Do You Find Trigger Point Illustrations Confusing?

Most books and sites on trigger points are usually focused on a the characteristics of a trigger point. They help you primarily understand its areas of referral, impaired functions, sensation, activities of onset, etc. If you’re a therapist that can be interesting for detailed assessment. Most people are overwhelmed by all that. I’d venture to say that many therapist are overwhelmed by that. It leads them to avoid talking about trigger point patterns. They often try to point out problems in the research, which is, by the way, amazingly solid and has been proven with many years of clinical success.

My posts on trigger points are different; they focus on connecting a problem in typical activities with a trigger point. They offer some safe self-care and help you distinguish it from similar referral patterns. Those posts also point out when you should really be taking this problem to a therapist. For the average person this approach seems to be more useful. People don’t usually say, “my splenii trigger points are active – can you release them?” They say, “I have a headache on top of my head” or “my neck is stiff.”

This post is to help you understand that some trigger points are clear-cut and easy to identify while others require a complex understanding of referral patterns, bio-mechanics and behavioral tendencies to identify. Often, the referral illustration is not as straight-forward as it looks. I’ll start with a simple example and build into more complex examples so that you can see how that might happen.

Let’s start with the basics…

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referrals - occipitalisThe illustrations have dark-red areas which are the areas that most often present intense sensation when the pattern is clinically elicited. The medium-red areas are not as common as the dark-red areas and the pink areas are reported least often but still reported with statistical significance. Those patterns are very similar with minor variations from one author to another.

Many of them have more than one dark red or medium red area. That doesn’t necessary mean that every dark-red area is always noticed or reported when that referral pattern is active. In this referral pattern, some people complain of the headache along the top of the head, some people complain of eye pain but most people have reported pain in both areas.

The little green asterisk represents the spot where the trigger point occurs. Compared to most therapists, I’m a more focused on the entire muscle than the actual trigger point so I don’t talk about the actual point very much in my posts.

As the activity level of the trigger point increases, the referral pattern becomes stronger and more parts of the pattern are noticed. There is a practical explanation of the levels of activity in this post.

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Here is a very simple pattern.

referral - thoracic multifidiThis is the pattern of thoracic multifidi. The tight little band of muscle is easily palpated by a therapist right under the spot where it hurts. It pain around the muscle diminishes when that area is worked. The classic “lamina groove” routine in neuromuscular therapy is great for gently working this area with multiple passes until the joints are freed and the multifidi relax. This routine is the more gentle, neuromuscular version of a spinal adjustment.

This is not the case of most trigger points. It is a common belief among bodyworkers, even those who don’t treat trigger points, that the one who treats at the point of pain is usually lost.

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Here is a more common scenario.

referral - SCM - sternal

This is one of the patterns of sternocleidomastoid. People almost always complain of the pain around the brow right where the dark red area indicates. It is also easy for a trained therapist to recognize the imbalance in the neck muscles. There are, however, a few things that are different from the simplest patterns.

  • The trigger point is in the neck, far away from the area of pain, which is the norm among referral patterns. There are no obvious nerve pathways that the two have in common. It is, however, easy to correlate the two as the sensation around the brow dissipates as the trigger point in the neck is released. You can see that happens in one of the stretches in the video in this post.
  • Secondly, there are a couple of other trigger points that produce pain around the brow but have other differentiating characteristics. The “Similar Patterns” section of each post helps with those comparisons.
  • Thirdly, this muscle produces parasympathetic phenomenon. That means that the referral pattern is associated more than pain. It is also associated with blurred vision, irritated sinuses and vertigo, which diminish as the trigger point’s activity level goes down. It is not common that people connect things like earache, tooth sensitivity or fight-or-flight with trigger points but research bears it out. Once they understand this, people are more likely to talk about other symptoms as they describe their concerns during the session.

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Here is an pattern that can be misleading.

referral - hamstring - medialThis is the pattern for medial hamstrings. There is a cluster of trigger points about mid-way through the muscle associated to the referral pattern(s).

People seldom complain about this referral pattern at the base of the buttock when I’m asking about their concerns unless there is an acute onset.That dark area at the top of the thigh is the most common area of sensation when the pattern is elicited by stretching the hamstring or, according to research, when the trigger point is injected.  In real life, unless there is an acute onset, it is easy to avoid eliciting this pattern by changing our movement patterns. By turning the foot out and dropping the shoulders forward when walking, the medial hamstrings don’t contract and lengthen as much. How common is that? That way of walking is what we all call “athletic swagger.”

The research indicates that when people complain of the knee problem, it is the primary complaint. I also find this to be true in my clinical experience. The knee pain is hard to avoid and is sharper when it occurs, even though it occurs less often. People have more concern about a sharp pain in the knee and are quicker to report the pain.

An injured athlete or victim of a fall will have the pain at the top of the thigh and will see this illustration as their pattern. The average person with a chronic hamstring problem “swaggers” and does not usually see this as their pattern. The knee problem isn’t as common but produces sharp pain so that the person looks to get the fragile knee treated. There are 3 other muscles who have their primary referral in this area and the hamstring is often overlooked. This is why I create posts based on the complaint like this post on an unexpected source of tennis elbow.

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And finally, a complex pattern.

referrals - scalenes - anterior referral - scalene - posterior1

Here is the pattern of scalenes. I seldom have someone complain of the entire pattern. In fact, they seldom complain of more than one or two of the dark areas. They most often complain of painful and/or swollen hands in the morning or while driving. Another common complaint is pain along the shoulder-blade. When I press into the trigger point, they will often report much more of the pattern in the arm, back and chest. While I was writing this post, I showed it to a client for editing. When he saw it, he remarked that he has pain in all of the darker areas, on a regular basis. He is always focused on his low back and had never mentioned them during his complaints. I have seen that client for more than 20 years.

There are dozens of referral patterns in the shoulder, neck and arm that overlap this pattern. It is easy to confuse this with other patterns and requires a more complete assessment to pinpoint the source. In situations like this, knowing the activities that are typically impaired is part of more accurate assessment. Eliciting the sensation or relieving the sensation by working with the trigger point may be the best route of assessment.

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Trigger Point Assessment is useful and, well, even fun. Good assessment is often under-valued and provides a more direct route to effective treatment. If you are used to the treatment in spas and massage chains, this work looks very different. More time is spent talking, assessing and helping people understand the route to lasting results.

Many people report that they recognize their pattern in my posts and find relief with the home care. The illustration is part of the assessment. Impaired activities, onset of symptoms, muscle testing, and many other factors create a clearer path to understanding the problem. If you only get temporary relief or find yourself overwhelmed by the information, find a practitioner and get lasting relief.


Tony Preston has a practice in Atlanta, Georgia where he sees clients.

He has written and taught about anatomy, trigger points and cranial therapies since the mid-90s.

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Do You Find Trigger Point Illustrations Confusing