Myofascial trigger points peripheral or central phenomenon-

Curr Rheumatol Rep (2014) 16:395
DOI 10.1007/s11926-013-0395-2

CHRONIC PAIN (R STAUD, SECTION EDITOR)

Myofascial Trigger Points: Peripheral
or Central Phenomenon?
César Fernández-de-las-Peñas & Jan Dommerholt

Published online: 22 November 2013
# Springer Science+Business Media New York 2013

Abstract Trigger points (TrP) are hyperirritable spots in a
taut band of a skeletal muscle, which usually have referred
pain. There is controversy over whether TrP are a peripheral or
central nervous system phenomenon. Referred pain, the most
characteristic sign of TrP, is a central phenomenon initiated
and activated by peripheral sensitization, whereby the peripheral nociceptive input from the muscle can sensitize dorsal
horn neurons that were previously silent. TrP are a peripheral
source of nociception, and act as ongoing nociceptive stimuli
contributing to pain propagation and widespread pain. Several
studies support the hypothesis that TrP can induce central

sensitization, and appropriate TrP treatment reduces central
sensitization. In contrast, preliminary evidence suggests that
central sensitization can also promote TrP activity, although
further studies are needed. Proper TrP management may prevent and reverse the development of pain propagation in
chronic pain conditions, because inactivation of TrP attenuates
central sensitization.

This article is part of the Topical Collection on Chronic Pain

Introduction

C. Fernández-de-las-Peñas
Department Physical Therapy, Occupational Therapy, Rehabilitation
and Physical Medicine, Universidad Rey Juan Carlos, Alcorcón,
Madrid, Spain
Esthesiology Laboratory of Universidad Rey Juan Carlos, Alcorcón,
Madrid, Spain
Cátedra de Investigación y Docencia en Fisioterapia: Terapia Manual
y Punción Seca, Universidad Rey Juan Carlos, Alcorcón, Madrid,
Spain
J. Dommerholt
Myopain Seminars, LLC, Bethesda Physiocare, Inc, Bethesda, MD,
USA
J. Dommerholt
Universidad CEU Cardenal Herrera, Valencia, Spain
J. Dommerholt
Shenandoah University, Winchester, VA, USA
C. Fernández-de-las-Peñas (*)
Facultad de Ciencias de la Salud, Universidad Rey Juan Carlos,
Avenida de Atenas s/n, 28922 Alcorcón, Madrid, Spain
e-mail: cesar.fernandez@urjc.es

Keywords Trigger points . Referred pain . Sensitization .
Central . Peripheral . Myofascial . Nociception

Myofascial trigger points (TrP) are one of the most overlooked
and ignored causes of musculoskeletal pain. There is evidence
suggesting that TrP are a common primary dysfunction and
not necessarily secondary to other diagnoses [1]. In other
words, TrP may occur in the absence of any underlying
medical condition and can constitute an independent cause
of pain. TrP can, however, also be co-morbid with a variety of
medical musculoskeletal conditions, including osteoarthritis
of the hip or knee [2], or with visceral conditions, for example
endometriosis [3], interstitial cystitis [4], irritable bowel syndrome, dysmenorrhea, or prostatitis [5].
The most commonly accepted definition describes a TrP as
a hyperirritable spot in a taut band of a skeletal muscle, which
is painful on compression, stretch, overload, or contraction of
the muscle and usually has a distinct referred pain pattern [6].
Clinically, we can distinguish active and latent TrP. The local
and referred pain from active TrP reproduces symptoms suffered by patients, who identify the pain as their usual or
familiar pain. There is evidence that the local and referred pain
from active TrP reproduces the sensory symptoms of individuals with idiopathic neck pain [7], lateral epicondylalgia [8],
chronic tension-type headache [9], shoulder pain [10, 11], and

