We want to talk about the compare and contrast of what is a motor point, what is a trigger point, which is a very, very common question and also how to use them clinically.
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Hello everyone. Thank you very much for attending our Sports Acupuncture Webinars sponsored by the American Acupuncture Council. My name is Matt Callison. I’m here with my colleague and good friend,
Brian Lau. So
Last month we had Josh Lerner as a guest. I was not able to make it last month, but Brian and Josh talked about trigger points quite a bit, and the pathophysiology and also different clinical uses. We wanted to this month to discuss and build upon last months, a narrative. We want to talk about the compare and contrast of what is a motor point, what is a trigger point, which is a very, very common question and also how to use them clinically. So before we actually start going into, let me talk about Josh a little bit here on the reason why we have him is he’s like Brian, who is, uh, not only just an excellent clinician, but a true academic. So that’s a pretty rare combination to have, uh, Josh graduated from the north west Institute of acupuncture and Oriental medicine in 2001. And he’s currently on faculty of the Seattle Institute of east Asian medicine, or he’s teaching orthopedic medicine trigger point theory, muscle-skeletal amp and also points and channels. Now he’s studied with Tom Bizzio and Frank Butler for quite a while. Starting in 2006, he also started taking trigger point release, uh, acupuncture trigger point release in 2007, and started dry needling classes in 2016, which he has become certified in dry needling in 2019. Now being an overachiever that Josh is, he also took the smack program at the same time and graduated from the sports medicine acupuncture certification program in 2017. So Josh is welcome. Thank you very much for coming Josh and help us out with this podcast webinar. Really appreciate it.
Thanks for having so you appreciate being asked back for this.
Yeah, absolutely. Well fun. All right. So we only have 30 minutes, so let’s jump right into what is the motor point? Well, you didn’t get into the trigger point, then start talking a little bit about case studies and how to be able to use them. Uh, first things first, the motor point when I first started studying them, this would be before I was an acupuncturist when I was going in and, uh, physical education and athletic training school at San Diego state university. I graduated from SDSU in 1986. Now in the training room, we were taught to use one inch by one inch or two inch by two inch could be even four inch by four inch electrical pads to place them over the central aspect of the muscle in order to influence the muscle belly or the motor point region. Now, it was common to be able to use these pads on agonist and antagonist muscles, for example, hamstrings and quadriceps, or even on hamstrings and then to a distal tendon or a proximal tendon in order to influence the electrical energy of that particular muscle.
Now, when I became an acupuncturist graduating from Pacific college Oriental medicine, which is now called Pacific college of health sciences, graduated from Pacific college in 1992, always was curious about the motor point and wondered as an acupuncturist. What would it be like to take a highly conductive electrical material, a stainless steel needle, and put it into this region as defined as having the lowest resistance to electrical conductivity. So therefore we, you have a region that has the lowest resistance to electrical electrical conductivity. That means that there is a enormous amount of cheap potential to manipulate. Now, of course, an acupuncture needle is much thinner than a one by one or a two by two pad. So therefore I started my journey and researching motor points. Where are they located at that time? Nobody was really talking about motor points, trigger points was the big thing.
Um, it was still under a lot of influence of Janet Chevelles and Dr. Simon’s enormous work and trigger point theory and their books as well. Um, and at that time, I, like I was saying, motor points really weren’t discussed very much. They were mentioned in the Shanghai text of acupuncture, which is an interesting read with that. And then going online and trying to find who was actually doing acupuncture on motor points, um, was Dr. Chan Gunn. Now he was up in Canada and he was also researching on motor points, but she’s got some incredible research if you guys wanted to go and check that out on Google scholar, um, being more of the dry dealer, um, he was really staying quite a bit away from traditional Chinese medicine and taking it more toward the dry needling aspect of it. And so we’ll finish that story at another time.
So what I found was taking acupuncture to the Motorpoint region was changing range of motion, changing muscle strength, decreasing pain. And this was really very, very exciting. Um, but trying to find where those motor points are at that time was very difficult because there really weren’t that many maps available. It was more of a line drawing with just like a black dot on it. So gathering a number of different research articles. I think it was in the forties or fifties, and today it’s well over 300 research articles that I have on motor points in their locations. But back then, there wasn’t very much so collecting that information and then also electrocuting a triathlete friend of mine with the surface surface electrode, trying to find exactly where these motor points are. Then I would map them and then locate them according to bony landmarks and acupuncture points for the acupuncturist.
