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Trigger Points

TABLE 2. Recommended Criteria for Identifying Latent and Active Trigger Points Essential Criteria

Taut band palpable (if muscle is accessible)

Exquisite spot tenderness of a nodule in a taut band

Patient's recognition of current pain complaint by pressure on the tender nodule (identifies active trigger point)

Painful limit to full passive stretch range of motion

Confirmatory Observations

Visual or tactile identification of local twitch response

Observation of a local twitch response induced by needle penetration of a tender nodule

Pain or altered sensation (in the distribution expected from a trigger point in that muscle) on compression of a tender nodule

Electromyographic demonstration of spontaneous electrical activity characteristic of active loci in the tender nodule of a taut band

Trigger points are subdivided into two groups. Active trigger points cause referred pain and usually have predictable patterns specific to each muscle. These trigger points are rarely located where the patient reports the pain. The pain pattern does not usually follow a specific dermatomal pattern. The suspected muscle should be palpated until a band or feeling of tightness is located. This finding is often described as a ropiness or nodularity in the muscle. Clinicians should then apply pressure until they find the "spot of maximum tenderness" along the length of the taut band of muscle fiber.

When the trigger point is palpated, the patient may localize the discomfort and involuntarily withdraw from contact (jump sign). Such a finding is a strong indication of a trigger point. Sustained digital pressure on a trigger point usually evokes the same referred pain pattern that brought the patient into the clinic. Occasionally, anatomically controlled phenomena, such as a change in skin temperature, color, or perspiration, may occur.

The second type of myofascial trigger point that Travell describes is the latent trigger point. On exam, the patient may have a nodular area that, while associated with a taut band of muscle, does not reproduce pain. This finding, along with increased muscle tension and a restricted range of motion, separates this particular myofascial trigger point from the tender points that are characteristic of fibromyalgia.

Treating Trigger Points

After identifying the characteristic trigger points of MPS and ruling out other diagnoses, various treatment protocols can be implemented in an office setting.

Trigger point injections. Various compounds have been described for use in injections, including 3% promethazine-hydrochloride, 0.5% procaine hydrochloride, 1% lidocaine hydrochloride without vasoconstrictors, and 0.25% lidocaine with normal saline. Indications for trigger point injections are a limited number of tender spots coinciding with the patient's complaint that produce the jump sign in response to pressure. Several contraindications for injections have been proposed (table 3).

To avoid pneumothorax, never aim the needle at an intercostal space. (Even with proper training and patient informed consent, we do not advocate injection in this area for outpatients.)
  • Use a needle long enough to keep the hub well above the skin surface during injection.
  • Never inject the needle to the hub, because, if the needle breaks, complications can arise.
  • Be aware of the tip of the needle at all times and avoid placing any sideward pressure on the syringe that could bend the needle and deflect the tip.
  • Check for a needle that has a rough tip surface, which may create a "drag" upon injection; the impact of the tip of such a needle produces a fish-hook burr, causing unnecessary bleeding.17 Needles can be replaced if a rough tip is found, even after the syringe is filled.

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