Trigger Point or Neural Entrapment? Differential Diagnosis in MSK Physiotherapy

Musculoskeletal physiotherapists frequently encounter patients presenting with pain, tingling, or radiating symptoms that mimic nerve irritation. The challenge lies in determining whether the source is a myofascial trigger point or a true neural entrapment. Although the symptoms may overlap, the underlying mechanisms and clinical implications differ significantly. Accurate differential diagnosis ensures safer treatment planning and faster recovery.

This comprehensive guide breaks down the key differences between trigger points and neural entrapment, clinical indicators, assessment strategies, and best-practice management approaches for MSK physiotherapists.

Understanding Trigger Points in MSK Physiotherapy

A myofascial trigger point (MTrP) is a hyper-irritable spot within a taut band of skeletal muscle. When compressed, it reproduces local pain or a predictable referral pattern. Trigger points can be active, causing spontaneous pain, or latent, producing discomfort only on palpation.

How Trigger Points Develop:

Trigger points are commonly caused by:

Muscle overload or repetitive strain
Poor posture
Direct trauma
Psychological stress
Compensatory movement patterns

These factors lead to an energy crisis in the muscle fibre, resulting in sustained contraction, hypoxia, and pain.

Key Symptoms of Trigger Points

Physiotherapists should look for:

Localized deep, aching pain
Referred pain following specific myofascial patterns
Muscle stiffness or weakness
Palpable taut bands
Positive jump sign during palpation

Importantly, trigger point referral pain often mimics nerve pain, which is why misdiagnosis can occur.

What Is Neural Entrapment?

Neural entrapment occurs when a peripheral nerve is compressed, irritated, or stretched along its anatomical pathway. This may result from muscular tightness, fascial restriction, joint dysfunction, or structural abnormalities.

Common Causes of Neural Entrapment

Prolonged compression (e.g., carpal tunnel syndrome)
Inflammation due to repetitive stress
Anatomical variations
Postural mechanical changes
Scar tissue or adhesion formation

Signs and Symptoms of Neural Entrapment

Unlike trigger points, nerve entrapment typically presents with:

Numbness or tingling
Burning or electric-shock-like pain
Dermatomal or cutaneous sensory loss
Muscle weakness in the nerve distribution
Hyporeflexia or absent reflexes
Symptoms reproduced with neurodynamic tension tests

Nerve symptoms often follow a predictable anatomical nerve pathway, rather than a muscular referral pattern.

Trigger Point vs Neural Entrapment: Key Differences

To make a correct diagnosis, physiotherapists should compare symptom patterns, palpation responses, and functional limitations.

1. Pain Quality

Trigger Points: Deep, dull ache; predictable referral pattern
Neural Entrapment: Sharp, burning, tingling; nerve pathway distribution

2. Symptom Reproduction

Trigger Points: Pain increases on direct palpation of the taut band
Neural Entrapment: Symptoms worsen with nerve tension tests (ULNT, SLR, slump)

3. Distribution

Trigger Points: Non-dermatomal, may radiate to distant areas
Neural Entrapment: Follows dermatome, myotome, or nerve pathway

4. Associated Findings

Trigger Points: Limited ROM, muscle stiffness, jump sign
Neural Entrapment: Sensory deficits, reflex changes, muscle atrophy (chronic cases)

5. Response to Treatment

Trigger Points: Improve with dry needling, manual therapy, and stretching
Neural Entrapment: Responds better to nerve gliding, decompression, postural correction

Understanding these differences is essential for accurate clinical decision-making.

Assessment Strategies for Accurate Differential Diagnosis

Effective diagnosis begins with a detailed patient history, followed by targeted physical examination.

1. Thorough Case History

Key questions include:

Onset and nature of pain
Occupational and activity-related factors
Presence of numbness or tingling
Postural habits
Previous injuries

2. Palpation

Identify:

Taut bands
Local twitch responses
Reproduction of referral pain

Trigger points often produce sharp, localized tenderness.

3. Neurodynamic Tests

Common tests include:

Upper Limb Neurodynamic Test (ULNT)
Straight Leg Raise (SLR)
Slump Test

Positive findings strongly indicate neural tension or entrapment.

4. Strength and Reflex Testing

Weakness or reduced reflexes typically point to nerve involvement.
Trigger points may cause inhibition but not true neurological deficit.

5. Sensory Mapping

Nerve entrapment follows dermatomal patterns, whereas trigger point referred pain does not.

6. Functional Movement Assessment

Look for:

Muscle imbalance
Movement compensations
Postural faults contributing to compression

Management Approaches

Once the source is identified, physiotherapists can design an effective treatment plan. Management of Trigger Points

Dry needling
Soft tissue mobilization
Trigger point release techniques
Myofascial stretching
Corrective exercises
Postural retraining
Heat therapy to improve circulation

Dry needling is particularly effective in reducing hyper-irritability and restoring normal muscle function.

Management of Neural Entrapment

Nerve gliding and tensioning techniques
Postural correction
Soft tissue release along the nerve pathway
Joint mobilizations to reduce compression
Ergonomic modifications
Anti-inflammatory strategies
Strengthening surrounding musculature

The goal is to reduce mechanical compression and restore optimal nerve mobility.

When to Refer Out (Red Flags)

Certain symptoms require further investigation or referral:

Progressive neurological deficit
Severe night pain
Loss of bowel or bladder control
Unexplained weight loss
History of cancer

These signs may indicate systemic or serious neurological conditions.