Now this was way back in the early 1990s. And that was when the motor point manual came out, which I even have a copy of that anymore, but also the motor point chart came out and I’ll since then, it’s also has been updated the motor point chart. And this just came out in 2019. The original came out in the year 2000. Also some of the work that I was doing back then in the year 2000, I actually collected a whole lot of notes and started writing quite a bit and then published this treatment of orthopedic disorders manual, which came out, like I said, in the year 2000 or actually 1998, it came out and it’s been used at all three Pacific college campuses since then now in 2007, then my research came out and published the motor point index in 2007. So long story short, my work has been out there for a long, long time and has actually influenced quite a few people over the years.
Um, this has a lot of accountability and a lot of responsibility to it because even as today, Motorpoint locations have changed a little bit. The definition of the motor point has changed. Um, motor points. Now over these last 15 years are talked a lot about you’ll see research articles all over the place. It has infiltrated our field pulled a lot from the work that I have created, but then also what other people are also doing with motor points. So it’s, it’s something that is needing some discussion about what is a trigger point and what is a motor point. Now, the definition of the motor point in the 1940s, fifties, and sixties was basically an umbrella term for where the motor nerve inserts into the muscle belly and where the motor nerve inserts at the intramuscular junction, the neuromuscular junction. So both of those locations, which can actually be far away from one another in a muscle was the umbrella term called motor point.
Now recently, I would say within the last five to seven years, you start to see articles talking about motor entry points. And this is actually a better way of describing where my work has actually been taken is I’ve been looking for the motor point where it goes actually into the muscle belly itself. And the reason why is because it has the largest diameter of the motor nerve, then going into that motor point and has the lowest resistance to electrical conductivity, I’m taking that acupuncture needle and inserting it into that spot is where we can actually change quite a few things within that muscle, not only within the muscle itself, but also how the central nervous system views what’s happening within that muscle.
So the interesting, interesting thing about this is with motor points, like I said, that’s more of an umbrella term for what’s now being clearly defined as a motor entry point or where the motor nerve inserts into the neuromuscular junction would be the intermuscular motor point. So again, as the motor nerve comes in and inserts into the muscle itself has the largest diameter that goes into the motor into the muscle. Then it usually will bifurcate and go into a proximal part of the tissue. And also the distal part of the tissue sometimes close within an inch sometimes far away, six to eight inches, depending on the length of the muscle. So these collateral branches from the motor nerve travel within the muscle tissue and then insert into the actual muscle itself back can be called the intramuscular motor point. So we have motor entry points. We have intermuscular motor points, VM umbrella term would be motor points.
So I hopefully that actually helps. Um, you don’t really see motor entry point too much discussed in our field, but I’m sure it will start to spread over this next five or 10 years. Just, just because that gives us a little bit more clear definition of what exactly we’re trying to be able to treat. Now, the motor entry point is where the green triangles are on the sports medicine, acupuncture textbook, and also on the motor point chart, that’s where the motor entry point is located. Okay. So then now the intramuscular motor points themselves, um, those can actually be turning into trigger points with Josh and Brian and I are going to go ahead and discuss that in just a little bit or a trigger point can also develop, uh, at the location of the motor entry point. So from here, why don’t we now start to compare and contrast with the trigger point? Josh, do you want to take it away or Brian, do you want to add anything?
Yeah, I’ll, uh, I’ll step in here. And so Matt and I have had lots and Brian, Matt and Brian, and I have all had lots of discussions about, um, comparing and contrasting, um, trigger point phenomenon with motor points. And so there are a few different, um, dimensions within which we can kind of talk about these both contrasting differences and comparing areas that are similar. So one of the things to keep in mind, especially once we start talking a little bit more clinically, is that as helpful as it is to really talk about the, the differences between ideas about motor points versus trigger points to a large degree, especially clinically there’s a huge amount of overlap. And it’s a, if you really like Venn diagrams, there’s like a big circle about trigger point phenomenon and a big circle about Motorpoint phenomenon. There’s a huge gray area of overlap between the two of them.
