From Travell & Simons Manuals

Travell & Simons, Trigger Point Therapy Manuals                

I have listed below, some information (excerpts) from the Travell & Simons, Trigger Point Manuals, with hope they may be useful to you in  your search for a solution to your chronic soft-tissue pain symptoms.  Travell & Simons' Myofascial Pain and Dysfunction: The Trigger Point Manual (2-Volume Set)

Keep in mind that this information is directly from the T&S manuals, and they are readily available to acquire from online sources.
These manuals are not really 'suggested reading' for the average layperson, as they are filled with medical terminology; However, I do recommend that all health practitioners, who deal with chronic soft-tissue pain on a daily basis, acquire and study them.
Note: If you are being treated for trigger points, your therapist must have these T&S manuals in their personal reference library... and the 2 volumes should look like they've been well-used!

I recommend that laypersons who need good, solid Trigger Point information, acquire a copy of The Trigger Point Therapy Workbook: Your Self-Treatment Guide for Pain Relief .

The information listed here, is in no particular order.

I will add to this list below, as often as I can.

Kindest Regards,  
William Huhn  

You can acquire your own set of these amazing textbooks - keep in mind that they are medical manuals, (not an easy read for laymen) complete with medical terminology  Travell & Simons' Myofascial Pain and Dysfunction: The Trigger Point Manual (2-Volume Set)  

Muscle... an orphan organ 

  'Muscle is an orphan organ. No medical specialty  claims it. As a consequence, no medical specialty  is concerned with promoting funded research  into muscular causes of pain, and medical  students and physical therapists rarely receive  adequate primary training in how to recognize  and treat myofascial trigger points'. 

Dr. David G. Simons, M.D. 
Co-author: Travell and Simons; Myofascial Pain and Dysfunction, The Trigger Point Manual

Exercise and Myofascial Trigger Points

Disturbances of motor functions caused by trigger points include spasm of other muscles,
weakness of the involved muscle function, loss of coordination by the involved muscle, and
decreased work tolerance of the involved muscle. The weakness and loss of work tolerance are
often interpreted as the indication for increased exercise, but if this is attempted without
inactivating the responsible trigger points, the exercise is likely to encourage and further ingrain
substitution by other muscles with further weakening and de-conditioning of the involved muscle.

Travell & Simons;  Myofascial Pain and Dysfunction,  The Trigger Point Manual

Depression and Myofascial Trigger Points

A major, well recognized contributor to depression is chronic pain. On the other hand, depression may lower the pain threshold, intensify pain, and impair the response to specific myofascial therapy. Patients who have suffered myofascial pain for months or years are likely also to have developed secondary depression and sleep disturbances, and to have restricted their activity and exercise. The ensuing restriction of body movement and the increased psychic tension aggravate their TrPs, causing a vicious cycle. All contributory factors should be identified and corrective actions taken.

Depression must be recognized. If untreated, it blocks recovery from myofascial symptoms. It is diagnosed by a variety of clues. Physiologic clues are insomnia, anorexia, and weight loss, impotence or decreased libido, or blurred vision. Mental-outlook symptoms include a sad mood, thoughts of suicide or death, and strong feelings of guilt. Other clinical changes are inability to concentrate, poor memory, indecisiveness, mumbled speech, and a negative reaction to suggestion. Socially, the patient exhibits a desire to be alone, disinterest in favorite activities, a drop in job performance, and neglect of personal appearance and hygiene.

Folic acid or pyridoxine deficiency and low thyroid function are potent contributors to depression, and may, in addition, increase neuromuscular irritability and TrP (trigger point) pain. An analysis of the problem should include, 'What are the characteristics of this patient who has this pain?', not just, 'What TrP involvement does this patient have?'

Travell and Simons; Myofascial Pain and Dysfunction, The Trigger Point Manual; 1999; pg. 110

It's Not Simply Pain

Disturbances of autonomic functions caused by TrPs include abnormal sweating, persistent lacrimation, persistent coryza, excessive salivation, and pilomotor activities. Related proprioceptive disturbances caused by TrPs include imbalance, dizziness, tinnitus, and distorted weight perceptions of lifted objects.

Travell and Simons; Myofascial Pain and Dysfunction, The Trigger Point Manual; 1999; pg. 21


Trigger Point Injections   (is your "trigger point injection" therapist following this procedure?)

