Call your doctor for medical advice about side effects. The two main types of trigger points are active and latent. Heyworth BE, Lee JH, Kim PD, Lipton CB, Strauch RJ, Rosenwasser MP. Before advancing the needle into the trigger point, the physician should warn the patient of the possibility of sharp pain, muscle twitching, or an unpleasant sensation as the needle contacts the taut muscular band.17 To ensure that the needle is not within a blood vessel, the plunger should be withdrawn before injection. See permissionsforcopyrightquestions and/or permission requests. Most patients, if they are going to respond, will respond after the first injection. The sequence of injections was randomized by Latin square design. Get emergency medical help if you have signs of an allergic reaction: hives; difficulty breathing; swelling of your face, lips, tongue, or throat. This risk lessens as the steroid dissipates. Dexamethasone may cause serious side effects. Patients are encouraged to remain active, putting muscles through their full range of motion in the week following trigger-point injections, but are advised to avoid strenuous activity, especially in the first three to four days after injection.10. Trigger points are discrete, focal, hyperirritable spots located in a taut band of skeletal muscle. You should not be treated with dexamethasone if you are allergic to it, or if you have: a fungal infection anywhere in your body. Search Bing for all related images, Management: Post-Procedure Instructions (Reduce postinjection flare), Roldan (2020) Am J Emerg Med 38(2): 311-6 [PubMed], Alvarez (2002) Am Fam Physician 65(4):653-60 [PubMed], Fomby (1997) Phys Sportsmed 25(2):67-75 [PubMed], Shipton (2023) Am Fam Physician 107(2): 159-64 [PubMed], Search other sites for 'Trigger Point Injection', Trigger Point Injection at trapzius insertion, Twitch response to pressure with referred pain, Unsafe injection site (e.g. St. Louis, Mosby, 2009. Trigger points are defined as firm, hyperirritable loci of muscle tissue located within a taut band in which external pressure can cause an involuntary local twitch response termed a jump sign, which in turn provokes referred pain to distant structures.1 Establishing a diagnosis of trigger points often includes a history of regional pain, with muscular overload from sustained contraction in one position or repetitive activity, presence of a taut band with exquisite spot tenderness, reproduction of the patients pain complaint, and a painful limit to muscle stretch.24 Despite being an integral component to the definition of trigger points, it has been reported that the twitch response cannot reliably be established.5, The two main types of trigger points are active and latent. The point of entry can be marked with an impression from a thumb-nail, a needle cap, or an indelible ink pen. Copyright 2023 American Academy of Family Physicians. Studies have reported that 14.4% of the population of the United States has experienced myofascial pain, and suggested that 21% to 93% of all pain complaints were myofascial in origin.40,41 Although long thought to be separate entities, there was no clear delineation between myofascial pain syndrome and fibromyalgia until the American College of Rheumatology published diagnostic criteria for fibromyalgia in 1990.42 This milestone was not universally celebrated within the medical profession, and some have contended that both myofascial pain syndrome and fibromyalgia were the products of junk medicine, supported by poorly designed trials and unfounded theories, with the aim of legitimizing somewhat vague psychosomatic illnesses.39 Trigger points may also be present in fibromyalgia, osteoarthritis, rheumatoid arthritis, or connective tissue disorders.43, The term myofascial trigger point was coined and popularized by Janet Travell, who was the personal physician to President John F. Kennedy. Description Your health care provider inserts a small needle and injects medicine into the painful and inflamed area. A common diagnostic indication for placing a needle in a joint is the aspiration of synovial fluid for evaluation. Trigger points are painful "knots" in your muscles that can be very sensitive to touch/pressure. About 23 million persons, or 10 percent of the U.S. population, have one or more chronic disorders of the musculoskeletal system.1 Musculoskeletal disorders are the main cause of disability in the working-age population and are among the leading causes of disability in other age groups.2 Myofascial pain syndrome is a common painful muscle disorder caused by myofascial trigger points.3 This must be differentiated from fibromyalgia syndrome, which involves multiple tender spots or tender points.3 These pain syndromes are often concomitant and may interact with one another. What is a trigger point? This study prompted some clinicians to abandon the local twitch response to more reliably quantify tenderness with pressure thresholds, as reflected in the most current diagnostic criteria for trigger points.24, Pressure threshold is