trigger points injections

This forum made possible through the generous support of SDN members, donors, and sponsors. Thank you.

oreosandsake

Full Member
15+ Year Member
Joined
Apr 6, 2007
Messages
2,058
Reaction score
1,009
what gauge/length needle are you using?

do you go perpendicular to the skin?

do you pinch muscle/skin/subcutaneous tissue away from the body?

what do you do?

curious if anyone knows of personal reports of pneumothorax with TPI.

FWIW, we use 25G 1.5 inch (almost regardless of BMI, although 5/8 in are also in the TPI tray) and just gauge how much needle to use by eyeball.

Members don't see this ad.
 
Heard of a pneumo with an EMG of an intercostal.
 
Members don't see this ad :)
yes.. the first reports were over 30 years ago.

wondering if anyone personally knows of some of these cases....

will look into trying 27G, thanks
 
I just recently did a talk on use of ultrasound for TPIs. There are some crazy case reports from bad stuff happening from simple TPIs. But closed claimed data shows that pneumothorax is the most common harm from TPIs.

I use a 25g 2inch needle, but I can see my tip and the lung.

I am amazed at how watching my needle tip has changed my understanding of what I think I am doing and treating with a TPI.
 
I just recently did a talk on use of ultrasound for TPIs. There are some crazy case reports from bad stuff happening from simple TPIs. But closed claimed data shows that pneumothorax is the most common harm from TPIs.

I use a 25g 2inch needle, but I can see my tip and the lung.

I am amazed at how watching my needle tip has changed my understanding of what I think I am doing and treating with a TPI.
And billing.
 
I don't bill or care about billing.

Ultrasound does add time to the procedure probably - not much, but does add time.

Then explain a 2" harpoon for a trigger point. I don't believe trigger point injections provide any meaningful benefit for more than hrs to 2-3 days. Will do with 30G 1/2" or 1" as pure lidocaine upon patient request.
 
  • Like
Reactions: 1 user
Would anyone perform trigger points to help kick start PT? For instance, in someone with scapular dyskinesis, periscapular trigger points, and some myofascial pain I've often thought taking care of some of the trigger points would better allow for muscular retraining and improved outcomes.
 
Then explain a 2" harpoon for a trigger point. I don't believe trigger point injections provide any meaningful benefit for more than hrs to 2-3 days. Will do with 30G 1/2" or 1" as pure lidocaine upon patient request.
Totally agree...if you are going to do trigger points with a 30g 1/2inch needle - it is totally worthless.

To get meaningful results, you need to hit the facial planes, and the deep ones - it is a very targeted and specific injection. My bias is that since I have been targeting specific structures (deep facial planes - and serratus muscle), the effectiveness has improved.

To answer your question, 2inch is for ease of ultrasound.

To see the needle effectively (using an in-plane approach), one needs to make sure the angle between the ultrasound beam and needle is less than 30 - 40 deg. To accomplish this, you need to enter the skin farther away from the probe. The payoff is you get to see the needle very well. The cost is you need a longer needle.
 
Totally agree...if you are going to do trigger points with a 30g 1/2inch needle - it is totally worthless.

To get meaningful results, you need to hit the facial planes, and the deep ones - it is a very targeted and specific injection. My bias is that since I have been targeting specific structures (deep facial planes - and serratus muscle), the effectiveness has improved.

To answer your question, 2inch is for ease of ultrasound.

To see the needle effectively (using an in-plane approach), one needs to make sure the angle between the ultrasound beam and needle is less than 30 - 40 deg. To accomplish this, you need to enter the skin farther away from the probe. The payoff is you get to see the needle very well. The cost is you need a longer needle.

Pissing contest? Got any literature supporting trigger point injections? With US? Wiyh 2" needle?
 
Members don't see this ad :)
Would anyone perform trigger points to help kick start PT? For instance, in someone with scapular dyskinesis, periscapular trigger points, and some myofascial pain I've often thought taking care of some of the trigger points would better allow for muscular retraining and improved outcomes.

I will do this for select cases, and yes it has facilitated PT in those cases. I don't bother with trigger points for typical scapula or shoulder pain, but found it most helpful for the tough cases.