Trigger Point Injections require first, accurate localization of the TrP by palpation and then, confirmation of precise placement of the needle-elicited pain and local twitch response. Enough finger pressure is applied to ensure hemostasis. After injection, the patient should perform three full cycles of slow active range of motion to reestablish normal function of the muscle. 

Travell and Simons; Myofascial Pain and Dysfunction, The Trigger Point Manual; 1999; pg. 94

Why inject Trigger Points?   (Note: WHM TM Body Workers do not inject trigger points)

The decision whether to treat trigger points (TrPs) by manual methods or by injection depends strongly on the training and skill of the practitioner. Ideally, both approaches should be equally available to the patient and used when indicated. Manual methods are noninvasive, available for for the patient to learn to use for self-treatment, and can be used to release multiple TrPs at the same time in one muscle or a group of trigger points and several muscles that serve the same function. However, manual methods are more likely to require several treatments and the benefit of treatment may not be as fully apparent for a day or two, as compared to injection. It requires considerable time and effort to acquire the skills needed to use manual techniques or to inject trigger points effectively. 

Manual methods are specifically indicated when the trigger point is acute, when the goal is to train the patient and effective methods of self-management of the pain and dysfunction, when the patient is severely needle-shy, or when the central trigger points in the middle of the muscle belly are not accessible to injection (iliacus and psoas muscles) for most clinicians.

One well-performed injection can fully inactivate a trigger point immediately, which is reassuring to their clinician and the patient. Identification and injection of key trigger points can produce impressive results. Success depends strongly on the accuracy of the clinicians aim. This accuracy depend strongly on the precision with which the trigger point was localized and on the skill of the clinician.

Injection is indicated when a few trigger points remain that are unresponsive to manual methods, when skilled manual trigger point therapy is not available, when there are only a few relatively acute trigger points and the treatment time is severely limited, and when the patient has hyperuricemia and symptoms of gout. Injections can be helpful when the muscle cannot be stretched for mechanical reasons, or when stretch should be limited because of hypermobility.

Patients with both fibromyalgia and myofascial trigger points are much more sensitive to painful therapeutic techniques (which, for them, or likely to be counterproductive) than are patients with trigger points but without fibromyalgia. Patients with both conditions respond to trigger point injections, but they do not respond as well as patients with only myofascial trigger points.

It is a serious mistake to judge the efficacy of trigger point treatment by manual methods or by injection if the practitioner was not both well trained AND experienced in the techniques used for the muscles reportedly treated. Knowledgeable, skillful practitioners of trigger point therapy can be difficult to locate. So often, when patients give a history of being treated for TrPs without benefit, careful questioning makes it clear that treatment was given without adequate examination for TrPs or was not performed in a manner that one would expect to be effective.

Travell and Simons; Myofascial Pain and Dysfunction, The Trigger Point Manual; 1999; pg. 151

Active or Latent Trigger Point

Active Myofascial Trigger Point: A myofascial trigger point that causes a clinical pain complaint. It is always tender, prevents full lengthening of the muscle, weakens the muscle, refers a patient-recognized pain on direct compression, mediates a local twitch response of muscle fibers when adequately stimulated, and, when compressed within the patient's pain tolerance, produces referred motor phenomena, generally in it's pain reference zone, and causes tenderness in the pain reference zone. To be distinguished from a latent myofascial trigger point.

Travell and Simons; Myofascial Pain and Dysfunction, The Trigger Point Manual; 1999; pg. 1

Latent Myofascial Trigger Point: A myofascial trigger point that is clinically quiescent with respect to spontaneous pain; it is painful only when palpated. A latent trigger point may have all the other characteristics of an active trigger point and always has a taut band that increases muscle tension and restricts range of motion.

Travell and Simons; Myofascial Pain and Dysfunction, The Trigger Point Manual; 1999; pg. 4

Psychological Factors

A number of psychological factors can contribute to perpetuation of myofascial trigger points. Most important, the physician must be careful not to assume that the psychological factors are primary. It is all too easy for the physician to blame the patient's psyche for the inability of the physician to recognize the muscular skeletal sources of the patients pain. This wrong assumption can be and often is devastating to the patient. We have so much to learn about pain, especially pain from muscles!

Patients who misunderstand the nature of their condition may be depressed, may exhibit anxiety tension, or maybe victims of the "good sport" syndrome; some may be exhibiting secondary gain and/or sick behavior; a very few will evidence conversion hysteria. Each must be diagnosed on its own merits.