395, Page 2 of 6

temporomandibular pain [12]. In contrast, the local and referred pain from latent TrP may not reproduce any symptom
familiar or usual to the patient [6].
Although latent TrP do not induce spontaneous pain,
they can provoke motor dysfunction, e.g. muscle weakness, inhibition, increased motor irritability [13], muscle
cramps [14], and altered motor recruitment [15]. During
the past decade, an increasing number of researchers have
shown an interest in the etiology and clinical relevance of
latent TrP [16••].
Development or activation of TrP can result from a variety
of factors, including repetitive muscle overuse, acute muscle
overload, repetitive minor muscle trauma, psychological
stress, and visceral disorders [17]. TrP are located within
discrete bands of contractured muscle fibers called taut bands.
A taut band signifies a contracture arising endogenously within a limited number of muscle fibers, but not involving the
entire muscle [6]. Studies have observed that taut bands have
higher stiffness [18], reduced vibration amplitude [19], higher
peak systolic velocities, and negative diastolic velocities [20]
compared with normal muscle sites. Although different theories have been proposed, the integrated hypothesis is the most
accepted model for explaining the pathophysiology of muscle
TrP [21•]. In summary, the integrated hypothesis proposes that
abnormal depolarization of the post-junctional membrane of
motor endplates causes a localized hypoxic energy crisis
associated with sensory and autonomic reflex arcs that are
sustained by complex sensitization mechanisms. The presence
of spontaneous electrical activity or endplate noise, and the
clinical evidence that treating TrP eliminates or significantly
reduces this endplate noise, support the notion that TrP are
located in close proximity to dysfunctional motor endplates
[22]. A recent study reported that TrP in the upper trapezius
muscle are located in well-defined areas proximal to innervation muscle zones [23]. Although current evidence supports
the hypothesis that TrP are associated with dysfunctional
motor endplates, the function of muscle spindles in the etiology of TrP has been also investigated [24–26].
The integrated hypothesis postulates that the origin of TrP
is a primary dysfunction of the motor endplate. A more recent
hypothesis suggests that TrP are caused by a nociceptioninduced central nervous system disorder, which is centrally
maintained by α-motoneuron plateau depolarization, but experimental evidence for this hypothesis is lacking [27].
Recently, several researchers have investigated a possible
relationship between TrP and sensitization mechanisms
[28••]. TrP may be a cause of central sensitization, but it is
also conceivable that TrP are the result of central sensitization;
in other words, are TrP a peripheral or a central phenomenon?
This paper will discuss different sensory aspects of TrP,
whereby both peripheral and central sensitization mechanisms
are involved simultaneously, and briefly address clinical
implications.


Muscle Referred Pain: Peripheral or Central
Phenomenon?
One of the characteristic signs of TrP is the presence of referred
pain. Pain felt at the source of pain is termed “local pain” or
“primary pain,” whereas pain felt in a region away from the
source of pain is termed “referred pain.” Referred pain can be
perceived in any region of the body, but the size of the referred
pain area is variable and at least partially affected by paininduced changes to central somatosensory maps. Because the
intensity of referred pain and the size of the referred pain area
are positively correlated with central nervous system excitability, it is now generally assumed that muscle referred pain is a
central sensitization process mediated by a peripheral sensitization phenomenon, with additional sympathetic activity facilitation and dysfunctional descending pain inhibition [29, 30].
Among the different theories explaining the neurophysiology of referred pain, the central hyper-excitability theory
explains the principal characteristics of referred pain in most
detail. According to this theory, referred pain occurs at the
dorsal horn level and is the result of activation, by means of
sensitization mechanisms, of quiescent axonal connections
between affective nerve fibers’ dorsal horn neurons [1].
Hoheisel et al. reported that new receptive fields emerged
within minutes after experience of noxious stimuli [31],
explaining the delay between the noxious input and development of referred pain [32]. In clinical practice referred pain
appears within seconds of stimulation of a TrP, suggesting that
induction of these axonal changes is a rapid process. TrP are
more effective than non-TrP regions at inducing neuroplastic
changes in the dorsal horn neurons [33].
These findings support the hypothesis that referred pain
elicited by TrP is a central phenomenon initiated, activated,
and maintained by peripheral sensitization. Peripheral nociceptive input can sensitize previously silent dorsal horn neurons. Because anesthetization of the referred pain area reduces
pain, it would seem that peripheral processes contribute to
referred pain [34].
However, it is also clear that central sensitization processes
are involved in the development of spreading pain, because
larger referred pain areas in patients with chronic pain are a
consequence of higher central neural plasticity [35]. Maintenance of referred pain is dependent on ongoing nociceptive
input from the site of primary muscle pain [29]. There is
currently insufficient data to determine which sensitization
mechanism, peripheral or central, is more relevant to the
development of referred pain.

