1 Establishing a diagnosis of trigger points often includes a history of regional pain, Additionally, local circulation was thought to be compromised, thus reducing available oxygen and nutrient supply to the affected area, impairing the healing process. Trigger point injections can be used to treat a number of conditions including fibromyalgia, tension headache, and myofascial pain syndrome. There is some concern that corticosteroid preparations, with repeated use, may accelerate normal, aging-related articular cartilage atrophy or may weaken tendons or ligaments. official website and that any information you provide is encrypted Thus, a classic trigger point is defined as the presence of discrete focal tenderness located in a palpable taut band of skeletal muscle, which produces both referred regional pain (zone of reference) and a local twitch response. Version: 5.01. The shots are commonly used to treat pain and inflammation caused by conditions like tendonitis, bursitis, and arthritis. We report on 68 women who underwent injections by a single physician and show an improvement in VAS pain scores in 65% of patients. A prospective randomized controlled trial of injection of dexamethasone versus triamcinolone for idiopathic trigger finger Mixing the corticosteroid preparation with a local anesthetic is a common practice for avoiding the injection of a highly concentrated suspension into a single area. TPIs may be classified according to the substances injected, which may include local anesthetic, saline, sterile water, steroids, nonsteroidal anti-inflammatory drugs, botulinum toxin, 5-HT3 receptor antagonists, or even dry needling. Thermographic imaging evaluation has previously demonstrated elevated temperatures in the referral pain pattern of trigger points, suggesting increased local heat production from increased metabolism or neural activity. Figure 24-2 Locations of trigger points in the iliocostalis (A) and longissimus (B) muscles and their common referral zones. Pay attention to the depth of needle insertion to avoid needle trauma to articular cartilage. Trigger point injections cause less soreness than dry-needling techniques. Knowledge of the anatomy of the area to be injected is essential. 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. St. Louis, Mosby, 2009. MeSH (From Muscolino JE: The muscle and bone palpation manual with trigger points, referral patterns, and stretching. Ball EM et al. Thermographic imaging evaluation has previously demonstrated elevated temperatures in the referral pain pattern of trigger points, suggesting increased local heat production from increased metabolism or neural activity.65 Gerwin and colleagues recently expanded on Simons integrated hypothesis for trigger point formation and proposed a complex molecular pathway whereby unconditioned muscle undergoes eccentric exercise or trauma, which results in muscle fiber injury and hypoperfusion from capillary constriction.66 Sympathetic nervous system activation further enhances this constriction and creates a hypoxic and acidic environment, facilitating the release of calcitonin gene-related peptide and acetylcholine. However, these injections are probably best performed by physicians with postgraduate education in musculoskeletal anatomy, and a greater understanding of orthopedic and neurologic disorders. reported HPA axis suppression in 87% of participants seven days post-injection, 43% at day 14, and 7% at day 28 following epidural injection of 80 mg of methylprednisolone. TPI also can be used to treat fibromyalgia and tension headaches. Evidence-based reviews of joint and soft tissue injection procedures have found few studies that support or refute the efficacy of common joint interventions in medical practice.13 However, substantial practice-based experience supports the effectiveness of joint and soft tissue injection for many common problems. Choice of Corticosteroid Solution and Outcome After Injection for Trigger Finger. Copyright 2002 by the American Academy of Family Physicians. A common diagnostic indication for placing a needle in a joint is the aspiration of synovial fluid for evaluation. (Courtesy of Kopecky Campbell Associates as found on www.kcadocs.com/trigger_point.html). The indication for TPIs is CLBP with active trigger points in patients who also have myofascial pain syndrome that has failed to respond to analgesics and therapeutic exercise, or when a joint is deemed to be mechanically blocked due to trigger points and is unresponsive to other interventions.67 The best outcomes with TPIs are thought to occur in CLBP patients who demonstrate the local twitch response on palpation or dry needling.13,68 Patients with CLBP who also had fibromyalgia reported greater post-injection soreness and a slower response time than those with myofascial pain syndrome, but had similar clinical outcomes.50,69,70. Patients may have regional, persistent pain resulting in a decreased range of motion in the affected muscles. Tell your doctor if you are pregnant or breastfeeding. 