Travell and Simons; Myofascial Pain and Dysfunction, The Trigger Point Manual; 1999; pg. 220


Patients who have been erroneously convinced that their pain is due to untreatable physical factors, such as degenerative joint disease, a 'pinched nerve' that is in operable, or 'rheumatism' which they must learn to live with, often live in dread of aggravating their condition by any movement or activity that begins to elicit the pain. The result is that they avoid all painful movements, including those that would stretch the muscles and help them recover function. When their pain is primarily due to myofascial TrPs, this excessive restriction of movement and activity aggravates and perpetuates their trigger points.

An essential first step with these patients is to convince them that their pain is of muscular origin and treatable , and that they must understand and respect their muscles. Acceptance of this revises the patients' concept of the prognosis. As they learn what activities to avoid and what they themselves can do to inactivate the trigger points, they realize they are gaining control of the source of their pain. This new confidence in the future of their neuromuscular function lifts a great load from their shoulders.

Travell and Simons; Myofascial Pain and Dysfunction, The Trigger Point Manual; 1999; pg. 220, 221


Anxiety and Tension

In some individuals, high levels of anxiety are expressed in the form of muscle tension. Many muscles are held in sustained contraction that overloads them and perpetuates myofascial trigger points. These patients are easily identified as they sit up stiff and straight, leaning away from the backrest of a chair, maintaining their shoulders and elevated position, and displaying a tense facial expression. Generally, they are unaware of these muscular expressions of tension. Biofeedback and relaxation therapy can help many of them to discriminate between unnecessarily tense muscles and relaxed ones. They need to learn conscious techniques of relaxation and how to turn excess tension off.

Travell and Simons; Myofascial Pain and Dysfunction, The Trigger Point Manual; 1999; pg. 221

'Good Sport' Syndrome

The 'good sport' syndrome is the opposite of hypochondriasis. The 'good sport' has a stoical attitude and is determined to ignore pain. He or she charges forth engaging in activities with total disregard, if not outright defiance, of the pain, thereby overloading the muscles and aggravating trigger points. 'Good sports' often believe that their pain is a sign of "weakness" and that they must push on to demonstrate their mastery of it. They must learn how this abuse of their muscles contributes to their pain, and how new ways of doing things can let them perform the activities important to them safely and comfortably.

Travell and Simons; Myofascial Pain and Dysfunction, The Trigger Point Manual; 1999; pg. 221


Acute myofascial pain due to TrPs caused by a clearly identifiable strain on one muscle is, as a rule, able to be fully relieved and normal function restored. The longer the period between the acute on set of pain and the beginning of treatment, the greater the number of treatments that will be required over a longer period of time.

Patients who have had a stable pattern of referred TrP pain for months or longer, without extension to other muscles, are likely to respond better to treatment than patients with progressively more severe symptoms. When the pain has spread and is gaining momentum with successively more muscles becoming involved, multiple perpetuating factors must be eliminated before specific myofascial therapy can provide sustained relief.

Travell and Simons; Myofascial Pain and Dysfunction, The Trigger Point Manual; 1999; pg. 110

Other non-pain symptoms 

Patients may report excessive lacrimation, nasal secretion, pilomotor activity and occasionally changes in their sweat patterns, but TrP activity is rarely seriously considered as the source of these symptoms. An involved limb may feel cold as compared with the opposite one due to reflex vasoconstriction. The examiner should be alert for symptoms of postural dizziness, spatial disorientation, and disturbed weight perception. All of these phenomena can be caused by myofascial TrPs; some are specific to particular muscles, others are not.

Travell and Simons; Myofascial Pain and Dysfunction, The Trigger Point Manual; 1999; pg. 109

Nerve Entrapment 

TRIGGER POINT EXAMINATION of a muscle requires a knowledge of the location and direction of its fibers in relation to those of neighboring muscles. Objective confirmation of a TrP requires special examination techniques for locating its taut band, nodule, and spot tenderness by palpation. The diagnosis of an active trigger point is established by patient recognition of the pain elicited by pressure on the TrP and may be confirmed by eliciting a local twitch response (LTR) from it. Nerve ENTRAPMENT may occur because of pressure by the palpable bands of taut muscle fibers that are associated with myofascial TrPs, when the nerve passes through the muscle between taut bands, or when it is compressed between such a band and bone. The cause of the neurological symptoms and signs of neurapraxia that result is easily misinterpreted if this mechanism of entrapment is not recognized.