Trigger Points: A Peripheral Source of Nociception
Peripheral sensitization is described as a reduction in the pain
threshold and an increase in responsiveness of the peripheral


nociceptors. Muscle pain is associated with the activation of
muscular nociceptors by a variety of endogenous substances,
including neuropeptides and inflammatory mediators [1].
Studies conducted by Shah et al. revealed that the concentrations of bradykinin (BK), calcitonin gene-related peptide
(CGRP), substance P, tumor necrosis factor-α (TNF-α), interleukins 1β, IL-6, and IL-8, serotonin (5-HT), and norepinephrine were significantly higher at active TrP than at latent TrP or
non-TrP points [36]. Interestingly, concentrations of the same
biochemical and algogenic substances in a pain-free area of
the gastrocnemius muscle were also higher for subjects with
active TrP in the upper trapezius muscle compared with subjects with latent TrP or non-TrP points [37]. More recently,
Hsieh et al. confirmed the presence of multiple biochemical
substances in the immediate proximity of TrP [38••]. Both the
studies by Shah et al. [36, 37] and Hsieh et al. [38••] provided
evidence that therapeutic intervention with dry needling could
modulate and normalize the chemical environment of TrP,
supporting the theory that TrP may be a source of peripheral
nociceptive input.
Li et al. observed nociceptive (hyperalgesia) and nonnociceptive (allodynia) hypersensitivity at TrP, suggesting that
TrP sensitize nociceptive and non-nociceptive nerve endings
[39]. Wang et al. reported that blocking large-diameter myelinated muscle afferents increased pressure pain and referred
pain thresholds at TrP, but not at non-TrP regions, suggesting
that non-nociceptive large-diameter myelinated muscle afferents are also involved in TrP pain [40]. These studies establish
the presence of nociceptive pain hypersensitivity at TrP and
confirm that TrP are a focus of peripheral sensitization.
Myofascial TrP can act as ongoing nociceptive stimuli
contributing to spatial pain propagation and widespread pain,
as confirmed by a study in which painful stimulation of latent
TrP in asymptomatic subjects induced early occurrence of a
locally enlarged area of pressure hyperalgesia and central
sensitization [41].

Trigger Points can Induce Central Sensitization
Emerging research suggests a physiological link between the
clinical manifestations of TrP, e.g. hyperalgesia, allodynia,
and referred pain, and central sensitization, although the causal mechanisms are still unclear. Mense suggested that, because
TrP constitute a continued peripheral nociceptive afferent
barrage into the central nervous system, the presence of multiple TrP in the same or different muscles or the presence of
TrP for prolonged periods of time can sensitize spinal cord
neurons and supra-spinal structures [42].
A relationship between active TrP and central sensitization
has been suggested for many years, but it was not until the past
decade that neuro-physiological studies were initiated. Kuan
et al. observed that spinal cord connections of TrP were more

Page 3 of 6, 395

effective than non-TrP tissue at inducing neuroplastic changes
in the dorsal horn neurons, and were connected to a greater
number of small sensory or nociceptive neurons [33]. Xu et al.
reported that painful stimulation of latent TrP induced central
sensitization in healthy subjects, because stimulation of TrP
increased pressure hypersensitivity of extra-segmental tissues
[43]. A few studies observed that stimulation of TrP induced
enhanced activity of brain areas including the primary and
secondary somatosensory cortex, the inferior parietal cortex,
and the mid and anterior insula [44, 45], supporting the
hypothesis that TrP can induce central sensitization.
TrP are also a focus of peripheral noxious sensitization, as
illustrated by Fernández-de-las-Peñas et al., who formulated a
pain model applied to tension-type headache. Peripheral sensitization of muscle nociceptors and central sensitization both
seem to be linked to active TrP located in muscles innervated
by the upper cervical nerve roots and the trigeminal nerve. TrP
may be responsible for peripheral nociception and produce a
continuous afferent barrage into the trigeminal nerve nucleus
caudalis, hence sensitizing the central nervous system [46].
Further support for the hypothesis that TrP may induce central
sensitization can be derived from the observation that proper
management of TrP can reduce central sensitization. There is
evidence that central sensitization is a reversible process in
individuals with TrP [35], although traditionally central sensitization has been believed an irreversible process, at least in
animals [47]. Injections into TrP of neck muscles produced
rapid relief of palpable scalp and facial tenderness and associated symptoms of migraine [48]. Anesthetic injections into
active TrP significantly reduced mechanical hyperalgesia,
allodynia, and referred pain for individuals with migraine
[49], fibromyalgia [50], and whiplash [51].
The cause of the rapid decrease in local and referred pain
associated with TrP therapy, observed in clinical practice, is
not fully understood. The resolution of TrP-associated referred
pain is related to the decrease of nociceptive input to dorsal
horn neurons of the spinal cord, and to interruption of the
spread of pain and central sensitization. The reversal of referred pain is fast, suggesting that central sensitization can
indeed be reversed with proper treatment. A recent study
supported the hypothesis that altered pain processing seems
to be driven by peripheral noxious stimuli. The researchers
described normalization of widespread pressure-pain
hyperalgesia after successful hip replacement in subjects with
symptomatic hip osteoarthritis [52]. Several factors affect
central sensitization associated with TrP, including descending
inhibitory pathways and sympathetic or neuropathic activity.

