In this section you will learn about including the diagnosis of myofascial pain, due to trigger points (TrPs), in a differential diagnosis. Inclusion of this common pain generator and appropriate intervention can make a tremendous difference in the lives of your patients.
“Working with MT's and PT's has taught me
another useful skill. I learned how to find and
treat trigger points..."
While this section is designed to give some insight to the diagnosis of trigger points and myofascial pain syndrome it is important to realize there is no substitute for practical, 'hands on' education. There is only one educational program in the USA which focuses on musculoskeletal pain and trigger points that is designed for physicians. The program is called, "The Janet Travell Seminar Series" and is presented by Bob Gerwin MD, Jan Dommerholt PT, among others.
To diagnose trigger points in your patient, you must complete a comprehensive medical history to determine and rule out any pathological conditions which may be the cause of pain. Many times trigger points go unrecognized because they look like other conditions, such as but not limited to: bursitis, appendicitis, tendonitis, epicondylitis, subacromial bursitis, tennis elbow, tension headache, and thoracic outlet syndrome. The reason muscles can mimic so many different disorders is because they can refer pain and tenderness to distal regions of the body that overlay these areas. Other symptoms trigger points may cause are radiculopathy due to nerve entrapment (as the nerve passes through hypertonic areas of muscle), proprioceptive disturbances, and tinnitus.
Myofascial Trigger Point (clinical definition): A hyperirritable spot in skeletal muscle that is associated with a hypersensitive palpable nodule in a taut band. The spot is painful on compression and can give rise to characteristic referred pain, referred tenderness, motor dysfunction, and autonomic phenomena.
Check out the cross section of a trigger point.
Diagnostic Criteria
- Presence of a tender nodule in a taught band of muscle.
- Local twitch response (LTR)
- Compression of the trigger point will elicit its referred pain or increase the intensity of referred pain.
The best way to find trigger points and muscular tension is to actually palpate the muscles. A palpatory exam will, many times, cause pain to refer when the trigger point is located, thus confirming the patient's pain complaint.
A particularly helpful tool in the understaning of trigger points are the Trigger Point Wall Charts, which are available through Lipencott Williams & Wilkins.
Dr. Maier MD makes the following statement in a recent issue of Practical Pain Management
“Working with MT’s and PT’s has taught me another useful skill. I learned how to find and treat trigger points… I have their chart [Travell and Simons] in my examining room and use it every day… The therapists have the chart in their heads and find the trigger point by working backward from the pattern
of pain radiation. Locating a trigger point by feel is much like locating a vein for venepuncture in the antecubital fossa by feel; it takes some practice.”1
Once you have identified muscular tension and/or trigger points, you may then decide how you would like to proceed with treatment. Many physicians refer out for this type of work, but some will treat using a variety of effective treatment techniques.
Footnotes:
- Maier, RJ. Diagnosis of Low Back Pain: Physical, hands-on examination can yield useful information for a differential diagnosis. Practical Pain Management. 2009; 5:48-49.