
Trigger Point Injection (13)
Gastrocnemius Trigger Point Injection
Written by Nicolas E. Walsh and Maxim EckmannIndications
Gastrocnemius injection is a useful diagnostic and therapeutic procedure for myofascial pain.
Techniques
After informed consent is obtained, the patient is placed in a supine position. The gastrocnemius and soleus muscles are palpated from the knee to the ankle. The injection sites are identified as points of maximal tenderness to deep palpation, reproducing the patient’s pain complaint. This may or may not result in referred pain. The patient is prepared in a standard aseptic fashion over an area large enough to allow palpation of landmarks, and sterile technique is used throughout the procedure. A 1½-in. (4-cm), 21- to 25-gauge needle is inserted at the point of maximal tenderness and advanced to the area of the trigger point. After negative aspiration, the trigger point area is injected with 4 mL of local anesthetic (Fig. 67-33).
FIGURE 67-33. Gastrocnemius and soleus trigger points and referred pain patterns.
Comment
The patient should be fully familiar with the stretching program for the gastrocnemius muscle and be instructed in a home program. Failure to include a home stretching program usually results in short-term relief. The referred pain pattern for the gastrocnemius and soleus muscles often involves the posterior knee, calf, heel, and plantar aspect of the foot.
Complications
Significant complications are uncommon with gastrocnemius trigger point injections.
Source: Physical Medicine and Rehabilitation - Principles and Practice
Hip Adductor Trigger Point Injection
Written by Nicolas E. Walsh and Maxim EckmannIndications
Hip adductor muscle injection is a useful diagnostic and therapeutic procedure for myofascial pain.
Techniques
After informed consent is obtained, the patient is placed in the supine position and the affected limb flexed, adducted, and externally rotated. The adductor longus, adductor brevis, and adductor magnus are palpated along the medial aspect of the humerus and thigh. The injection sites are identified as points of maximal tenderness to deep palpation, reproducing the patient’s pain complaint. This may or may not result in referred pain. The patient is prepared in a standard aseptic fashion over an area large enough to allow palpation of landmarks, and sterile technique is used throughout the procedure. A 1½-in. (4-cm), 21- to 25-gauge needle is inserted at the point of maximal tenderness and advanced to the area of the trigger point. After negative aspiration, the trigger point area is injected with 4 mL of local anesthetic (Fig. 67-32).
FIGURE 67-32. Hip adductor trigger points and referred pain patterns.
Comment
The referred pain pattern for the adductor muscles of the hip often involves the proximal hip, medial thigh, anterior thigh, and knee. The patient should be fully familiar with the stretching program for the adductor muscle and be instructed in a home program. Failure to include a home stretching program usually results in short-term relief.
Complications
Significant complications are uncommon with hip adductor trigger point injections.
Source: Physical Medicine and Rehabilitation - Principles and Practice
Piriformis Trigger Point Injection
Written by Nicolas E. Walsh and Maxim EckmannIndications
Piriformis muscle injection is a useful diagnostic and therapeutic procedure for myofascial pain.
Techniques
After informed consent is obtained, the patient is placed in the lateral Sims’ position. The piriformis muscle is palpated from the sacrum toward the hip. The injection sites are identified as points of maximal tenderness to deep palpation, reproducing the patient’s pain complaint. This may or may not result in referred pain. The patient is prepared in a standard aseptic fashion over an area large enough to allow palpation of landmarks, and sterile technique is used throughout the procedure. A 1½-in. (4-cm), 21- to 25-gauge needle is inserted at the point of maximal tenderness and advanced to the area of the trigger point. After negative aspiration, the trigger point area is injected with 4 mL of local anesthetic (Fig. 67-31).
FIGURE 67-31. Piriformis trigger points and referred pain patterns.
Comments
The referred pain pattern for the piriformis muscle often involves the buttocks, iliosacral region, and posterior hip. The patient should be familiar with the stretching program for the piriformis muscle and be instructed in a home program. Failure to include a home stretching program usually results in short-term relief.
Complications
Attention to the anatomy of the sciatic nerve in this region will prevent intraneural injection; otherwise, significant complications are uncommon with trigger point injections. Severe pain on injection suggests the possibility of an intraneural injection, and the needle should be repositioned immediately. Temporary lower extremity weakness is possible from regional spread of the local anesthetic.
