If you have pelvic pain, chances are you have trigger points somewhere within or adjacent to your pelvic floor muscles.
trigger points are a key factor in many pelvic pain syndromes. For that
reason, I’m dedicating this week’s blog post to them. I’ll begin with
an overall explanation of what they are. Then, I’ll explore the part
they play in pelvic pain syndromes. And lastly, I’ll wrap up with a
discussion of how pelvic pain trigger points are diagnosed and treated.
The Trouble with Trigger Points
muscle is made up of numerous fibers. A trigger point is a small, taut
patch of involuntarily contracted muscle fibers within a muscle or
muscle fascia. The tightly contracted fibers that form a trigger point
effect blood supply to the nearby tissue, which in turn makes the area
hyperirritable when compressed.
In addition to the local pain they
cause, trigger points often refer pain elsewhere. On top of that, they
can pull on tendons and ligaments associated with the muscle they are
in, and can even cause pain deep within a joint where there are no
Once trigger points made it onto the medical map, it
became obvious that a handful of different kinds existed. For instance,
there are active trigger points, which as their name suggests, actively
cause pain and other symptoms. There are latent trigger points, which
are dormant, but have the potential to cause trouble. And there are
satellite trigger points, which can crop up in another trigger point’s
referral zone. For instance, a trigger point in the levator ani muscle
can cause a trigger point to occur in the abdomen.
So not only can
trigger points refer their pain to other regions, they can actually
cause other brand new trigger points to crop up in other places. That’s
why it’s important to keep in mind that trigger points can be very
misleading, and when dealing with them it’s a mistake to always assume
the problem is where the pain is.
For example, in women, trigger
points in the obturator internus muscle of the pelvic floor can refer
pain/irritability to the urethra. So say Jane Doe has an active trigger
point in her obturator internus. As a result, Jane begins to experience
urethral burning and urgency. So she visits her doctor believing she has
a urinary tract infection. But a battery of tests shows that there’s
nothing wrong with Jane’s urinary tract. Jane’s doctor tells her that
everything is fine. But Jane is frustrated because everything’s not
fine. She’s in pain and feels like she constantly has to urinate.
both the doctor and Jane are missing is that the cause of her urinary
symptoms is a patch of constricted muscle fibers in a small,
out-of-the-way muscle in Jane’s pelvic floor.
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This is a
frustratingly common scenario. Indeed, pretty much everyone will deal
with trigger points at some time in their lives. If you have lingering
pain, tightness, or muscle restriction, chances are you have trigger
points. Plus, trigger points are at the root of many ailments you
wouldn’t expect such as dizziness, nausea, tooth pain, restless leg
syndrome, painful periods, and irritable bowel syndrome. However,
oftentimes issues caused by trigger points are misdiagnosed as
arthritis, tendonitis, bursitis, or ligament injury.
The good news
is that inroads are being made, new research on trigger points is being
undertaken, and the medical community is increasingly starting to
recognize them as causes of pain. More good news is that even though
there are some 620 potential trigger points possible in human muscle,
they show up in pretty much the same places in everyone. So trigger
point maps do exist complete with referral patterns, and that goes for
the pelvic floor too.
Trigger Points and the Pelvic Floor
Now let’s get to the main reason you’re reading this blog about trigger points: their relationship with the pelvic floor.
Trigger points play a role in the vast majority of pelvic pain syndromes. Indeed, in some cases, they’re the only culprits.
instance, I recently had a male patient, let’s call him Ben, who had
trigger points in his rectus abdominus from doing too many sit ups over a
period of years. His main complaints were lower abdominal pain and
penile pain. After about eight months of working to release those
trigger points, Ben is now symptom-free.
However, while it is
possible for trigger points to be the sole cause of pelvic pain, it’s
much more common for them to be just one component in a multi-layered
For instance, another patient of mine, Lori, had trigger
points in her bulbospongiosus, obturator internus, and piriformis
muscles. However, in addition to these trigger points, she had
connective tissue dysfunction, an overall hypertonic (or tight) pelvic
floor, and urinary urgency and frequency.