the minimum pressure that reproduces pain (or tenderness) in a suspected trigger point, and has been claimed to be an objective, reproducible, and reliable method for their detection.48,50,7577 Fischer attempted to establish standard, normal pressure thresholds, which were found to be different for each gender and each muscle.76, Click to share on Twitter (Opens in new window), Click to share on Facebook (Opens in new window), Click to share on Google+ (Opens in new window). There are several proposed histopathologic mechanisms to account for the development of trigger points and subsequent pain patterns, but scientific evidence is lacking. Any physician familiar with the localization of trigger points and the use of therapeutic musculoskeletal injections may perform TPIs. Maillefert's review of epidural injections with dexamethasone, a nonparticulate steroid with theoretically shorter duration of action, still demonstrated profound decreases in serum ACTH and free cortisol levels on postinjection days 1 and 7, with normal ACTH levels returning on day 21. Also, early reaccumulation of fluid can occur in many cases. 2021 May;16(3):321-325. doi: 10.1177/1558944719855686. J Child Orthop. Additionally, local circulation was thought to be compromised, thus reducing available oxygen and nutrient supply to the affected area, impairing the healing process. The concept of abnormal end-plate potentials was used to justify injection of botulinum toxin to block acetylcholine release in trigger points.57 McPartland has expanded on the idea of excessive acetylcholine by suggesting that congenital or acquired genetic defects in presynaptic, synaptic, or postsynaptic structures may contribute to an individuals susceptibility to myofascial pain.45. A trigger point injection (TPI) is an outpatient procedure used to treat painful areas of muscle that contain trigger points, or "knots" of muscle that form when muscles do not relax. Bookshelf That means you'll have little to no downtime at all. 2007 Mar;15(3):166-71. doi: 10.5435/00124635-200703000-00006. Unauthorized use of these marks is strictly prohibited. nd produces clearly definable, clinically relevant cutoff points to determine whether responsiveness to steroid injection correlates to clinical staging. However, these injections seldom lead to significant, long-lasting relief. However, these substances have been associated with significant myotoxicity.10,19 Procaine has the distinction of being the least myotoxic of all local injectable anesthetics.10. A set of trigger point injections means injections in several trigger points in one sitting. When possible, the patient should be placed in the supine position. Endogenous opioid release may play a role in TPIs. Find patient medical information for dexamethasone sodium phosphate injection on WebMD including its uses, side effects and safety, interactions, pictures, warnings and user ratings. Active trigger points can cause spontaneous pain or pain with movement, whereas latent trigger points cause pain only in response to direct compression. Bethesda, MD 20894, Web Policies HHS Vulnerability Disclosure, Help Differentiating between the trigger points of myofascial pain syndrome and the tender points of fibromyalgia syndrome has also proven problematic. a parasite infection that causes diarrhea (such as threadworms); a muscle disorder such as myasthenia gravis; diabetes (steroid medicine may increase glucose levels in your blood or urine); stomach ulcers, ulcerative colitis, diverticulitis, inflammatory bowel disease; congestive heart failure, a heart attack; or. Patients should sign documentation that informed consent for the procedure was given and understood. It is available in forms that can be taken by mouth, through a patch placed on the skin, as a cream, in eye drops, and as an injectable. 3. Systemic effects are possible (especially after triamcinolone acetonide [Aristocort] injection or injection into a vein or artery), and patients should always be acutely monitored for reactions. Thoracic spinal stenosis. Injection technique requires knowledge of anatomy of the targeted area and a thorough understanding of the agents used. Trigger point injection is one of many modalities utilized in the management of chronic pain. J Hand Surg Am. However, these injections are probably best performed by physicians with postgraduate education in musculoskeletal anatomy, and a greater understanding of orthopedic and neurologic disorders. Relative contraindications are less well defined and should be considered on a case-by-case basis. Soft tissue (fat) atrophy and local depigmentation are possible with any steroid injection into soft tissue, particularly at superficial sites (e.g., lateral epicondyle). Always consult your healthcare provider to ensure the information displayed on this page applies to your personal circumstances. After the close of the study, there were 8 recurrences among patients with documented absence of triggering in the triamcinolone cohort and 1 in the dexamethasone cohort. To avoid