Source: Physical Medicine and Rehabilitation - Principles and Practice
Gluteal Trigger Point Injection
Written by Nicolas E. Walsh and Maxim EckmannIndications
Gluteal muscle injection is a useful diagnostic and therapeutic procedure for myofascial pain.
Techniques
After informed consent is obtained, the patient is placed in the lateral position with the unaffected side down, or in the prone position. The gluteus maximus, minimus, and medius muscles are palpated. The injection sites are identified as points of maximal tenderness to deep palpation, reproducing the patient’s pain complaint. This may or may not result in referred pain. The patient is prepared in a standard aseptic fashion over an area large enough to allow palpation of landmarks, and sterile technique is used throughout the procedure. A 1½-in. (4-cm), 21- to 25-gauge needle is inserted at the point of maximal tenderness and advanced to the area of the trigger point. After negative aspiration, the trigger point area is injected with 4 mL of local anesthetic (Fig. 67-30).
FIGURE 67-30. Gluteal trigger points and referred pain patterns.
Comment
The referred pain pattern for the gluteus maximus usually involves the sacroiliac joint, hip, and buttock. The referred pain pattern for the gluteus medius often involves the iliac crest, sacroiliac joint, and buttock. The referred pain pattern for the gluteus minimus muscle usually involves the buttock and lateral aspect of the lower extremity. The patient should be fully familiar with the stretching program for the gluteal muscle and be instructed in a home program. Failure to include a home stretching program usually results in short-term relief.
Complications
Significant complications are uncommon with gluteal trigger point injections; however, the anatomy of the region, including the sciatic nerve, must be carefully considered with these injections. Intraneural injection may result in nerve damage. Severe pain on injection suggests the possibility of an intraneural injection, and the needle should be immediately repositioned. Temporary lower extremity weakness is possible from regional spread of the local anesthetic.
Source: Physical Medicine and Rehabilitation - Principles and Practice
Paraspinal Musculature Trigger Point Injection
Written by Nicolas E. Walsh and Maxim EckmannIndications
The paraspinal muscle injection is a useful diagnostic and therapeutic procedure for myofascial pain.
Techniques
After informed consent is obtained, the patient is placed in the prone position. The appropriate thoracic and lumbar regions are palpated. The injection sites are identified as points of maximal tenderness to deep palpation, reproducing the patient’s pain complaint. This may or may not result in referred pain. The patient is prepared in a standard aseptic fashion over an area large enough to allow palpation of landmarks, and sterile technique is used throughout the procedure. A 1½-in. (4-cm), 21- to 25-gauge needle is inserted at the point of maximal tenderness and advanced to the area of the trigger point. After negative aspiration, the trigger point area is injected with 4 mL of local anesthetic (Fig. 67-29).
FIGURE 67-29. Paraspinal musculature. Trigger points and referred pain patterns.
Comment
The referred pain pattern for the thoracic paraspinal muscles often involves the scapular and chest wall region, as well as the lower thoracic paraspinal muscles and abdomen region. The referred pain pattern for the lumbar paraspinal muscles often involves the buttock, iliac crest, and sacroiliac joint region. These muscles involve the erector spinae, semispinalis cervicis, longissimus capitis, longissimus cervicis, longissimus iliocostalis thoracis, iliocostalis lumborum, and semispinalis multifidus. The patient should be fully familiar with the stretching program for the affected paraspinal muscle and be instructed in a home program. Failure to include a home stretching program usually results in short-term relief.
Complications
Significant complications are uncommon with paraspinal trigger point injections.
Source: Physical Medicine and Rehabilitation - Principles and Practice
Quadratus Lumborum Trigger Point Injection
Written by Nicolas E. Walsh and Maxim EckmannIndications
Quadratus lumborum injection is a useful diagnostic and therapeutic procedure for myofascial pain.
Techniques
After informed consent is obtained, the patient is placed in a prone position. The quadratus lumborum muscle is palpated from the 12th rib to the iliac crest and from vertebral attachments L1 to L4 to its lateral border. The injection sites are identified as points of maximal tenderness to deep palpation, reproducing the patient’s pain complaint. This may or may not result in referred pain. The patient is prepared in a standard aseptic fashion over an area large enough to allow palpation of landmarks, and sterile technique is used throughout the procedure. A 1½-in. (4-cm), 21- to 25-gauge needle is inserted at the point of maximal tenderness and advanced to the area of the trigger point. After negative aspiration, the trigger point area is injected with 4 mL of local anesthetic (Fig. 67-28).
