“Remember it’s a sin to kill a mockingbird.” That was the only time I ever heard Atticus say it was a sin to do something, and I asked Miss Maudie about it. “Your father’s right,” she said. “Mockingbirds don’t do one thing but make music for us to enjoy … but sing their hearts out for us. That’s why it is a sin to kill a mockingbird.”

The late Harper Lee struck an intense moral chord in the USA with her acclaimed novel – To Kill a Mockingbird (1960).

But does the innocent mockingbird have anything in common with the “myofascial trigger point (MTrP)”? Is it a sin to kill a MTrP?

There are physical therapists who firmly believe that MTrPs can cause considerable harm to people:

Myofascial TrPs are a preventable cause of musculoskeletal pain, they cause dysfunctions, such as blurry vision, erectile dysfunction, balance disturbance and dizziness, irritable bowel, diarrhea, vomiting, voice disturbances, and loss of fine motor control. They can cause colic in babies or contribute to falls in the elderly–and in the rest of us [Starlanyl & Sharkey, 2013].

Furthermore, in their eyes the potential havoc that MTrPs can wreak extends even to fibromyalgia (aka chronic widespread pain).

In their recent book Starlanyl and Sharkey (2013) make this promise to their readers:

“You will discover how TrPs can cause or maintain fibromyalgia and why the ability to control the TrPs directly affects the control of FM symptoms … the key to controlling trigger points is identifying and controlling perpetuating factors.”

Accordingly, Starlanyl and Sharkey (2013) see fit to issue a stern warning to those individuals who are unfortunate enough to harbour MTrPs:

If the perpetuating factors are not brought under control, satellite TrPs can develop in muscles that overwork trying to compensate for the TrP-weakened ones, or in muscles in the referral zone. Once primary TrPs develop satellite TrPs in other body areas, life, and treatment, becomes more complex. The satellites themselves can develop more satellites involving more of the body. Trigger points can cause body-wide pain.

On close examination, these perpetuating factors, of which the list is exceedingly lengthy, turn out to have only been figments of the fertile imagination of the original proponents of the MTrP theory [Travell & Simons, 1983].

The belief that MTrPs can be “controlled” has spawned a worldwide industry of therapists eager to kill (“deactivate”) them by various drastic methods, which include needling, compression, and manual release.

On her website Starlanyl (2014) advises therapists to proceed cautiously, as follows:

“Use the least invasive option for therapy, with the understanding that most treatment options may activate more TrPs and cause a temporary increase in pain. Toxins and waste materials trapped in the myofascia (sic) must be processed by the body and be eliminated, and that can only proceed so fast. It takes a while for the Gordian knot to unravel, and the process is not fun for the patient.

Starlanyl (2014) describes: “… a cadre of patients with too many TrPs to count, in multiple levels in multiple muscles. They have chronic myofascial pain (CMP). The muscles may be so tight and swollen that you can’t see them move beneath the skin, and the pain levels escalate. These patients may have had multiple surgeries and procedures. There may have been multiple traumas. There may be a wide variety of perpetuating factors.”

When the preferred treatment fails to kill the MTrP(s), the blame then shifts from the therapist to the pain sufferer, who without any shadow of doubt must harbour one or more of these so-called perpetuating factors.

It may be a sin to kill a mocking-bird – but has any one ever seen a “dead” MTrP, let alone be able to identify and describe its true nature? No doubt there are some who would see it as sinful should therapists not try to “kill” as many MTrPs as possible in their attempts to alleviate human suffering. However the published research on outcomes for “treating trigger points” suggests that they are not easy to kill [Cohen & Quintner, 2008; Quintner et al., 2015].

Could this apparent resistance to destruction be explained by their very non-existence? Unless and until this is appreciated, the MTrP will continue to mock its followers.


John Quintner



Cohen ML, Quintner JL. The horse is dead: let myofascial pain syndrome rest in peace [letter]. Pain Medicine 2008; 9: 464-465.

Quintner J, Bove G, Cohen M. A critical evaluation of the “trigger point” phenomenon. Rheumatology 2015; 54: 392-399.

Starlanyl DJ, Sharkey J. Healing through trigger point therapy: a guide to fibromyalgia, myofascial pain and dysfunction. Berkeley, California: North Atlantic Books, 2013.

Starlanyl D. Fibromyalgia and trigger points for care providers, 2014. Available at: Accessed 13th May 2016.

Travell JG, Simons DG. Myofascial pain and dysfunction: the trigger point manual. Baltimore: Williams and Wilkins, 1983.


  1. John,

    In the review I wrote a few years ago I noted that it is extremely rare for clinical studies on MTrPs to include a process for checking that they are ‘dead’ following the intervention, subjectively successful or not.

    I haven’t looked in a while but for all the talk about the importance of managing perpetuating factors at the time I only found two relevant publications:

    “However, many of these factors are controllable. In a cohort study of 25 patients with chronic myofascial head and neck pain, Graff-Radford et al examined the use of a structured interdisciplinary format of physical and cognitive-behavioral therapies aimed at reducing factors that perpetuate MPS. The results immediately following treatment, and at 3, 6, and 12 months post-treatment showed highly reliable reductions in self-reported pain and medication intake when compared to pre-treatment scores. However, there are no randomized controlled trials that address the duration of pain relief associated with management of contributing and perpetuating factors.

    In a study investigating factors that may influence the outcome of trigger point injection therapy, Hopwood and Abram found that an increased risk of treatment failure was associated with unemployment due to pain at the start of treatment, no relief from analgesic medication, constant pain, high levels of pain-at-its-worst and pain-at-its least, prolonged duration of pain, change in social activity, lower levels of coping ability, and alcohol use. They concluded that several factors should be considered in treating patients with MPS with trigger point injections. The study is consistent with the evidence that MPS is a multi-dimensional phenomenon and that a plethora of factors may influence treatment outcome.”

