Trigger Point Injections

Chapter
Part of the Musculoskeletal Medicine book series (MUM)

Abstract

Myofascial pain syndrome (MPS) as defined by Travell and Simons is characterized by trigger points (TrP), limited ROM of the affected muscle(s), and neurologic symptoms (autonomic, proprioceptive) (Simons DG, Travell JG, Postgrad Med 73:66–108, 1983). The diagnosis of MPS is based on the presence of 1 or more trigger points. Trigger points (TrP) can be latent or active (Simons DG, Travell JG, Postgrad Med 73:66–108, 1983). Latent TrP are associated with stiffness and restricted ROM but no pain unless palpated. Active TrP produce a referred pain pattern specific to that muscle spontaneously and when the TrP is palpated. The physical findings for diagnosis of a myofascial trigger point are (1) palpation of a tender nodule in a taut band, (2) a referred pain pattern specific for the muscle, (3) a local twitch response (LTR) with snapping palpation or triggering with needle, and (4) restricted ROM (Travell J, Simons DG, Myofascial pain and dysfunction: the trigger point manual, vol 1. Williams & Wilkins, Baltimore, 1983).

Keywords

Diazepam Lidocaine Ibuprofen Calcitonin Bupivacaine 

References

  1. 1.
    Simons DG, Travell JG. Myofascial origins of low back pain. Parts 1, 2, 3. Postgrad Med. 1983;73:66–108.PubMedGoogle Scholar
  2. 2.
    Travell J, Simons DG. Myofascial pain and dysfunction: the trigger point manual, vol. 1. Baltimore: Williams & Wilkins; 1983.Google Scholar
  3. 3.
    Shah JP, Heimur J. New frontiers in the pathophysiology of myofascial pain. Pain Pract. 2012;22(2):26–33.Google Scholar
  4. 4.
    Simons DG, Travell JG, Simons LS. Travell & Simons’ myofascial pain and dysfunction: the trigger point manual, vol. 1. 2nd ed. Baltimore: Williams & Wilkins; 1999.Google Scholar
  5. 5.
    Hubbard DR, Berkoff GM. Myofascial trigger points show spontaneous needle activity. Spine. 1993;18:1803–7.PubMedCrossRefGoogle Scholar
  6. 6.
    Simons DG, Hong CZ, Simons LS. Endplate potentials are common to midfiber myofascial trigger points. Am J Phys Med Rehabil. 2002;81(3):212–22.PubMedCrossRefGoogle Scholar
  7. 7.
    Shah JP, Phillips TM, Danoff JV, Gerber LH. An in vivo micro-analytical technique for measuring the local biochemical milieu of human skeletal muscle. J Appl Physiol. 2005;99:1977–84.PubMedCrossRefGoogle Scholar
  8. 8.
    Shah JP, Danoff JV, Desai M, et al. Biochemicals associated with pain and inflammation are elevated in sites near to and remote from active myofascial trigger points. Arch Phys Med Rehabil. 2008;89:16–23.PubMedCrossRefGoogle Scholar
  9. 9.
    Shah JP, Gilliams EA. Uncovering the biochemical milieu of myofascial trigger points using in-vivo microdialysis: an application of muscle pain concepts to myofascial pain syndrome. J Bodyw Mov Ther. 2008;12(4):371–84.PubMedCrossRefGoogle Scholar
  10. 10.
    Mense S. How do muscle lesions such as latent and active trigger points influence central nociceptive neurons? J Musculoskelet Pain. 2010;18(4):348–53.CrossRefGoogle Scholar
  11. 11.
    Woolf CJ. Central sensitization: implications for the diagnosis and treatment of pain. Pain. 2011;152(3 Suppl):S2–15.PubMedCrossRefGoogle Scholar
  12. 12.
    Niddam DM, Chan RC, Lee SH, Yeh TC, Hsieh JC. Central modulation of pain evoked from myofascial trigger point. Clin J Pain. 2007;23:440–8.PubMedCrossRefGoogle Scholar
  13. 13.
    McPartland JM. Travell trigger points: molecular and osteopathic perspectives. J Am Osteopath Assoc. 2004;104:244–9.PubMedGoogle Scholar
  14. 14.
    Jones LH. Strain and counterstrain. Colorado Springs: The American Academy of Osteopathy; 1981.Google Scholar
  15. 15.
    Kuchera WA, Kuchera ML. Foundations for osteopathic medicine. 2nd ed. Philadelphia: Lippincott Williams & Wilkins; 2003.Google Scholar
  16. 16.
    Annaswamy TM, De Luigi AJ, O’Neill BJ, et al. Emerging concepts in the treatment of myofascial pain: a review of medications, modalities, and needle-based interventions. PM R. 2001;3:940–61.CrossRefGoogle Scholar
  17. 17.
    Lewit K. The needle effect in the relief of myofascial pain. Pain. 1979;6(1):83–90.PubMedCrossRefGoogle Scholar
  18. 18.
    Hong CZ. Lidocaine injection versus dry needling to myofascial trigger point. The importance of the local twitch response. Am J Phys Med Rehabil. 1994;73(4):256–63.PubMedCrossRefGoogle Scholar
  19. 19.