FIGURE 67-28. Quadratus lumborum. Trigger points and referred pain patterns.
Comment
The referred pain pattern for the quadratus lumborum muscle usually involves the iliac crest, hip, and buttock. The patient should be fully familiar with the stretching program for the quadratus lumborum muscle and be instructed in a home program. Failure to include a home stretching program usually results in short-term relief.
Complications
Significant complications are uncommon with quadratus lumborum trigger point injections.
Source: Physical Medicine and Rehabilitation - Principles and Practice
Deltoid Trigger Point Injection
Written by Nicolas E. Walsh and Maxim EckmannIndications
Deltoid muscle injection is a useful diagnostic and therapeutic procedure for myofascial pain.
Techniques
After informed consent is obtained, the patient is placed in the sitting position. The anterior, middle, and posterior components of the deltoid muscle are palpated. The injection sites are identified as points of maximal tenderness to deep palpation, reproducing the patient’s pain complaint. This may or may not result in referred pain. The patient is prepared in a standard aseptic fashion over an area large enough to allow palpation of landmarks, and sterile technique is used throughout the procedure. A 1½-in. (4-cm), 21- to 25-gauge needle is inserted at the point of maximal tenderness and advanced to the area of the trigger point. After negative aspiration, the trigger point area is injected with 4 mL of local anesthetic (Fig. 67-27).
FIGURE 67-27. Deltoid. Trigger points and referred pain patterns.
Comment
The referred pain pattern for the deltoid muscle usually involves the shoulder and proximal upper extremity. The patient should be fully familiar with the stretching program for the deltoid muscle and be instructed in a home program. Failure to include a home stretching program usually results in short-term relief.
Complications
Significant complications are uncommon with deltoid trigger point injections.
Source: Physical Medicine and Rehabilitation - Principles and Practice
Pectoralis Trigger Point Injection
Written by Nicolas E. Walsh and Maxim EckmannIndications
Pectoralis muscle injection is a useful diagnostic and therapeutic procedure for myofascial pain.
Techniques
After informed consent is obtained, the patient is placed in the supine position. The pectoralis muscles are palpated. The injection sites are identified as points of maximal tenderness to deep palpation, reproducing the patient’s pain complaints. This may or may not result in referred pain. The patient is prepared in a standard aseptic fashion over an area large enough to allow palpation of landmarks, and sterile technique is used throughout the procedure. A 1½-in. (4-cm), 21- to 25-gauge needle is inserted at the point of maximal tenderness and advanced to the area of the trigger point. After negative aspiration, the trigger point area is injected with 4 mL of local anesthetic (Fig. 67-26).
FIGURE 67-26. Pectoralis. Trigger points and referred pain patterns.
Comment
The referred pain pattern for the pectoralis muscles usually involves the anterior chest wall and breast regions. The patient should be fully familiar with the stretching program for the pectoralis muscle and be instructed in the home program. Failure to include a home stretching program usually results in short-term relief.
Complications
Significant complications are uncommon with pectoralis trigger point injections; however, the anatomy of the region, including the close proximity of the thoracic cavity, must be carefully considered. The risk for pneumothorax is reduced by approaching the trigger point with the needle tangential to the thoracic wall.
Source: Physical Medicine and Rehabilitation - Principles and Practice
Infraspinatus Trigger Point Injection
Written by Nicolas E. Walsh and Maxim EckmannIndications
Infraspinatus injection is a useful diagnostic and therapeutic procedure for myofascial pain.
Techniques
After informed consent is obtained, the patient is placed in the sitting or prone position. The infraspinatus muscle is palpated from the infraspinous fossa of the scapula to the humerus. Trigger points are most often located below the spine of the scapulae. The injection sites are identified as points of maximal tenderness to deep palpation, reproducing the patient’s pain complaint. This may or may not result in referred pain. The patient is prepared in a standard aseptic fashion over an area large enough to allow palpation of landmarks, and sterile technique is used throughout the procedure. A 1½-in. (4-cm), 21- to 25-gauge needle is inserted at the point of maximal tenderness and advanced to the area of the trigger point. After negative aspiration, the trigger point area is injected with 4 mL of local anesthetic (Fig. 67-25).
FIGURE 67-25. Infraspinatus. Trigger points and referred pain patterns.