    How such factors could create focal ‘satellite’ muscle pathology certainly requires some serious explaining.

  2. Luke, thank you for your comment.

    In our 1994 paper we wrote: “In their efforts to preserve the centrality of the myofascial TrP, myofascial pain theorists have allowed the number and nature of predisposing, precipitating, and perpetuating factors to be open-ended and to encompass the full spectrum of etiology, including the untestable psychogenic level. This serves only to perpetuate the circularity of the reasoning.”
    Evidently, nothing has changed since then!

    Reference: Quintner JL, Cohen ML. Referred pain of peripheral neural origin: an alternative to the “Myofascial Pain” construct. Clin J Pain 1994; 10: 243-251.

  3. Luke, your question prompted me to refresh my memory on the vexed subject of the myofascial trigger point (MTrP).

    Sad to say I found that nothing has really changed since 1994!

    There are still clinicians who without any scientific evidence believe that a discrete pathophysiological entity known as the MTrP actually exists and that it is endowed with magical properties.

    Because the MTrP can assume a number of guises, thereby confusing the uninitiated clinician (and patient), I have compiled a beginner’s guide to the world of the MTrP.

    The “Active” MTrP is said to be the “cause” of both local and referred pain when the person who happens to harbour it is at rest. If provoked (i.e. poked) the pattern of referred pain is said to resemble that of the person’s complaint.

    Clinicians believe that MTrPs are “hyperirritable” varmints that reside within “taut bands” of “contractured” muscle fibres. In the words of Devin Starlanyl, MD author of Fibromyalgia and Chronic Myofascial Pain Syndrome: A Survivor’s Manual:

    “You cannot strengthen a muscle that has a trigger point, because the muscle is already physiologically contracted. Too many physical therapists see a weakened muscle and immediately attempt to strengthen it without testing for the presence of trigger points. Attempts at strengthening a muscle with trigger points will only cause the trigger points to worsen…”

    The “Latent” MTrP is quite a different beast. It can lie quietly in wait within a muscle, sometimes for years, before becoming “active”. But evidently the initiated clinician who interrogates the muscle can detect its lurking presence. Clues that could point to its existence and location are weakness and/or restricted movement of the relevant muscle.

    The “Satellite” MTrP develops within a muscle that just happens to be minding its own business but has the misfortune to reside within the pain reference zone of another TrP. A chain reaction can occur when a satellite MTrPs begets more satellite MTrPs.

    As the National Association of Myofascial Trigger Point Therapists (NAMTPT) explains:

    “Prolonged referral of pain and weakness from a one trigger point to another area of the body will generally cause other trigger points to develop in that area. These, in turn, if left untreated, can activate and also refer pain, creating multiple pain patterns. The more areas that have pain and the longer you have had the pain, the more trigger points you are likely to have. It is rare for someone with pain to only have one or two muscles with trigger points.”

    On the NAMTPT website, Robert Gerwin M.D., a leading proponent of the construct of myofascial pain syndrome (MPS) reassures sufferers: “If an MPS becomes chronic, it tends to generalize, but it does not become fibromyalgia … but it is nonetheless a muscle disease that can be satisfactorily treated.” He did not disclose the name of this particular disease.

    The “Secondary” MTrP can develop in a muscle or muscles that are either synergists or antagonists of the muscle said to contain the “active” MTrP. If the muscle happens to be a synergist, the development of an MTrP indicates that the muscle is “standing in” for the affected muscle. By contrast, development of a MTrP in an antagonist muscle is a phenomenon of “overload” due to that muscle trying its hardest to overcome the “tautness” of its opposite partner.

    The “Dead” MTrP appears to be so rare that no one has ever described it. This is quite surprising given the vigorous efforts of “properly” trained clinicians to silence “active” MTrPs. Perhaps they are tricky and never die but simply revert to an earlier form by again becoming “latent”.

    Welcome to the weird world of the MTrP!

    Useful reference: The National Association of Myofascial Trigger Point Therapists. Trigger point therapy: what is it? Myofascial made simple. Available at

  4. In the words of Plato: “Necessity is the mother of invention.”

    Lo and behold, a new trigger point has just been invented – the Super Trigger Point.

    It can be accorded its rightful place in the “trigger point” pantheon.

    In the words of its ingenious inventor, such a “trigger point” is “active all the time in everyone – it is like they have to be there. They are the myofascial strange attractors. Treating these trigger points appears to have greater systemic effects than expected, often including profound physiological effects (such as autonomic changes). These effects are well beyond the “normal” trigger point reactions, hence the name Super Trigger Points.”

    Interested readers can follow this link to find out more about the Super Trigger Point:

  5. Luke, I must say that I abruptly stopped reading when I saw this (unreferenced) claim being made on their blog-site: “Both peripheral and central sensitization can have serious unwanted effects: the advice therefore is to interfere with this process as soon as possible. The good news is that myofascial trigger point release and dry needling techniques have both been reliably demonstrated to reduce these effects.”


    It appears they have awarded themselves an unrestricted licence to hunt down and kill every single “trigger point” that might be harboured by patients with Fybromyalgia (sic).

    The words of Johann Wolfgang von Goethe [1749-1832] aptly sum up this situation: “Nothing is more terrible than to see ignorance in action.” From Maxims and Reflexions, I (tr. by John Stuart Blackie in The Wisdom of Goethe)

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