So I’m going to try and keep that in mind as I’m discussing this, but it might sound at times like I’m being a little bit arbitrarily black and white about differences between them when that’s really not the case. So, um, one of the, one of the areas of contrast is that the motor points are basically a, a normal physiological phenomenon. Everybody has motor points. It’s just how the body works. Whereas trigger points are very specifically a pathological phenomenon. I’m not going to talk too much about the details about trigger point physiology, Brian and I spent an hour actually last time talking about a lot of that stuff. And so if you want to brush up on that, you can kind of go watch the previous podcast that Brian and I did. I think there are also going to be some links to some other discussions that Brian and I and a few others have had about trigger point stuff.
So you can refer back to that. Um, so that’s the first contrast is just normal physiology versus a pathological condition, right? Trigger points. Are they form due to some kind of muscle damage, right there, a small contracture in a muscle fiber that is the response to either like an excessive eccentric load or, uh, a low level contraction that goes on a long time and kind of wears out the fiber. Uh, another, another type of contrast between them is that motor points in a lot of ways are more like acupuncture points in that not only everybody has them, but the, the locations tend to be somewhat predictable, even though there can be quite a bit of variety of from person to person, whereas trigger points can really form just about anywhere in a muscle. So when you’re looking to treat trigger points, you really have to palpate the entire length of a muscle.
Whereas when you are treating motor points, um, you’re generally starting from a somewhat relatively defined position. Like it’s, uh, say, you know, in the middle, like the middle part of a muscle, or like in the case of say the rectus femoris, one of the common motor points is going to be halfway between like stomach 31 and hunting, right. You still have to palpate locally and the actual location you’re going to be looking for like a kind of an usher point. It might be, you know, one up to sooner, so away from that point, but you’re starting roughly from [inaudible].
Um, another, another area of contrast, uh, that I think will probably open up interesting discussion because Matt and I have talked about this quite a bit is how you use them clinically and what muscles you choose to treat, whether if you’re thinking about a trigger point versus a, um, a motor point. And so I’ll just kind of talk just very briefly about my take on this and then maybe, uh, Brian and Matt, if you guys want to pop in and, uh, contradict what I’m saying. Awesome, nice and heated, spicy debate going. So motor points in my practice, I tend to use very, uh, very kind of more generally to really overall improve the functioning of the muscle and to treat in the sense of the little skeletal homeostasis, what I’m really focusing a lot on biomechanical issues, where there’s a joint dysfunction in gallons of muscle pull across a joint, or are treating, uh, a muscle in one area of the body.
And I want to treat the entire senior channel. I might need other muscles more display or more proximally in that CGU channel. I’m 10 years motor points is in those locations, more commonly, um, and for trigger points, I tend to overall use the more specifically to treat the referral patterns when there’s pain or some other like parasthesia, that might be part of the referral, but even having said that there’s a huge amount of overlap between them. And so I also very commonly will use trigger points to treat more general biomechanical issues and old very often also use motor points to treat painful conditions. Um, and there’s a more subtle distinction to be made. And how I diagnose personally between the use of those two things. Um, it has to do with the fact that when you have pain, sometimes the pain is coming from a motor point, but you can have pain due to a muscle dysfunction that isn’t sorry, a trigger point.
Um, you can have pain from muscle dysfunction that is not from a trigger point pain, but just you can have pain because the muscle itself isn’t firing correctly, which can send signals to the central nervous system, kind of a warning signal. That just something isn’t right. We’re going to just give you some pain. So you stop using the muscle. Um, so you can have cases of pain that are in a muscle that are not to the trigger point, but they can be helped a lot by motor points. Um, so there are just kind of muddied the whole discussion a little bit with that. So I I’ll, uh, let’s open this up, Matt, Brian, uh, what do you guys want to talk about in terms of that?
Uh, Brian, I’ve got a few things to say, but why don’t you go ahead and start? Uh,
Well, I just say something simple and that’s, uh, you, both of you guys painted an ice clear picture of, uh, a difference between a motor point in a, in a trigger point. But if you look at a lot of the discussion and sometimes even the research out there, it’s not always so clear cut as, as Josh kind of alluded to it, the Venn diagram of how they overlap in terms of, um, comparisons, but even in terms of discussion like Matt was mentioning, sometimes they use the term motor entry points, sometimes motor point to encompass all of that. It’s not always very, um, consistent sometimes there’s discussions of trigger points that talk about, like, I saw several research articles that talked about an anatomical basis for trigger points. And they were basically looking at the motor entry point as the site of where trigger points tend to form.