Comment
The referred pain pattern for the infraspinatus often involves the deltoid muscle, as well as the area over the lateral shoulder and proximal upper extremity. Pain also may be referred in the infrascapular region. The patient should be fully familiar with the stretching program for the infraspinatus muscle and be instructed in a home program. Failure to include a home stretching program usually results in short-term relief.
Complications
Significant complications are uncommon with infraspinatus trigger point injections.
Source: Physical Medicine and Rehabilitation - Principles and Practice
Supraspinatus Trigger Point Injection
Written by Nicolas E. Walsh and Maxim EckmannIndications
Supraspinatus injection is a useful diagnostic and therapeutic procedure for myofascial pain.
Techniques
After informed consent is obtained, the patient is placed in a sitting or prone position. The supraspinatus muscle is palpated for trigger points from the supraspinous fossa to the humerus. The injection sites are identified as points of maximal tenderness to deep palpation reproducing the patient’s pain complaint. This may or may not result in referred pain. The patient is prepared in a standard aseptic fashion over an area large enough to allow palpation of landmarks, and sterile technique is used throughout the procedure. A 1½-in. (4-cm), 21- to 25-gauge needle is inserted at the point of maximal tenderness and advanced to the area of the trigger point. After negative aspiration, the trigger point area is injected with 4 mL of local anesthetic (Fig. 67-24).
FIGURE 67-24. Supraspinatus. Trigger points and referred pain patterns.
Comment
The referred pain pattern for the supraspinatus muscle often involves the posterior lateral aspect of the shoulder and upper extremity. The patient should be fully familiar with the stretching program for the supraspinatus muscle and be instructed in a home program. Failure to include a home stretching program usually results in short-term relief.
Complications
Significant complications are uncommon with supraspinatus trigger point injections.
Source: Physical Medicine and Rehabilitation - Principles and Practice
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Levator Scapulae Trigger Point Injection
Written by Nicolas E. Walsh and Maxim EckmannIndications
Levator scapulae trigger point injection is a useful diagnostic and therapeutic procedure for myofascial pain.
Techniques
After informed consent is obtained, the patient is placed in a sitting or prone position. The levator scapulae muscle is palpated along the attachment at the C1 to C4 vertebrae and the superior angle of the scapulae. The injection sites are identified as points of maximal tenderness to deep palpation reproducing the patient’s pain complaint. This may or may not result in referred pain. The patient is prepared in a standard aseptic fashion over an area large enough to allow palpation of landmarks, and sterile technique is used throughout the procedure. A 1½-in. (4-cm), 21- to 25-gauge needle is inserted at the point of maximal tenderness and advanced to the area of the trigger point. After negative aspiration, the trigger point area is injected with 4 mL of local anesthetic (Fig. 67-23).
FIGURE 67-23. Levator scapulae. Trigger points and referred pain patterns.
Comment
The entire body of the levator scapulae muscle should be palpated from origin to insertion and all trigger points injected.
Total injection should not exceed maximum safe dosage. The referred pain pattern for the levator scapular muscle often includes a posterior lateral neck and occipital and temporal regions. The patient should be fully familiar with the stretching program for the levator scapulae muscle and be instructed in a home program. Failure to include a home stretching program usually results in short-term relief.
Complications
Nerve root blockade may result from improper needle placement or injection of large quantities of local anesthetic in the vertebral region. Intraneural injection may result in nerve damage. Severe pain on injection suggests the possibility of an intraneural injection, and the needle should be repositioned immediately.
Source: Physical Medicine and Rehabilitation - Principles and Practice
Trapezius Trigger Point Injection
Written by Nicolas E. Walsh and Maxim EckmannIndications
Trigger point injection of the trapezius muscle is used to treat myofascial pain.
Techniques
After informed consent is obtained, the patient is placed in the sitting or prone position. The trapezius muscle is palpated. The injection sites are identified as points of maximal tenderness to deep palpation reproducing the patient’s pain complaint. This may or may not result in referred pain. The patient is prepared in a standard aseptic fashion over an area large enough to allow palpation of landmarks, and sterile technique is used throughout the procedure. A 1½-in. (4-cm), 21- to 25-gauge needle is inserted at the point of maximal tenderness and advanced to the area of the trigger point. After negative aspiration, the trigger point area is injected with 4 mL of local anesthetic (Fig. 67-22).
FIGURE 67-22. Trapezius. Trigger points and referred pain patterns.