Still, they only get it once, maybe twice if they beg. I stress that their participation in PT is key, not them passively receiving an injection.
 
  • Like
Reactions: 1 user
Pissing contest? Got any literature supporting trigger point injections? With US? Wiyh 2" needle?

Literature - nope. And? Need I point out that despite no evidence for chronic opioid therapy, you still vigorously defend your use? How about the fact that you absolutely jump on the fact that despite evidence to the contrary, you vehemently claim interlaminar and transformational are far superior to caudal epidurals? I'm fine with you being dogmatic about making decisions based on tried and true data proven techniques. But if you are going to do that, you have to make EVERY choice and decision based on this with no wiggle room. Otherwise, I don't think it reasonable to pick and choose (which we all do) but then criticize someone else who picked a different topic than you to make a clinical decision on rather than data proven.

Regarding needle length, I thought that was clear. I can't explain it beyond what I already said. If you use ultrasound, you would totally understand my answer.

I don't understand your pissing contest comment.
 
Last edited:
  • Like
Reactions: 1 user
The one thing I do know about trigger point injections is that they are the one thing not worth having a internet forum flame war over. If you want to do one, then do it. Who cares how. Doesn't matter. Just don't drop a lung. This is just Pain Medicine, guys.
 
what gauge/length needle are you using?

do you go perpendicular to the skin?

do you pinch muscle/skin/subcutaneous tissue away from the body?

what do you do?

curious if anyone knows of personal reports of pneumothorax with TPI.

FWIW, we use 25G 1.5 inch (almost regardless of BMI, although 5/8 in are also in the TPI tray) and just gauge how much needle to use by eyeball.

wait a minute: you have a TPI "tray"?

One of my colleagues dropped a lung with a 1.5 inch. if you go anterior, you are much less likely to pop the balloon
 
the tray is a plastic bin with a handle. it is filled with plastic syringes, needles, iodine sticks, etc. and used for occipital blocks, knees, GTBs, etc I guess we should call it the "front office plastic bin with a handle for non fluoro suite procedures." we have 4 of them. they must have been named by the nurses since TPI tray is easier to understand

can you explain, "go anterior"

thanks
 
the tray is a plastic bin with a handle. it is filled with plastic syringes, needles, iodine sticks, etc. and used for occipital blocks, knees, GTBs, etc I guess we should call it the "front office plastic bin with a handle for non fluoro suite procedures." we have 4 of them. they must have been named by the nurses since TPI tray is easier to understand

can you explain, "go anterior"

thanks
Are you in private practice? If so, calculate the cost of that tray, especially the stuff you throw away which is almost always the case with pre-fab trays. Subtract that from the minuscule reimbursement for a TPI, including the time spent making a trigger point more complicated than it needs to be.

The key to remember with this procedure, by far: Do no harm. You're not 110% sure your needle went deep enough? Not a big deal. It's not a good enough procedure with efficacy or reimbursement to be dropping a lung once per year by trying to aggressively make sure you get deep into muscle. Some patients love them and ask for them, so I'll do them. But otherwise it's not worth getting too crazy with TPIs constantly.
 
Last edited:
  • Like
Reactions: 1 user
Are you in private practice? If so, calculate the cost of that tray, especially the stuff you throw away which is almost always the case with pre-fab trays. Subtract that from the minuscule reimbursement for a TPI, including the time spent making a trigger point more complicated than it needs to be.

The key to remember with this procedure, by far: Do no harm. You're not 110% sure your needle went deep enough? Not a big deal. It's not a good enough procedure with efficacy or reimbursement to be dropping a lung once per year by trying to aggressively make sure you get deep into muscle. Some patients love them and ask for them, so I'll do them. But otherwise it's not worth getting to crazy with TPIs constantly.

university pain department.

I will keep that in mind if I end up in PP. I also completely agree with you. I'm not trying to bury the needle.. i have one attending that keeps telling me "go deeper, go deeper..."

and let me clarify by "tray." this is the same thing as we have. it is a "carry tray"

http://systemhygiene.co.uk/images/pictures/products/car110-carry-tray-(page-picture-large).jpg
 
university pain department.