direct needle injury to articular cartilage or local nerves, attention should be paid to anatomic landmarks and depth of injection. This material is provided for educational purposes only and is not intended for medical advice, diagnosis or treatment. The rates 3 months after injection were 27 of 41 in the triamcinolone cohort and 22 of 31 in the dexamethasone cohort. These injections are most useful in instances of joint or tissue injury and inflammation. Abdul et al. Orthopedics 2013; 36(9):e1141-e1148. Seek emergency medical attention or call the Poison Help line at 1-800-222-1222. Additional proinflammatory mediators (e.g., adenosine triphosphate, serotonin, tumor necrosis factor-1a, interleukin 1, substance P, and H ions) are then released from damaged muscle fibers, leading to activation of nociceptors and end-plate activity. This site needs JavaScript to work properly. Repeated injections in a particular muscle are not recommended if two or three previous attempts have been unsuccessful. The analysis was according to intention to treat principles. Tell your doctor about all your current medicines and any medicine you start or stop using. A needle with a smaller gauge may also be deflected away from a very taut muscular band, thus preventing penetration of the trigger point. Using a needle with a smaller diameter may cause less discomfort; however, it may provide neither the required mechanical disruption of the trigger point nor adequate sensitivity to the physician when penetrating the overlying skin and subcutaneous tissue. Ethyl chloride is a rapid-acting general anesthetic that becomes flammable and explosive when 4 to 15 percent of the vapor is mixed with air.10 Nevertheless, ethyl chloride remains a popular agent because of its local anesthetic action and its greater cooling effect than that of dichlorodifluoromethane-trichloromonofluoromethane.5, The decision to treat trigger points by manual methods or by injection depends strongly on the training and skill of the physician as well as the nature of the trigger point itself.10 For trigger points in the acute stage of formation (before additional pathologic changes develop), effective treatment may be delivered through physical therapy. Ask your doctor before stopping the medicine. Peters-Veluthamaningal C, Winters JC, Groenier KH, Jong BM. Store at room temperature away from moisture and heat. See permissionsforcopyrightquestions and/or permission requests. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. Trigger points are defined as firm, hyperirritable loci of muscle tissue located within a taut band in which external pressure can cause an involuntary local twitch response termed a jump sign, which in turn provokes referred pain to distant structures. The number of trigger points injected at each session varies, as does the volume of solution injected at each trigger point and in total. Trigger points are discrete, focal, hyperirritable spots located in a taut band of skeletal muscle. Joint injections should always be performed using sterile procedure to prevent iatrogenic septic arthritis. Although there were no differences 3 months after injection, our data suggest that triamcinolone may have a more rapid but ultimately less durable effect on idiopathic trigger finger than does dexamethasone. Each thrust coincided with the injection of 0.02 to 0.05mL of injectate, up to a total of 0.5 to 1mL in each trigger point. Using sterile technique, the needle is then inserted 1 to 2 cm away from the trigger point so that the needle may be advanced into the trigger point at an acute angle of 30 degrees to the skin. Before receiving TPIs, patients should first be assessed for LBP using an evidence-based and goal-oriented approach focused on the patient history and neurologic examination, as discussed in Chapter 3. The indications for joint or soft tissue aspiration and injection fall into two categories: diagnostic and therapeutic. Although there were no differences 3 months after injection, our data suggest that triamcinolone may have a more rapid but ultimately less durable effect on idiopathic trigger finger than does dexamethasone. This therapeutic approach is one of the most effective treatment options available and is cited repeatedly as a way to achieve the best results.5, Trigger-point injection is indicated for patients who have symptomatic active trigger points that produce a twitch response to pressure and create a pattern of referred pain. The .gov means its official. This list may not describe all possible side effects. official website and that any information you provide is encrypted Table 3 lists general corticosteroid dosing guidelines. Trigger Finger. Ann Furthermore, manual methods are indicated for patients who have an extreme fear of needles or when the trigger point is in the middle of a muscle belly not easily accessible by injection (i.e., psoas and iliacus muscles).10 The goal of manual therapy is to train the patient to effectively self-manage the pain and dysfunction. Dosage. Clinicians should also