Trigger Point Workshop

1. Trigger Point Workshop Phillip Snider, RD, DO Amelia Medical Associates Bon Secours Medical Group Norfolk, VA

2. Common Complaints • Headaches • Low Back Pain • Tennis Elbow • Post-surgical Neuropathic Pain • Runners • Glutes • TFL • Hamstring • Gastroc / Soleus • FDB

3. Treatments • OMT • TPI (trigger point injections) • Neural Therapy • PT • Posture education • Watch for trigger point irritation • Muscle relaxants

4. Treatments cont’d • NSAIDs – po, gel, drops, patch • Lidoderm patch • Tylenol • Narcotics • Short term use is best • Narcotic contract is a must • Urine drug testing • Drug monitoring system – pill counts, PMP • HA Meds (BB, CCB, Antiepilectics)

5. Trigger Point Injections • 0.25% Lidocaine w/ NaHCO3 • 1cc into each muscle • 30ga 1.5 inch needle • Avoid use in face and forearm • Dry Needling (Acupuncture needle) • My favorite: Lhasa OMS (www.lhasaoms.com) • Name brands: • Seirin • Hwa-to

6. Trigger Point Injections Needle Diameter Hypodermic Gauge

7. Trigger Point Injections • Needle Sizes • .30 x 50 mm for most muscles • .30 x 60 for QL • .30 x 75 for psoas or glutes in obese pt • .20 x 25 mm for forearm • .14 x for face / head • .12 x for hands / feet

8. Headaches • Migraines • IHS Criteria • Anyone can get one • Triggers often include MSK component • Most Common Offenders • Traps • SCM • Levator Scapulae

9. IHS Migraine Criteria • 4+ HA lasting 4 - 72 hr, 2 of the 4 with: • Unilateral location • Pulsating quality • Moderate or severe intensity (affecting ADLs) • Aggravated by walking stairs or similar routine physical activity • During headache at least 1 of the 2 following symptoms occur: • Phonophobia, photophobia or osmophobia • Nausea and/or vomiting

10. Trapezius

11. Trapezius Needling • Patient supine • Pincer grasp of muscle • Insert needle anterior to posterior • 30ga x 1.5” or .30 x 50mm • Muscle twitches can be significant

12. Levator Scapulae

13. Levator Scapulae Needling • Patient prone • Insert needle at shallow angle toward superior angle of scapula • .30 x 50mm or 30ga x 1” • DO NOT insert needle posterior to anterior • Muscle twitch is moderate

14. Sternocleidomastoid

15. SCM Needling • Patient supine • Pincer grasp of muscle • 30ga x 1” or .30 x 50mm • Avoid external jugular (bruising) • Insert needle only through portion of muscle you’re holding • Muscle twitch is moderate • Responsible for many ENT-like symptoms

16. Low Back Pain • Common muscle trouble makers: • QL • Iliopsoas • Multifidis • Iliocostalis & Longissimus • Glute medius

17. Quadratus Lumborum

18. QL Needling • Patient on side, affected side up • May need pillow under unaffected side • 1 – 2” posterior of iliac crest apex, approx ½ way b/w there and rib 12 • Insert .30 x 50mm or .30 x 60mm needle lateral to medial toward midshaft of spinous process

19. QL Stretch

20. Iliopsoas

21. Iliopsoas Needling • Patient prone • Insert .30 x 75mm needle posterior lateral to anterior medial through QL • Patient on side • Insert a .30 x 75mm needle posterior lateral to anterior medial lateral through QL; aim for base of transverse process

22. Iliopsoas

23. Iliopsoas Stretch

24. Multifidus

25. Multifidus Needling • Patient supine • Safety zone is 1 finger width lateral to spinous process • Insert .30 x 50mm needle from posterior lateral to anterior medial; aim for base of transverse process and lamina

26. Iliocostalis & Longissimus

27. Iliocostalis & Longissimus Needling • Patient prone • .30 x 50mm needle • Identify trigger point • Use index and middle fingers to block the adjacent intercostal spaces • Insert needle using shallow angle

28. Gluteus Medius

29. Glute Medius Needling • Patient on side • .30 x 50mm needle into trigger point • Muscle twitch ranges from barely noticeable to fairly strong • Can mimic greater trochanteric bursitis

30. Tennis Elbow • Don’t Forget - Joint Above and Below • Shoulder • Radial head • Wrist • Myofascial Pain Referral Patterns • Trigger Point Injection/needling • Don’t use Lidocaine near the radial nerve

31. Supinator

32. Supinator Needling • Have patient supinate forearm to identify muscle • .20 x 25mm needle

33. Brachioradialis

34. Brachioradialis Needling • Pincer grasp of muscle • .20 x 25mm needle • Insert needle only through portion of muscle you’re holding • Mimics OA pain in the 1st MTP • Mimics scaphoid pain

35. ECRL

36. ECRL Needling • .20 x 25mm needle • Muscle twitch is strong

37. Extensor Digitorum

38. ED Needling • .20 x 25mm needle • Muscle twitch is strong

39. Triceps

40. Triceps Needling • Pincer grasp of muscle • .30 x 50mm needle • Insert needle only through portion of muscle you’re holding • Review anatomy to avoid median nerve and radial nerve • Muscle twitch is strong

41. Anconeus

42. Anconeus Needling • .20 x 25mm needle • Muscle twitch is vague to moderate

43. Supraspinatus

44. Supraspinatus Needling • Pt seated or prone • 30ga x 1.5” or .30 x 50mm needle • You must identify the spine of scapula • Insert needle anterior to posterior and medial to lateral • Muscle twitch is vague • Very common trigger point in shoulder pain

45. Infraspinatus

46. Infraspinatus Needling • Pt seated or prone • 30ga x 1.5” or .30 x 50mm needle • You must identify the medial border and inferior angle of scapula • Muscle twitch is moderate • Very common trigger point in shoulder pain

47. Serratus Posterior Superior

48. Serratus Posterior Superior Needling • Patient prone • .30 x 50mm needle • Identify trigger point • Use index and middle fingers to block the adjacent intercostal spaces • Insert needle using shallow angle • Muscle twitch vague to moderate

49. Serratus Posterior Superior Needling • Patient side-lying, affected side down • Arm internally rotated with hand behind back • Pull scapula away from ribs • Insert .30 x 50mm needle parallel to rib cage and scapula • Also treats: Rhomboid, Subscapularis, Serratus anterior

50. Post-Surgical Neuropathic Pain (729.2) • Occurs due to surgical scar • Pain is burning and usually local • Neural therapy • Injection of 0.25% Lidocaine along scar • 30ga needle