    Kamanli A, Kaya A, Ardicoglu O, et al. Comparison of lidocaine injection, botulinum toxin injection, and dry needling to trigger points in myofascial pain syndrome. Rheumatol Int. 2005;25:604–11.PubMedCrossRefGoogle Scholar
  20. 20.
    Cummings TM, White AR. Needling therapies in the management of myofascial trigger point pain: a systematic review. Arch Phys Med Rehabil. 2001;82:986–92.PubMedCrossRefGoogle Scholar
  21. 21.
    Ferrante FM, Bean L, Rothrock R, King L. Evidence against trigger point injection techniques for the treatment of cervicothoracic myofascial pain with botulinum toxin type A. Anesthesiology. 2005;103:377–83.PubMedCrossRefGoogle Scholar
  22. 22.
    Graboski CL, Gray DS, Burnham RS. Botulinum toxin A vs bupivacaine trigger point injections for the treatment of myofascial pain syndrome: a randomized double blind crossover study. Pain. 2005;118:170–5.PubMedCrossRefGoogle Scholar
  23. 23.
    Botwin KP, Sharma K, Saliba R, Patel BC. Ultrasound-guided trigger point injections in the cervicothoracic musculature: a new and unreported technique. Pain Physician. 2008;11:885–9.PubMedGoogle Scholar
  24. 24.
    Rha D, Shin JC, Kim YK, Jung JH, Kim YU, Lee SC. Detecting local twitch responses of myofascial trigger points in the lower-back muscles using ultrasonography. Arch Phys Med Rehabil. 2011;92:1576–80.PubMedCrossRefGoogle Scholar
  25. 25.
    Ballyns JJ, Shah JP, Hammond J, Gebreab T, Gerber LH, Sikdar S. Objective sonographic measures for characterizing myofascial trigger points associated with cervical pain. J Ultrasound Med. 2011;30:1331–40.PubMedGoogle Scholar
  26. 26.
    Sikdar S, Ortiz R, Gebreab T, Gerber LH, Shah JP. Understanding the vascular environment of myofascial trigger points using ultrasonic imaging and computational modeling. Conf Proc IEEE Eng Med Biol Soc. 2010;2010:5302–5.PubMedGoogle Scholar
  27. 27.
    Sikdar S, Shah JP, Gebreab T, Yen RH, Gilliams E, Danoff J, Gerber LH. Novel applications of ultrasound technology to visualize and characterize myofascial trigger points and surrounding soft tissue. Arch Phys Med Rehabil. 2009;90:1829–38.PubMedCrossRefGoogle Scholar
  28. 28.
    Shankar Hartharan H, Reddy S. Two- and three-dimensional ultrasound imaging to facilitate detection and targeting of taut bands in myofascial pain syndrome. Pain Med. 2012;13:971–5.CrossRefGoogle Scholar
  29. 29.
    Gerwin RD, Duranleau D. Ultrasound identification of the myofascial trigger point [Letter]. Muscle Nerve. 1997;20(6):767–8.PubMedGoogle Scholar
  30. 30.
    Niraj G, Collett BJ, Bone M. Ultrasound-guided trigger point injection: first description of changes visible on ultrasound scanning in the muscle containing the trigger point. Br J Anaesth. 2011;107(3):474–5.PubMedCrossRefGoogle Scholar
  31. 31.
    Standring S. Gray’s anatomy: the anatomical basis of clinical practice. 40th ed. Edinburgh: Churchill-Livingstone, Elsevier; 2008.Google Scholar
  32. 32.
    Kessler J, Gray AT. Course of the spinal accessory nerve relative to the brachial plexus. Reg Anesth Pain Med. 2007;32(2):174–6.PubMedGoogle Scholar
  33. 33.
    Torriani M, Gupta R, Donahue DM. Sonographically guided anesthetic injection of anterior scalene muscle for investigation of neurogenic thoracic outlet syndrome. Skeletal Radiol. 2009;38:1083–7.PubMedCrossRefGoogle Scholar
  34. 34.
    Torriani M, Gupta R, Donahue DM. Botulinum toxin injection in neurogenic thoracic outlet syndrome: results and experience using a ultrasound-guided approach. Skeletal Radiol. 2010;39:973–80.PubMedCrossRefGoogle Scholar
  35. 35.
    Urmey WF, Talts KH, Sharrock NE. One hundred percent incidence of hemidiaphragmatic paresis associated with interscalene brachial plexus anesthesia as diagnosed by ultrasonography. Anesth Analg. 1991;72(4):498–503.PubMedCrossRefGoogle Scholar
  36. 36.
    Kessler J, Schafhalter-Zoppoth I, Gray AT. An ultrasound study of the phrenic nerve in the posterior cervical triangle: implications for the interscalene brachial plexus block. Reg Anesth Pain Med. 2008;33(6):545–50.PubMedGoogle Scholar
  37. 37.
    Hong JS, Sathe GG, Niyonkuru C, Munin MC. Elimination of dysphagia using ultrasound guidance for botulinum toxin injections in cervical dystonia. Muscle Nerve. 2012;46:535–9.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2014

Authors and Affiliations

  1. 1.Department of Rehabilitation MedicineIcahn School of Medicine at Mount SinaiNew YorkUSA

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