Comments
The referred pain pattern for the upper trapezius is often along the posterior lateral aspect of the neck, as well as periarticular and temporal regions. The referred pain pattern for the mid trapezius often involves the shoulder and paraspinal region. The referred pain pattern for the lower trapezius usually involves the paraspinal region. The patient should be fully familiar with the stretching program for the trapezius muscle and be instructed in a home program. Failure to include a home stretching program usually results in short-term relief.
Complications
Significant complications are uncommon with trapezius trigger point injections.
Source: Physical Medicine and Rehabilitation - Principles and Practice
Commom Muscle Injection Techniques
Written by Nicolas E. Walsh and Maxim EckmannGeneral
Trigger points may occur in any muscle or muscle group of the body. They are commonly found in muscle groups that are routinely overstressed or those that do not undergo full contraction and relaxation cycles. Many trigger points are characterized by pain originating from small circumscribed areas of local hyperirritability involving myofascial structures, resulting in local and referred pain. Pain is aggravated by stretching, cooling, and compression of the affected area, which often gives rise to a characteristic pattern of referred pain (11,12).
Trigger points are best localized by deep palpation of the affected muscle, which reproduces the patient’s pain complaint both locally and in the referred zone. Trigger points are usually a sharply circumscribed spot of exquisite tenderness when they are present; passive or active stretching of the affected muscle routinely increases the pain. When compared with equivalent palpation pressure in normal muscle, the trigger point region displays isolated bands, increased tenderness, and referred pain. The muscle in the immediate vicinity of the trigger point is often described as ropey, tense, or a palpable band. The trigger point is injected after palpation of the affected muscle, and the point of maximal tenderness reproducing the pain complaint is identified. When the point of injection has been determined, it is best marked with the tip of a retracted ballpoint pen or needle hub by pressing the skin to reproduce temporary indentation to mark the point of entry. The patient is prepared in a standard aseptic fashion over an area large is used throughout the procedure. The skin and subcutaneous tissue at the injection site are usually not anesthetized. A 1½- to 2-in. (4- to 5-cm), 22- to 25-gauge needle is advanced into the muscle at the point of maximum tenderness. Before injecting the medication, an attempt should always be made to aspirate to avoid accidental or intravascular injection. Verification that the needle is at the trigger point may be established by the jump sign or reproduction of the pain complaint. Medication should be injected in a fanwise manner in the area of the trigger point.
Indications for Trigger Point Injections
Trigger point injections may be used to determine the source of pain and to provide maximum pain relief from myofascial pain and to facilitate physical therapy for the stretching of trigger points.
Contraindications for Trigger Point Injections
Absolute contraindications to trigger point injection include localized infection, a skin condition that prevents adequate skin preparation, the existence of a tumor at the injection site, history of allergy to local anesthetics, gross coagulation defects, septicemia, or an uncooperative patient.
Complications
The complications associated with trigger point injections include infection, increased pain, local anesthetic overdose, or intravascular injection that can result in CNS toxicity and, in some cases, pulmonary and cardiac arrest. Intraneural injection may result in nerve damage. Severe pain on injection suggests the possibility of an intraneural injection, and the needle should be immediately repositioned. Other complications depend on location of the trigger point injection and are discussed separately.
Techniques
Before the injection, the affected muscle is palpated and the trigger points located and marked. The skin is scrubbed with antiseptic and allowed to dry for 2 minutes. The wearing of sterile gloves is required so that muscle in the sterile field may be palpated throughout the procedure. Before the injection, the trigger point is repalpated and stabilized between the fingers for injection (Fig. 67-20). Routinely, a 1½-in. (4-cm), 21- to 25-gauge needle transverses the skin’s subcutaneous tissue and is advanced smoothly into the area of the trigger point.
FIGURE 67-20. Trigger point palpation. A, B: Palpation and localization of trigger point by rolling beneath two fingers (arrows). C: Stabilization of trigger point for injection by spanning with two fingers (arrows).
Aspiration should be done to ensure there is no intravascular penetration. If this does occur, the needle should be repositioned and aspirated to ensure that blood vessels have been avoided, and then the medication is injected. A fanwise manner of injection often results in the longest pain relief, owing to increased distribution of local anesthetic (Fig. 67-21). The needle is then withdrawn, with pressure applied to minimize bleeding.
FIGURE 67-21. Fanwise injection technique for trigger point.
Source: Physical Medicine and Rehabilitation - Principles and Practice
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