inquire about medication history to note prior hypersensitivity/allergy or adverse events (AEs) with drugs similar to those being considered, and evaluate contraindications for these types of drugs. A second diagnostic indication involves the injection of a local anesthetic to confirm the presumptive diagnosis through symptom relief of the affected body part. TPI also can be used to treat fibromyalgia and tension headaches. The spots are painful on compression and can produce referred pain, referred tenderness, motor dysfunction, and autonomic phenomena.4, Trigger points are classified as being active or latent, depending on their clinical characteristics.5 An active trigger point causes pain at rest. Each subject received a single injection of 6 mg of dexamethasone acetate. 2012 Jul;37(7):1319-23. doi: 10.1016/j.jhsa.2012.03.040. 17 In fact, in a . The highest inter- and intra-examiner reliability for locating trigger points was achieved with pressure threshold algometry.48,49 Once trigger points are located and marked with a skin pen, the skin is generally prepared with a standard antibacterial agent such as isopropyl alcohol or betadine solution. Ball EM et al. Palpation of a hypersensitive bundle or nodule of muscle fiber of harder than normal consistency is the physical finding typically associated with a trigger point. Version: 5.01. For instance, suspected septic arthritis is a contraindication for therapeutic injection, but an indication for joint aspiration. A 22-gauge, 1.5-inch needle is usually adequate to reach most superficial muscles. A patient information handout about joint and soft tissue injection, written by the authors of this article, is provided on page 290. For soft tissue injections, the following modalities may be used for short-term partial anesthesia: applying ice to the skin for five to 10 minutes; applying topical vapo-coolant spray; or firmly pinching the skin for three to four seconds at the injecting site.12 Once the skin is anesthetized, the needle should be inserted through the skin to the site of injection. Long term side effects (depending on frequency and dose) include thinning of skin, easy bruising, weight gain, puffiness in the face, higher blood pressure, cataract formation, and osteoporosis (reduced bone density). The triamcinolone cohort had significantly better satisfaction and Quinnell grades than did the dexamethasone cohort at the 6-week follow-up but not at the 3-month follow-up. Methods: If therapeutic effect is achieved, a maximum of four injections per year is recommended. Therapeutic responses to corticosteroid injections are variable.4 The patient's response to previous injection is important in deciding whether and when to proceed with reinjection. Hand (N Y). When injecting or aspirating a joint space, sterile technique should be used. Documentation is kept as part of the patient's record. The stabilizing fingers apply pressure on either side of the injection site, ensuring adequate tension of the muscle fibers to allow penetration of the trigger point but preventing it from rolling away from the advancing needle.10 The application of pressure also helps to prevent bleeding within the subcutaneous tissues and the subsequent irritation to the muscle that the bleeding may produce. A postinjection steroid flare, thought to be a crystal-induced synovitis caused by preservatives in the injectable suspension, may occur within the first 24 to 36 hours after injection.11 This is self-limited and responds to application of ice packs for no longer than 15-minute intervals. Epub 2019 Jun 18. The injection was given intramuscularly at the point of maximum tenderness, and patients were subsequently evaluated 1 week, 1 month and 3 months after the procedure. Thoracic disc herniation with pain radiating into your back or arm. The injection technique recommended by Hong and Hsueh for trigger points was modified from that proposed by Travell and Simons. Procedure. Increased bleeding tendencies should be explored before injection. Trigger points help define myofascial pain syndromes. Avoid injection into adjacent nerves of the target area (e.g., ulnar nerve when injecting for medial epicondylitis). Roberts JM, Behar BJ, Siddique LM, Brgoch MS, Taylor KF. Click on the image (or right click) to open the source website in a new browser window. Examples of predisposing activities include holding a telephone receiver between the ear and shoulder to free arms; prolonged bending over a table; sitting in chairs with poor back support, improper height of arm rests or none at all; and moving boxes using improper body mechanics.11, Acute sports injuries caused by acute sprain or repetitive stress (e.g., pitcher's or tennis elbow, golf shoulder), surgical scars, and tissues under tension frequently found after spinal surgery and hip replacement may also predispose a patient to the development of trigger points.12, Patients who have trigger points often report regional, persistent pain that usually results in a decreased range of motion of the muscle in question.