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. Increased bleeding tendencies should be explored before injection. In this overview, the indications, contraindications, potential side effects, timing, proper technique, necessary materials, pharmaceuticals used and their actions, and post-procedure care of patients are presented. Diagnostic indications include the aspiration of fluid for analysis and the assessment of pain relief and increased range of motion as a diagnostic tool. Hand (N Y). Sixty-seven patients completed the 6-week follow-up (35 triamcinolone arm, 32 dexamethasone arm), and 72 patients completed the 3-month follow-up (41 triamcinolone arm, 31 dexamethasone arm). 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. The entry point for injection or aspiration should be identified. Peters-Veluthamaningal C, Winters JC, Groenier KH, Jong BM. Identification of trigger points is required before performing these injections and is generally performed with a thorough manual and orthopedic examination. With training, physicians can incorporate joint and soft tissue injection into daily practice, yielding many benefits. These trigger points produce a referred pain pattern characteristic for that . Call your doctor for instructions if you miss a dose. It differentiates a trigger point from a tender point, which is associated with pain at the site of palpation only (Table 1).8, A latent trigger point does not cause spontaneous pain, but may restrict movement or cause muscle weakness.6 The patient presenting with muscle restrictions or weakness may become aware of pain originating from a latent trigger point only when pressure is applied directly over the point.9. Side Effects Problems with cortisone shots can range from mild to quite serious. Her contribution to medical pain management was primarily the study and description of myofascial pain with the publication, along with coauthor and physician David Simons, of the text Myofascial Pain and Dysfunction: The Trigger Point Manual in 1983.44 Travell and Simons continued to advance their proposed understanding of myofascial pain treatment and published a second edition of their manual in 1992.2 Although the method proposed by Travell and Simons for identifying and injecting trigger points became prominent, it was based largely on anecdotal observations and their personal clinical experience.39,45 The use of injection therapy for trigger points had previously been reported almost four decades earlier in 1955 by Sola and Kuitert, who noted that Procaine and pontocaine have been most commonly used but Martin has reported success with injections of benzyl salicylate, camphor, and arachis oil.46. Eighty-four patients were enrolled in a prospective randomized controlled trial comparing dexamethasone and triamcinolone injection for idiopathic trigger finger. The duration of effect is inversely related to the solubility of the preparation: the less soluble an agent, the longer it remains in the joint and the more prolonged the effect. Copyright 2023 American Academy of Family Physicians. An official website of the United States government. Needle breakage; avoid by never inserting the needle to its hub. Effusion of unknown origin or suspected infection (only diagnostic), Minimal relief after two previous corticosteroid injections, 10 to 25 mg for soft tissue and small joints, Methylprednisolone acetate (Depo-Medrol) or triamcinolone acetonide (Aristocort), 2 to 10 mg for soft tissue and small joints, Dexamethasone sodium phosphate (Decadron), 0.5 to 3 mg for soft tissue and small joints, Betamethasone sodium phosphate and acetate (Celestone Soluspan), 1 to 3 mg for soft tissue and small joints, 25- to 30-gauge 0.5- to 1.0-inch needle for local skin anesthesia, 18- to 20-gauge 1.5-inch needle for aspirations, 22- to 25-gauge 1.0- to 1.5-inch needle for injections, Laboratory tubes for culture or other studies (aspiration), Hemostat (if joint is to be aspirated and then injected using the same needle), Adhesive bandage or other adhesive dressing. Tell your doctor about all your medical conditions, and all the medicines you are using. Dexamethasone sodium phosphate injection USP is a sterile, clear, colorless solution, free from visible particles and a water-soluble inorganic ester of dexamethasone which produces a rapid response even when injected intramuscularly. TPI is a procedure used to treat painful areas of muscle that contain trigger points (knots of muscle that form when muscles do not relax). Epub 2008 Jan 7. sharing sensitive information, make sure youre on a federal They involve injecting a small amount of an anesthetic to relieve