Central Sensitization can Promote Trigger Point Activity
Although there is evidence that TrP can initiate central sensitization, there is also some preliminary evidence that central

395, Page 4 of 6

sensitization can promote TrP activity. It is known that a
sensitized central nervous system may modulate referred muscle pain. For example, infusions of the N-methyl-D-aspartate
(NMDA) antagonist ketamine reduced referred pain areas in
subjects with fibromyalgia [53]. In addition, an increased
degree of central sensitization is associated with larger referred pain areas from TrP [1, 9, 29].
The only study suggesting that TrP can result from central
sensitization was conducted by Srbely et al. [54], who hypothesized that pain arising from TrP may be caused by neurogenic
mechanisms secondary to central sensitization. They postulated that central sensitization may increase TrP sensitivity in
segmentally related muscles; however, the study did not establish a cause-and-effect relationship [54]. If central sensitization could cause TrP, it would be reasonable to assume that
TrP would not be present in healthy, pain-free subjects where
central sensitization mechanisms are not present. There are,
however, several studies revealing that asymptomatic healthy
subjects also have TrP—because the subjects are pain free,
these would be classified as latent TrP, [2, 3, 7–15, 16••, 23,
24, 40, 41, 43]. Latent TrP are not spontaneously painful, but
they do provide nociceptive barrage into the dorsal horn
[13–15, 16••, 24, 40, 41, 43].
Although there is no evidence supporting the hypothesis
that TrP are a result of central sensitization, in clinical practice
individuals with higher levels of central sensitization present
with multiple TrP.

Implications for Clinical Practice
Current data supports the hypothesis that TrP can affect the
development of central sensitization. Because muscle TrP are
common in many chronic pain conditions and they initiate,
activate, and maintain sensitization of central pathways, it is
important to realize that untreated TrP can cause chronic or
persistent pain. Therefore, TrP should be treated as soon and
as effectively as possible to avoid development of persistent
pain. Proper management of TrP may prevent and reverse the
development of spatial pain propagation in chronic pain conditions. Inactivation of TrP is associated with attenuation of
central sensitization [49–51] and induction of spinal inhibition
[55, 56]. Determining the proper treatment approach for each
individual patient with chronic or persistent pain is challenging for clinicians, because patients will probably have different clinical presentations. In developing an effective management plan, the manifestations of both peripheral and central
sensitization mechanisms of a particular condition or clinical
presentation must be included in the decision tree. In other
words, clinical management of patients with central sensitization needs to extend beyond tissue-based pathology and incorporate strategies directed at normalizing or reducing central
nervous system sensitivity [57].


The treatment plan should include two main components. First, peripheral and central nervous system sensitivity must be targeted by means of appropriate interventions. Second, the descending inhibitory systems must be
activated [58]. Inactivating TrP and addressing their perpetuating and promoting factors has an important function
in achieving these objectives, because removing the peripheral nociceptive input from TrP will modulate the
patient’s central sensitivity.
Clinically, when a patient presents with a pain problem
mediated by predominantly peripheral sensitization mechanisms, functional activity and early and appropriate treatment of the noxious inputs should be encouraged. This
may involve inactivating TrP, and mobilizing joints and
nerves. For a patient with a more persistent condition
mediated by predominantly central sensitization mechanisms, a multimodal therapy program is the preferred
approach, which may include pharmacological and medical management, physical therapy, and cognitive behavioral or psychodynamic therapy. Depending on the chronicity of the disorder and the associated disability, patients
should receive pain neuroscience education addressing the
neurobiology of pain and pain mechanisms, fear, anxiety,
and other psychosocial variables [59]. Patients need to
develop different strategies for optimizing normal functional movement and to undertake active and specific or
more global exercises, including aerobic exercise.

Conclusions
To determine whether muscle TrP are a peripheral or
central phenomenon, multiple lines of research must be
considered. Available data supports the hypothesis that
TrP are a persistent peripheral source of nociception contributing to pain propagation and widespread pain. The
clinical finding that inactivating TrP attenuates central
sensitization further supports the hypothesis that TrP are
a primarily peripheral phenomenon. As research in this
field continues to expand, it is conceivable that central
phenomena will be found to contribute to the development of TrP. However, experimental evidence is currently
sparse.

Compliance with Ethics Guidelines
Conflict of Interest César Fernández-de-las-Peñas and Jan Dommerholt
declare that they have no conflict of interest.
Human and Animal Rights and Informed Consent This article does
not contain any studies with human or animal subjects performed by any
of the authors.


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