Doug Leland is no stranger to back pain. After two failed back surgeries he is on long-acting narcotics in addition to high doses of seizure medications to dull the relentless nerve pain that burns day and night like an eternal fire deep inside his left leg.
A few weeks ago Doug went to the emergency room several days after slipping on his icy front steps. I read the report with some surprise. He had caught himself, and didn’t actually fall. He didn’t have broken ribs or any other serious injury, but was experiencing so much pain under his right shoulder blade that the ER doctor had decided to give him two intravenous injections of hydromorphone, a very strong, fast-acting opioid, plus high doses of a muscle relaxant and an anti-inflammatory medication.
When I saw him last week he was miserable. Every little movement of his upper body bothered him. His pain covered an area under his shoulder blade about the size of one of his large hands. Dead center in this area was an exquisitely sore spot with a palpable knot in the upper portion of his latissimus dorsi muscle. Even mild pressure on this tender spot caused a burning pain that radiated down the back of his right arm. This didn’t fit with the anatomy of any cervical or thoracic nerve.
I didn’t want to continue increasing his narcotics as they clearly weren’t providing him relief. With Doug’s ulcer history, he wasn’t a good candidate for continued anti-inflammatory drugs.
I decided to offer him something I haven’t done for a few years – a trigger point injection. They were common twenty years ago, but seem to have somewhat fallen out of fashion.
Doug was game: “Anything, Doc. Anything that might help, I’ll try it!
I mixed lidocaine and saline in a 3 cc syringe and attached a 25G 1½ inch needle. I localized the tender spot again and circled it with a ballpoint pen. I cleaned his skin with iodine and inserted the injection needle into the trigger point I had marked. I aspirated the syringe to make sure the needle wasn’t in a blood vessel.
“You’re in the right spot, Doc!” Doug groaned.
“Okay, Doug, here we go…” I told him.
A few minutes later Doug was moving his shoulders around, bending his back comfortably in all directions.
“The pain’s gone…”
“The Novocain is in the right spot, then,” I explained. “We’ll have to see if there is a lasting effect. Come back after the weekend and let me see how you’re doing.”
Doug came back, still smiling. There was a small area of tenderness several inches above where I had put the needle, but his pain was essentially gone. Doug was grateful.
“You’re a magician, Doc!”
“It’s an old trick I had almost forgotten,” I confessed.
“I’m sure glad you thought of it, Doc!”
That evening I thought more about trigger point injections. I don’t remember hearing about them in medical school or my internship in Sweden. I heard of them soon after I came to this country, thirty years ago.
I decided to do some research.
Trigger points were first described in 1942 by Janet Travell, MD. She became the personal physician to President John F Kennedy, who suffered from chronic back pain. Her first edition of “The Trigger Point Manual” was published in 1983 when I was a Family Practice resident here in the United States. I learned to inject trigger points in patients with myofascial syndrome in my residency, but this is not something all physicians learn today. Other modalities, from manual pressure to laser therapy, are now sometimes applied to trigger points.
Trigger points are thought to relate to dysfunctional end plates within the sympathetic nervous system. Acetylcholine levels and pH are thought to be important factors in myofascial pain.
The effect of trigger point injections can be reversed with naloxone, an opiate antidote. This suggests that the release of endorphins may be partly responsible for the effect of trigger point injections.
Very few articles have been published on this topic in recent years. There are few randomized controlled trials, and not all of them have found trigger point injections to be effective. One recent study found similar results for trigger point injections and acupuncture.
There are many similarities between trigger points and acupuncture points, but they have been viewed as very different in how they work. Trigger point injections, regardless of which chemical is used, are thought to cause physical changes at the injection site. Some clinicians even do “dry needling” of trigger points with the same results. The insertion of an acupuncture needle is generally thought to affect energy flow in predetermined meridians.
Intentional or accidental trigger point pressure can cause referred pain in other locations, similar to the correlation between acupuncture points and meridians. In fact, a 2006 study shows that of 255 trigger points with referred pain patterns described by Janet Travell and her collaborator, David Simons, 170 correspond to classic and 64 to newer acupuncture points and their meridians. This raises the question of whether the 70-year-old trigger point theory isn’t just Western medicine’s rediscovery of an ancient form of energy medicine. Doug’s pain pattern, radiating from the tip of she shoulder blade to the back of the arm, fits one described by Travell. It also closely follows one of the large acupuncture meridians.
What I did in the case of Doug Leland the other day may not just date back to 1942, but three or four thousand years.