pain. Trigger Point Therapy takes just a few minutes, and is performed by our Medical Doctor. Trigger points help define myofascial pain syndromes. Dosage. Multiple insertions in different directions from the subcutaneous layer were fast in and fast out to probe for latent trigger points. Call your doctor for medical advice about side effects. Travell recommends that this is best performed by immediately having the patient actively move each injected muscle through its full range of motion three times, reaching its fully shortened and its fully lengthened position during each cycle.10, Postinjection soreness is to be expected in most cases, and the patient's stated relief of the referred pain pattern notes the success of the injection. Common side effects of dexamethasone may include: fluid retention (swelling in your hands or ankles); acne, thinning skin, bruising or discoloration; changes in the shape or location of body fat (especially in your arms, legs, face, neck, breasts, and waist). Therapeutic indications for joint or soft tissue aspiration and injection include decreased mobility and pain, and the injection of medication as a therapeutic adjunct to other forms of treatment.5 Caution must be exercised when removing fluid for pain relief because of the possibility of introducing infection and precipitating further or new bleeding into the joint. Myofascial trigger points are self-sustaining hyperirritative foci that may occur in any skeletal muscle in response to strain produced by acute or chronic overload. Predisposing and perpetuating factors in chronic overuse or stress injury on muscles must be eliminated, if possible. J Am Acad Orthop Surg. Ann DAVID J. ALVAREZ, D.O., AND PAMELA G. ROCKWELL, D.O. Figure 24-1 A central trigger point (TrP) located within a taut band of muscle. This response is elicited by a sudden change of pressure on the trigger point by needle penetration into the trigger point or by transverse snapping palpation of the trigger point across the direction of the taut band of muscle fibers. Injections of an anesthetic mixture directly into the muscle can help the muscle relax and relieve pain. 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. Appropriate timing can minimize complications and allow a clear diagnosis or therapeutic response. Key points Trigger finger is a common cause of hand pain and dysfunction with a bimodal distribution in . Specific medications such as Botox are only approved for other indications and are thus used off-label for TPIs with CLBP. The patient should keep the injection site clean and may bathe. One study20 emphasizes that stretching the affected muscle group immediately after injection further increases the efficacy of trigger point therapy. Physicians should resist external pressure for a quick return of athletes to playing sports by the use of joint or soft tissue injections. Written by Cerner Multum. Manufacturers advise against mixing corticosteroid preparations with lidocaine because of the risk of clumping and precipitation of steroid crystals. Drug class: Glucocorticoids. Not all possible interactions are listed here. These effects are believed to result from several mechanisms, including alterations in neutrophil chemotaxis and function, increases in viscosity of synovial fluid, stabilization of cellular lysosomal membranes, alterations in hyaluronic acid synthesis, transient decreases in synovial fluid complements, alterations in synovial permeability, and changes in synovial fluid leukocyte count and activity.8 Whether this is exactly the same mechanism of action that occurs with orally or parenterally administered corticosteroids is uncertain.4. Capillary hemorrhage augments postinjection soreness and leads to unsightly ecchymosis.10 Patients should refrain from daily aspirin dosing for at least three days before injection to avoid increased bleeding. This includes prescription and over-the-counter medicines, vitamins, and herbal products. Often, the muscles used to maintain body posture are affected, namely the muscles in the neck, shoulders, and pelvic girdle, including the upper trapezius, scalene, sternocleidomastoid, levator scapulae, and quadratus lumborum.13 Although the pain is usually related to muscle activity, it may be constant. Purpose: Joint and soft tissue injections. Methods: The authors conducted a prospectively collected longitudinal study of trigger finger patients separated into four stages of severity. Six weeks after injection, absence of triggering was documented in 22 of 35 patients in the triamcinolone cohort and in 12 of 32 patients in the dexamethasone cohort. Participants were randomly . 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. Treatment of paediatric trigger finger: a systematic review and treatment algorithm. Dexamethasone is usually given by injection only if you are unable to take the medicine by mouth. 