Travell and Simons; Myofascial Pain and Dysfunction, The Trigger Point Manual; 1999; pg. 94


It is important to think beyond the obvious weak function of a muscle or muscle group and not assume that all it needs is strengthening exercises. The clinician must determine why it is weak and the type of weakness. Myofascial TrPs contributing to or causing the weakness may be in the same muscle and/or in functionally related muscles.

 Travell and Simons; Myofascial Pain and Dysfunction , The Trigger Point Manual; 1999; pg. 114



Myofascial trigger point activity is aggravated and the response to specific myofascial therapy is reduced or shortened by hypoglycemia. Recurrent hypoglycemic attacks perpetuate myofascial trigger points. The prevalence of hyperglycemia is controversial largely because the symptoms of hypoglycemia are caused chiefly by increased circulating epinephrine. Other conditions such as anxiety, also increase epinephrine levels, but without hypoglycemia. Clinically, the responses are often indistinguishable. Two kinds of hypoglycemia are generally recognized, fasting and postprandial; they occur for different reasons, but put present the same symptoms.

  Symptoms     The initial symptoms of hypoglycemia or increased epinephrine are usually sweating, trembling and shaking, a fast heart rate, and the feeling of anxiety. Activation of sternocleidomastoid trigger points may cause headache and dizziness. With progressively severe hypoglycemia due to unusual circumstances, symptoms similar to those of hypoxia develop and are caused by inadequate energy to sustain brain function: visual disturbances, restlessness, impaired speech and thinking, and sometimes syncope (loss of consciousness).

Fasting Hypoglycemia     Fasting does not cause hypoglycemia in a normal person because the liver releases glucose as the blood glucose starts to fall. Fasting hypoglycemia may result from failure of the liver to release the glucose, failure of the adrenal medulla to produce epinephrine that stimulates the liver to release the glucose, or failure of the anterior pituitary to stimulate the adrenal gland. Liver disease can impair this function of the liver. Alcohol ingestion when glycogen stores in the liver or depleted can precipitate severe hyperglycemia. Rarely, fasting hypoglycemia may be due to the deficiency of an enzyme, such as glucagon.

Postprandial (Reactive) Hypoglycemia     Symptoms of postprandial hypoglycemia typically occur at two or three hours after ingestion of a meal rich in carbohydrates, overstimulating the release of insulin. The insulin triggers a compensatory epinephrine response. The hypoglycemia caused by the insulinemia appears transiently for 10 to 30 minutes until it is terminated by the liver's response to an increased epinephrine level. Generally, the epinephrine causes most of the symptoms usually attributed to hypoglycemia. This form of hypoglycemia is associated with high anxiety levels and is most likely to occur during periods of emotional stress.

Travell and Simons; Myofascial Pain and Dysfunction, The Trigger Point Manual; 1999; pg. 219

Iliopsoas Muscle (Lower Back Pain, Groin Pain, Upper Thigh Pain) 

This "Hidden Prankster" can cause distorted posture that overloads back and neck muscles, perpetuating TrPs in them. The victimized muscles may include the hamstring, gluteal, the thoracolumbar paraspinal, and posterior cervical muscles.

Iliopsoas TrPs are usually associated with TrPs in other muscles and really present as a single-muscle myofascial syndrome. The iliopsoas and the quadratus lumborum Iliopsoasmuscles are usually involved together through their stabilizing action on the lumbar spine and the occasional extensor action of the psoas muscle. Therefore for lasting relief of an iliopsoas syndrome, TrPs in both the quadratus lumborum and iliopsoas muscles must be inactivated.

Bilateral involvement of the psoas leads to bilateral involvement of the quadratus lumborum, but one side is usually more severely affected than the other. The quadratus lumborum in the posterior portion of the iliacus muscle may form a continuous sheet the fibers where both attach along the crest of the ilium. 
Synergistic muscles likely to exhibit myofascial trigger points in association with Iliopsoas involvement include the rectus abdominis, quadratus lumborum, rectus femoris, tensor fascia latae, pectineus, lumbar paraspinal muscles, and the contralateral iliopsoas.


Travell and Simons; Myofascial Pain and Dysfunction, The Trigger Point Manual, Volume 2; 1993; pg. 101 

More excerpts to follow.  


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