Fibromyalgia tender/trigger points

Tender/trigger points are specific sites on the body that cause pain when pressed. The pain may spread when a tender point is pressed and cause or trigger pain in a larger area (for example, down the leg, arm, or back). To clearly diagnose Fibromyalgia, a person must have pain at 11 or more of the 18 tender points. There are 9 pairs of tender points. Each pair has one point on each side of the body, for a total of 18 points. These pairs are located:

1. Just behind the ear where the neck muscles attach to the base of the skull.

2. About halfway between the base of the neck and the tip of the shoulder.

3. At the spot where the back muscles attach to the shoulder blade, just below the 2nd trigger point.

4. On the front of the neck above the collarbone.

5. Just to the right and left of the breastbone (sternum) about 2 in. (5.08 cm) below the collarbone.

6. On each forearm just below and to the outside of the crease of the elbow.

7. Just above and to the outer right and left of each buttock.

8. On the outer upper leg just behind the bony part of the hip (this point is easier to find when standing).

9. On the inside of each knee.

Fibromyalgia

Fibromyalgia is a chronic musculoskeletal pain syndrome associated with widespread pain and localized areas of deep muscle tenderness.^[47] Patients typically complain of severe chronic pain, usually with stiffness that is most pronounced in the axial skeleton, shoulders, and hips, but the distal extremities are sometimes painful as well. Most patients complain of fatigue, which may be overwhelming, and nearly all patients report nonrefreshing sleep. A variety of other symptoms may be present, including headache, irritable bowel syndrome, paresthesia, swelling, and depression or anxiety.

Physical examination of the joints and muscles in patients with fibromyalgia is normal except for the presence of multiple localized areas of tenderness in periarticular areas, most commonly in specific anatomic areas [see Figure 4]. The diagnosis of fibromyalgia is based on the history of widespread chronic pain and the findings of tender points at a majority of these typical areas. Laboratory studies such as an erythrocyte sedimentation rate, muscle enzymes, thyroid profile, antinuclear antibodies, rheumatoid factor, or radiographs of specific areas are appropriate in the initial evaluation of patients to exclude other potential causes of widespread pain and fatigue.

Figure 4. Tender Points in Fibromyalgia. Patients with fibromyalgia exhibit many specific, widespread tender points that are revealed by deep palpation.

The pathogenesis of fibromyalgia is uncertain and probably complex. Most studies of patients with fibromyalgia have shown an increased incidence of previous depression or other psychological disorders, although a majority of patients are not clinically depressed at the time of diagnosis. Other abnormalities observed include disturbance of stage 4 sleep, decreased skeletal muscle high-energy phosphates, abnormalities in the concentration of substance P in the cerebrospinal fluid, subtle decreases in growth hormone, and other changes in hypothalamic-pituitary function.^[48] The relationship of these changes to the etiology and pathogenesis of this syndrome is unclear.

Therapy for fibromyalgia is usually only partially effective. Low-dose tricyclic antidepressants (e.g., amitriptyline, 10 to 50 mg at bedtime) and most other antidepressants have been shown to lead to improvement in symptoms when compared to placebo.^[49] Other agents that improve the quality of sleep may be effective as well. NSAIDs are less effective in general but may be useful in certain patients. Cardiovascular-fitness training and aerobic-exercise programs have been shown to be effective in many patients, and strategies that involve training patients in techniques of internal control ("mind-body therapy") may be useful as well.^[50] Most patients with fibromyalgia continue to have symptoms for years. The disease course is characterized by temporary improvements and relapses; complete remission occurs in a few patients.

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