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. There are several proposed histopathologic mechanisms to account for the development of trigger points and subsequent pain patterns, but scientific evidence is lacking. Non-sterile gloves can be used when injecting or aspirating soft tissue regions. Sometimes it is not safe to use certain medications at the same time. (Modified from Muscolino JE: The muscle and bone palpation manual with trigger points, referral patterns, and stretching. Corticosteroid injections effective for trigger finger in adults in general practice: a double-blinded randomised placebo controlled trial. A third party should witness the patient's signing. The needle must be long enough to reach the contraction knots in the trigger point to disrupt them. When accompanied by other symptoms, trigger points may also constitute myofascial pain syndrome, one of the most frequent causes of musculoskeletal pain (Figure 24-2).8 Many often inaccurate terms have been used to denote trigger points, including Travell points, myofascial pain syndrome, myofascitis, fibrositis, myofibrositis, myalgia, muscular rheumatism, idiopathic myalgia, regional fibromyalgia, nonarthritic rheumatism, tendinomyopathy nonarticular rheumatism, local fibromyalgia, and regional soft-tissue pain.1,9. PMC Patients report few systemic symptoms, and associated signs such as joint swelling and neurologic deficits are generally absent on physical examination.14, In the head and neck region, myofascial pain syndrome with trigger points can manifest as tension headache, tinnitus, temporomandibular joint pain, eye symptoms, and torticollis.15 Upper limb pain is often referred and pain in the shoulders may resemble visceral pain or mimic tendonitis and bursitis.5,16 In the lower extremities, trigger points may involve pain in the quadriceps and calf muscles and may lead to a limited range of motion in the knee and ankle. In comparative studies,17 dry needling was found to be as effective as injecting an anesthetic solution such as procaine (Novocain) or lidocaine (Xylocaine).10 However, post-injection soreness resulting from dry needling was found to be more intense and of longer duration than the soreness experienced by patients injected with lidocaine.10, One noncontrolled study17 comparing the use of dry needling versus injection of lidocaine to treat trigger points showed that 58 percent of patients reported complete relief of pain immediately after trigger-point injection and the remaining 42 percent of patients claimed that their pain was minimal (12/10) on the pain scale. 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). Prepare the area with an alcohol or povidone-iodine (Betadine) wipe. Antidepressants, neuroleptics, or nonsteroidal anti-inflammatory drugs are often prescribed for these patients.1. Time to Improvement After Corticosteroid Injection for Trigger Finger. Necessary equipment for joint and soft tissue injection or aspiration is listed in Table 4. Some drugs can affect your blood levels of other drugs you take, which may increase side effects or make the medications less effective. It can be injected into a joint, tendon, or bursa. However, its use is safer for both patient and physician than the original volatile vapor coolant, ethyl chloride. The serious complication of pneumothorax can be avoided by refraining from aiming the needle at an intercostal space. The injection technique recommended by Hong and Hsueh for trigger points was modified from that proposed by Travell and Simons. Copyright 2002 by the American Academy of Family Physicians. When symptoms are resistant, or when there is a history of trauma, a radiograph or other imaging study should be performed to help assist in the diagnosis. A more recent article on trigger point management is available. Careers. The affected area should be rested from strenuous activity for several days after the injection because of the small possibility of local tissue tears secondary to temporarily high concentrations of steroid. Results: Drugs.com provides accurate and independent information on more than 24,000 prescription drugs, over-the-counter medicines and natural products. Evidence-Based Management of Low Back Pain. itching of the genital area. Please enable it to take advantage of the complete set of features! Epub 2019 Jun 18. Get emergency medical help if you have signs of an allergic reaction: hives; difficulty breathing; swelling of your face, lips, tongue, or throat. ; Local Infection - Trigger points should not be performed in the presence of systemic or local infection. The rates 3 months after injection were 27 of 41 in the triamcinolone cohort and 22 of 31 in the dexamethasone cohort. low blood potassium--leg cramps, constipation, irregular heartbeats, fluttering in your