofascial trigger points” as “subluxations” and save ourselves the trouble of inventing yet another fable to tell our patients.

Anyone for throwing in the FRS/ERS yarn?