Um, so the it’s not so clear how we’re going to try to discuss it from a, um, you know, compare and contrast and as if they’re different, but there’s a lot of overlap out there. So if you’ve looked into this at all, sometimes it’s easy to get confused because it’s confusing cause there’s a lot of different, different people saying different things about it that aren’t always consistent. Um, and I know this isn’t the case with the newer edition at Trevell and Simon’s book, but, um, in the previous additions, you know, they had Xs on sort of the frequent location of where a trigger points tend to form. And there was numbers, you know, like trigger point number one, upper traps trigger point number two, and in a different regions and different kinds of common sites. Now, of course, within that common site, you’d have to palpate and find the exact location.
Um, uh, and it’s going to be very variable, but there were sort of go-to sites, so to speak. And, um, if you look at those go-to sites, you’ll see that those go-to sites tend to be at the motor point, the motor, uh, close to the motor entry point location, um, where the muscle is getting the innovation. So, uh, the reality is that motor points are at the location of where common trigger points form, and both of them share one similar thing in their description and their language is that a motor point is the highest concentration of motor in plates. It’s a motor in plates or the cite on muscles that are, uh, have receptors for acetylcholine. So a motor point is the highest concentration of motor end points, a boater, um, in plates. I think that’s more of the classical definition of, of a motor points. Now with motor entry points, that’s more about the entry side of the nerve, but the classic definition going a little farther back as the highest concentration of motor in plates and trigger point in the language is often described as forming at the site of the highest concentration of motor in plates. So there’s a lot of parallel and there’s a lot of overlap and it’s not always clear to differentiate one from the other, my turn.
All right. Thanks Brian. Um, Josh Brian, that was awesome. That was good. Uh, in, in my mind, the motor implants are going to be where the intramuscular motor points are a little kid at, um, where the motor nerve enters into the muscle. There can be collateral branches that go into the motor end plates, but not always. So let’s now take this information and see if we can be able to bring it into some kind of clinical sense, for example, let’s I remember before we get into clinical sense, let’s remember that motor points also can be used as empirical points that will take pain away from a distance site. And that pain from a distance site has nothing to do with the trigger point referrals. Like for example, a flexor carpi ulnaris motor entry point is pre magnificent and taking pain away from the levator scapula attachment.
And that lateral posterior side of the neck or the piriformis motor entry point takes pain away from a urinary bladder 10 region. So there’s a number of different ways of looking at the motor entry point. And also what the trigger point is. Let’s say that tomorrow a patient comes in with sciatica, you use slump tests, you use straight leg, raise tests, a neural tension test, and they’re negative. So it doesn’t seem like it’s true sciatica. So what could be causing the sciatica like sensations? There’s a number of things that can, for example, a Fossette joint can cause referral pain, a sick really act joint can cause referral pain trigger points can cause the sciatica like referral pain. So let’s say that with this patient that you’ve done slump test and straight leg raise, and you’ve ruled out sacred iliacs joint dysfunction or Fossette joint dysfunction.
And you’re palpating along the iliac crest where the gluten minimis attaches and you find with palpation, it reproduces that patient’s sciatica likes sensations. This is just in the hypothetical example. So you’re looking at the glute minimus at its attachment side, or maybe the muscular tenant is junction site that you’re palpating around that area. And it’s a way from the motor point, which would be the muscle belly halfway between the superior border of the greater show canter and the iliac crest. That point definitely needs to be treated because it was causing this person sciatica or sciatic, like sensation definitely needs to be treated and TCM. We look at it as being either as an access or deficient, is it cold? Is it damp? And we are treated according to how we know how to get rid of and resolve damp or treat cold, reduce access, reinforce the deficiency.