In Lori’s case, her pain
began after a urinary tract infection followed by a stubborn yeast
infection. The pain from the infections kicked off a so-called
“guarding” reflex within her pelvic floor. (Guarding occurs when muscles
contract rigidly around a painful area to protect it from further
damage. But, guarding causes further damage because it restricts blood
flow, which in turn causes more guarding and more pain.)
Lori, it’s impossible to know exactly what part trigger points played in
the creation of her pain cycle. An ongoing guarding reflex in and of
itself is sufficient enough to overload pelvic floor muscles and cause
the development of trigger points. But the overall muscle tightening
that followed the guarding could also have caused them to develop, not
to mention Lori’s new habit of holding her bladder because of her
Aside from an overuse/repetitive strain
situation as with Ben or pain from infection or guarding as with Lori,
trigger points in the pelvic floor can develop for a slew of different
reasons. For example, local trauma can cause them to crop up, such as
infertility treatments, rectal/vaginal ultrasound, a colonoscopy, a
tailbone fall, a bartholin’s abscess, or childbirth. Mechanical and
physical stressors, like a hip tear or endometriosis, can also cause the
development of trigger points.
Whatever the reason for their
development, trigger points are famous for complicating already painful
situations, and in many instances, they stick around long after the
original problem clears up.
Trigger Point Diagnosis and Treatment
Therapists treating pelvic pain should know how to identify and treat
trigger points in pelvic floor and pelvic girdle muscles. In addition,
he or she MUST be knowledgeable about the mapped out regions where
trigger points typically occur within the pelvic floor as well as the
dozens of referral patterns.
For instance, trigger points in the
piriformis muscle can refer pain down the back of the leg or into the
hip or a trigger point in the levator ani muscle can create the feeling
of having a golf ball in the rectum. Having this level of knowledge is
an important part of putting the pieces of the puzzle of a patient’s
pelvic pain symptoms together and forming a proper treatment plan.
it comes to diagnosing and treating trigger points, it’s important that
a PT evaluate all of the muscles and muscle fascia, both internal and
external from the navel to the knees, front and back.
Liz does a
great job of explaining what happens when she finds a trigger point, so
I’m going to defer to her here. Take it away Liz.
perpendicular along the muscle’s direction, when you come across a
trigger point, you will feel a very noticeable change. To me, it feels
sort of like a lentil. Plus, when I find a trigger point, I always get a
reaction from my patient, so I’m always tuned into him or her for
In addition, sometimes a twitch can be felt when a
trigger point is compressed, and sometimes that twitch response will
cause the entire muscle to contract. Lastly, the trigger point may feel
hotter to the touch than the area around it.
A handful of strategies exist for treating trigger points including:
- Manual release techniques: A good PT has a handful of trigger point release techniques in her toolbox.
- Dry needling: Almost all states, but not all, allow PTs to administer dry needling. California, where we practice, does not.
point injections: These are administered by physicians and typically
contain anesthetic; however, it’s the actual injection that will
successfully release the trigger point, not the anesthetic. The
anesthetic is simply on board to soothe and numb the tissue.
hope I’ve answered all of your questions about pelvic pain trigger
points in this post! If not, please don’t hesitate to ask any
additional questions you might have in the comments section below or
email me at email@example.com.
If you would like to do some further reading on trigger points, below are some resources that I recommend:
- “Myofascial Pain Syndromes–Trigger Points” by David Simons and Jan Domerholt, Journal of Musculoskeletal Pain, Vol. 13(1) 2005
- “Myofascial Pelvic Pain” by Rhonda Kotarinos
Trigger Points and Myofascial Pain Syndromes: A Critical Review of
Recent Literature” by David Simons and Jan Domerholt
- The Trigger Point Manual by Drs. David Simons and Janet Travell
- Myofascial Trigger Points: Pathophysiology and Evidence-Informed Diagnosis and Management by Jan Domerholt and Peter Huijbregts
All my best,