chest, increased thirst or urination, numbness or tingling, muscle weakness or limp feeling. Soft tissue (fat) atrophy and local depigmentation are possible with any steroid injection into soft tissue, particularly at superficial sites (e.g., lateral epicondyle). Methods In this single-blind randomized clinical trial, 54 low back pain patients with myofascial trigger points on QL muscle were investigated. FOIA Postinjection soreness, a different entity than myofascial pain, often developed, especially after use of the dry needling technique.17 These results support the opinion of most researchers that the critical therapeutic factor in both dry needling and injection is mechanical disruption by the needle.1,10. Using analysis of prospective randomized study comparing transforaminal lumbar epidural injection with lumbar paraspinal trigger-point injection for treatment of patients with sciatica from herniated discs. When clinicians were asked to examine patients with either myofascial pain, fibromyalgia, or healthy controls, the number of tender points identified was generally consistent.43 Even among experts in myofascial pain and fibromyalgia there was inconsistency in the number of taut bands, presence of referred pain, and local twitch responses reported. Chronic pain affects between 10% and 20% of the North American population, with 45% of Americans requiring treatment each year for pain at a cost of US$85-90 billion .Approximately 47% of chronic pain is of musculoskeletal origin, which covers many diagnostic categories including whiplash, fibromyalgia, myofascial pain syndrome, tension headache, and low back pain . dexamethasone can affect the results of certain medical tests. These injections should never be undertaken without diagnostic definition and a specific treatment plan in place. Brand names: Decadron, De-Sone LA It was found that dexamethasone significantly in- creased the FIB already after 2 days of administration, while it significantly decreased APTT starting after 1 week of dexamethasone injections. Tell your doctor about any illness or infection you had within the past several weeks. However, insufficient training in trigger point examination likely impedes recognition of myofascial pain, and palpation generally has poor interrater reliability.2,44,71 Hsieh and colleagues reported difficulties when attempting to reproduce findings of taut bands and local twitch responses, both characteristics of trigger points, in the lower back.72 In a study of intra-rater reliability, local twitch response and referred pain varied from one session to the next while taut bands, tender points, and jump sign remained consistent.73 Likewise, Njoo and van der Does found that jump sign and reproduction of pain were much more reliable than referred pain in identifying myofascial pain.74 It is interesting to note that when Hong and colleagues compared referred pain response from needling and palpation, they found that only 53.9% of their patients had referred pain from palpation, compared with 87.6% when needling.35, Differentiating between the trigger points of myofascial pain syndrome and the tender points of fibromyalgia syndrome has also proven problematic. You may have withdrawal symptoms if you stop using dexamethasone suddenly after long-term use. Once a trigger point has been located and the overlying skin has been cleansed with alcohol, the clinician isolates that point with a pinch between the thumb and index finger or between the index and middle finger, whichever is most comfortable (Figures 3a and 3b). Side effects are few, but may include tendon rupture, infection, steroid flare, hypopigmentation, and soft tissue atrophy. 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. If additional tender points are palpable, they should be isolated, needled and injected. This is best achieved by positioning the patient in the prone or supine position. Call your doctor for preventive treatment if you are exposed to chickenpox or measles. Although a few states currently allow physical therapists or naturopaths to perform dry needling, most states do not permit such injections by nonphysicians.47 This intervention is typically performed in private outpatient clinics, but can also be offered in specialty pain management or spine clinics. 8600 Rockville Pike 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. Decadron, Dexamethasone Intensol, Baycadron, Dexpak Taperpak, +4 more. Patients should be educated to look for signs of infection including erythema, warmth, or swelling at the site of injection, or systemic signs including fever and chills. 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. The two main types of trigger points are active and latent. Any physician familiar with the localization of trigger points and the use of therapeutic musculoskeletal injections may perform TPIs.