It’s all going to be predicated on your palpation. Now, from my experience, if we treated the motor points of the gluteus minimus, first that trigger point that was located two or three inches away would be difficult to find it’s not going to be reproducing that same type of parasthesia. So from my experience, I would like to treat the trigger point. First, what I’ll do clinically is treat the trigger point first because that’s what’s causing it. And they’re like what Josh was talking about before let’s treat the motor entry point, cause that’s going to be then communicating quite a bit, the central nervous system about where that muscle is in space. You guys want to comment on that? Yeah. So
I think, um, another really great aspect to think about motor points is that in that particular case that you’re talking about, the motor points are also going to be incredibly useful to then treat the other muscles that might be involved in why that glute minimus develop trigger points in the first place. Right? So there may be, uh, there may be some, you know, if there’s like a pelvic imbalance where you have to look at the balance between the, the hip, uh, AB doctors like the glute medius and minimus plus with the add doctors plus with like the QL, um, that there may be this larger muscle imbalance issue between keeping the pelvis level in the, in the frontal plane, right? So it could be that treating the motor points of the adductor longus and brevis the quadratus lumborum and even using the motor points more in a TCM sense of looking at excess and deficiency to try and balance.
A lot of that is going to be a really important part of the treatment to keep that one gluteus minimus that’s causing referral pattern to keep that from developing further trigger points, right? Cause the trigger points could just be the end result, like the last symptom of a dysfunction that has been going on from these other areas, right. Um, where you might need to treat motor points, uh, down in the, in the cap for any of the motor points for the muscles that control the foot of the ankle. Cause maybe the glute minimus is developing trigger points because of its being overloaded because of an ankle dysfunction. Right? So I think that’s another aspect to the balance between looking at trigger points versus motor points that can be really helpful clinically. Awesome. Brian, anything you wanna say?
Yeah, I would just add into that some distal channel points do it. Now we have a pretty comprehensive picture. You know, we, we use this one a lot with the glute medius and minimus minimus in this case. Cause it’s clearly on the gallbladder sinew channel ma uh, Josh mentioned the quadratus lumborum and the add doctors, which we on time to go into it now, but the QL is, uh, part of the liver send you a channel as the ad doctors are. So you could also include points, um, to affect the relationship between those channels like sourced and low combination gallbladder, 40 liver five would be a really good combination that we use quite easily in the program. So you do, maybe we have this one point, that’s creating a referral, but it’s linked, uh, functionally with other muscular structures. So glute minimus in this case, linked with quadratus, lumborum add doctors in terms of how they’re in dysfunction together. So we can use motor points and trigger points and combinations of those muscles along with distal channel points. And that’s a to create a good local distal and point combination from a TCM standpoint.
Oh, awesome. Yeah, that’s good. Let’s go farther into that. So remember you guys, Osher points have been treated for thousands of years. So trigger points and tender motor points have been observed and treated with traditional techniques. And in some of the discussions that Josh and Brian have had is that when a trigger point is located in a different location than the motor entry point, it’s really common to find a tight palpable band linking the two. So for example, from the motor entry point, if you cross fibered toward the trigger point, many times you’ll actually find that type palpable ban linking the two, which maybe is why punk’s a needle technique was developed, which is really quite common in myofascial acupuncture by kneeling three or four needles in a row within that tight palpable bag. One of the needles would be at the motor entry point.
One of the needles are two of the needles might be the trigger point. So you’re covering those bases. And then as Brian was talking about linking that particular channel with points that will open up the channels in the collateral Xi, cleft Lubo points and such, and let’s also remember this patient, what’s their internal balance. What’s happening with them? How well can they handle inflammation because it’s on the gallbladder channel. Well, how is their liver and gallbladder functioning in their life? Could the liver and the gallbladder be contributing to part of this clinical picture? Always something for us to be able to consider is people are not just coming in as meat suits. We treat the entire patient. Great discussion. You guys.
Yeah. Another really interesting aspect to, uh, bringing TCM theory into this is also looking at, uh, general, like we get into TCM basic constitutions, right? There’s I very often find an element of spleen Xi deficiency with certain types of people who tend to develop a lot of trigger points because of the, the spleen’s ability to supply energy to muscles. Right? Cause the trigger point formation is in a sense of problem with energy supply to the muscle after it gets damaged, right? There’s a, there’s a very strong case to be made for looking at the importance of blood status and using herb formulas to treat a lot of blood status. Um, I think I mentioned maybe in a previous discussion that Brian and I had, I’m a big fan of the drew Yutang family of formulas for treating various types of musculoskeletal pain for that, uh, for that purpose. So I think that that’s, that could be a whole other podcast. We could talk about like a TC woman also talking about like postural distortions and TCM constitutional diagnoses, and then talking about muscular relationships between postural distortions and TCM stuffs. That could be a whole other thing we can get. Right, right.