I will keep that in mind if I end up in PP. I also completely agree with you. I'm not trying to bury the needle.. i have one attending that keeps telling me "go deeper, go deeper..."

and let me clarify by "tray." this is the same thing as we have. it is a "carry tray"

http://systemhygiene.co.uk/images/pictures/products/car110-carry-tray-(page-picture-large).jpg
That's a UK web address. Are you in the UK or just happened to pull up that pic?
 
the tray is a plastic bin with a handle. it is filled with plastic syringes, needles, iodine sticks, etc. and used for occipital blocks, knees, GTBs, etc I guess we should call it the "front office plastic bin with a handle for non fluoro suite procedures." we have 4 of them. they must have been named by the nurses since TPI tray is easier to understand

can you explain, "go anterior"

thanks

face the patient. grap the upper trap. stick the needle into it from the front, just above the clavicle.
 
Hey epidural man. Curious what your experience has been with using US for these. Are the trigger points in the traps and upper rhomboids deeper than you thought prior to using US? I often times error on the shallow side and sometimes wonder if I'm even getting deep enough to get into the trigger point. Maybe I'll start using US for some of these. Well, I really don't do triggers often enough to make worth while I guess. Just curious
 
Hey epidural man. Curious what your experience has been with using US for these. Are the trigger points in the traps and upper rhomboids deeper than you thought prior to using US? I often times error on the shallow side and sometimes wonder if I'm even getting deep enough to get into the trigger point. Maybe I'll start using US for some of these. Well, I really don't do triggers often enough to make worth while I guess. Just curious
Absolutely I go deeper. There was no way I was going to get a pneumo so I barely went in. With ultrasound I go pretty deep.

Here is a video I made on my last patient I did. Not my best work but I will try and get a better example and post.

 
A simple question for those doing TPIs: What do you feel that you are exactly doing? Not being critical or judgmental of anyone.
 
A simple question for those doing TPIs: What do you feel that you are exactly doing? Not being critical or judgmental of anyone.

Well,

I think these people describe it best - this is a large two volume book dedicated to trigger points. Obviously some people think it does something scientific.

http://data:image/jpeg;base64,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

http://www.amazon.com/Travell-Simon...id=1412834120&sr=8-14&keywords=trigger+points
 
  • Like
Reactions: 1 user
^^ I read the first several chapters of that book. It was pure speculation and made me fairly confident that symptoms are referred rather than originate there.
 
A simple question for those doing TPIs: What do you feel that you are exactly doing? Not being critical or judgmental of anyone.
A single trigger point injection, done properly can, 1-Reduce physical pain, 2-Eliminate spiritual and emotional suffering, and 3-Reduce carbon foot-print, therefore easing climate change.

:)
 
  • Like
Reactions: 1 users
A single trigger point injection, done properly can, 1-Reduce physical pain, 2-Eliminate spiritual and emotional suffering, and 3-Reduce carbon foot-print, therefore easing climate change.

:)

I re-use all my needles 5 times, drapes x3. Saves the environment.
 
  • Like
Reactions: 2 users
Lets do this. I'll post an article that shows efficacy, then lobelsteve or pmrmd will post one that doesn't.

go!

Tekin, Levent, et al. "The effect of dry needling in the treatment of myofascial pain syndrome: a randomized double-blinded placebo-controlled trial." Clinical rheumatology 32.3 (2013): 309-315.
 

Attachments

  • TPI.pdf
    278.3 KB · Views: 44

Hold on...

I thought we were posting articles about the trigger point intervention and efficacy on reduction in pain.

This article seems to answer a different question which would be "Is physical exam a reliable method to predict myofascial trigger points" which is a great question too. Let's just stick to one topic however. I say we stick to the original one first, then move on.
 
Lets do this. I'll post an article that shows efficacy, then lobelsteve or pmrmd will post one that doesn't.go!

Like I noted, I'm not being judgmental or critical, just simply asking what you think you are accomplishing. Current thought is that there is a dysfunctional endplate. Fine. What do you think needling is doing to correct it?
 