That would be hours and hours and hours or people would just go to the smack program. Right. Well, this has been a great conversation, you guys, and I think there’s a lot of clarity that was added to this. Um, we are right approaching that 30 minute mark right now. Is there any closing comments that you guys want to be able to say?
Uh, I’ll just say, well first, um, Matt and Brian, thanks again for inviting me to do this. I really appreciate it. And uh, I just want to put it out there for everybody listening that the, the, the smack program, the sports medicine acupuncture program was one of the real turning points in my career. It kind of brought together, even though I’ve done a lot of work with trigger points and some orthopedic stuff before then, um, it really brought together, uh, so many different elements of what I was trying to get at when I was doing, um, orthopedic work with my patients that it’s probably saved me 15 or 20 years of studying on my own, trying to do a lot of this together. So I just wanted to say, thank you, Matt and Brian for, uh, giving people this opportunity. Great.
Well, thanks for that, Josh really appreciate that. And that’s good. Um, yeah, it’s always welcome. And no, Josh, you didn’t bug me with your questions during the smack program where you sat down as a no, no, you just have very inquisitive mind. And the thing is, is that kind of dialogue is so welcome to because other people are stimulated by that kind of conversation. So it’s always welcomed. So thank you, Josh, for that also for more, let me finish this one real quick, Brian, for more information about Josh in the comments section, there’s, uh, three different links that, um, he’s talking about trigger points for anybody who’s interested in a motor point chart or motor point book. There’s also, there’s going to be links for that as well. Go for what Brian.
Yeah. On the topic of, uh, messages coming up, there was a question which we could go into a lot of detail and we don’t have time, but it was about osteoarthritis of the hip. Um, and I just want to quickly say that the same discussion we were just having about balancing the pelvis, um, by using motor points, uh, in terms of like, if there’s a, uh, elevated Lem, QL, glute medius, and minimus, and the combination of motor points, plus distal points, that’ll help balance the hip joint would be really a great idea for osteoarthritis, but you could also look at, uh, what trigger point referrals are referring to that region of pain. The hip joint itself can refer pain and can be, can be the pain source. Sure. But since we’re talking about trigger points and motor points, looking at the trigger points that are part of that referral, uh, it could be that the trigger point is causing 20, 30, 40, 50, 60% of that pain. Um, so also treating the, the, uh, looking for trigger points in those, um, regions that could be referring to that area would be a, it would be a good idea to start with
Joshua say something, I’ve got something to add.
Um, uh, the only thing I would add to that is if you’re not used to looking up trigger point referral patterns, it not is going to not just be the muscles locally to the hip, right? One of the muscles that might recreate something like osteoarthritis of the hip could be like the lung just amiss muscles up around the thoracolumbar junction around T 12, right. That can refer pain down to the truck hacker. So there’s a lot that has that a lot of, um, resources out there to allow you to look up for pain in one particular area of the body, what is the list of different muscles that can all refer to that area? And it’s really helpful looking, you can find those online it’s in Trevell um, uh, yeah, very useful resource.
Um, just to add some clarity with this one, cause I don’t know what kind of diagnostics were made with the osteoarthritis. So the patient may actually have confirmed osteoarthritis, but now these comments that we’re making is that, um, there also could be, uh, pain contributors, which would be trigger points. So as we know, uh, trigger points can also live not only in muscle tissue that we’ve been addressing over these last couple of hours is also can live in joint capsules, tendons, ligaments. So needling the joint capsule itself may also help in this particular case as well.
All right. Anything else, gentlemen? I think we, uh, we covered most of the stuff we wanted to cover.
All right. Well thank you very much. Really, really appreciate it. And so stay tuned for next week, come in, check in, check out Jeffrey Grossman for next week. And Brian is, was nice hanging out with you, Josh. Thank you so much. Really, really appreciate it. Thanks you guys. Bye now. Bye-bye