Did I mention that I got a patient who used to get phenol tpi's from a crazy neurologist down the street!! She has all these scarred hypopigmented areas all over her lower cervical paraspinals and traps. That should fry those endplates right? ;)
 
  • Like
Reactions: 1 user
I have been doing ultrasound "trigger points" for about 3 years now, and have this to add to what I've previously posted in other threads:

Sometimes a trigger point isn't what you think it is. For the purposes of this discussion, I will define a TP as any area of radiating or localized point tenderness to palpation, whether you can feel a lump or not.

Occasionally you will see a calcified ball of muscle on ultrasound, and these usually respond to repeated needling attempts the way we were all trained. The benefit of using ultrasound is that you do the needling in a directed fashion. In 3 years I have only seen a handful of cases like this, but they all responded well.

More commonly, you will see nothing out of the ordinary on your ultrasound exam. No calcifications, masses, tears, etc.

Trigger points often occur over bony prominences or ridges. These cases may represent bursitis, ligamentous or tendinous pain (most frequent, IMHO), peripheral nerve entrapment, muscular irritation (??), or any of the above combined with centralized hypersensitivity (take your pick of etiologies).

In "bony prominence" pain problems, I will attempt to inject such as to lift the localized tissues away from the bone, and hydrodissect any localized tissue planes theorizing that this may enter a bursa, break down soft tissue adhesions, or treat an inflamed tendon sheath. One obvious example would be the common GTB injection. Performed under US I can not only inject the space between the GM muscle/tendon and the bone (the "bursa), but I can also inject the more superficial tendon sheath, watching the soft tissue planes open up as I do it. These are usually far more effective than the many blind injections these patients previously had before seeing me. They are less effective in the obese, inactive types with a million other pain complaints.

Another fairly obvious example would be the supraspinatous tendon sheath injection. If you're not doing these, you are missing a glaringly effective treatment option for shoulder pain. Patients with point tenderness over the SST insertion on the humerus (have them put their hand on the hip to roll the head of the humerus forward, then palpate the superoanterior aspect), pain with resisted abduction, and attempted "reach around the back" are excellent candidates. If there are tears apparent on the MRI, even more so. With ultrasound you can precisely guide the needle between the deltoid and SST and watch the injectate flow over the tendon and wrap around the back toward the SS muscle belly. Patients get immediate relief and can now raise their arm easily- very satisfying. I do these on my wife periodically and she uses terms like "friggin miracle" to describe how well it works. Of course, most durable results are achieved when you combine the technique with appropriate PT, exercise, and shoulder care.

I have often found trigger points in the chest wall to be localized to the junction of the abdominal wall musculature where it rides up over the ribs, particularly at the costal margin. Abdominal wall pain is frequently localized to the junction of the oblique muscles and rectus sheath. Inject carefully at these precise locations and you often see surprisingly good results.

I have been remarkably successful treating seemingly random foot pain in this manner. One recent patient was complaining of plantar fasciitis, but also pain along the anterolateral aspect of the mid foot. One injection along the soft tissue planes (likely placed over the various tendon sheaths) actually resolved this as of a 1-month follow up. The plantar fasciitis did not respond as well. I treated another patient a few days ago with pain just inferior to the medial malleolus, anterior aspect. I injected at this exact location and saw three tendon sheaths flood open. Instant relief. Now let's see if it sticks.

One unusual case I had recently involved a man who sustained a minor trauma to the extensor retinaculum along his ankle, and had two years of very painful foot ischemia with walking/running. He was referred from vascular who couldn't help him, although there were some minor seeming flow abnormalities in the ATA. They thought he might have CRPS. The patient had selfie pics demonstrating the ischemia. His entire food would go white below the retinaculum. After a single injection directed at expanding the tissues under the retinaculum, he was markedly improved. He could now walk 3 miles before his foot would start to get ischemic, and the pain would now stop when he ceased walking. Previously it took 30 minutes to resolve and was extremely painful. He continued to improve with two more injection sessions.

Sometimes you will find patients to have a painful lymph node or lipoma, but if you carefully dissect around it with anesthetic, the goal being mobilization, they will improve.

The two most common "TP" areas I see include the bilateral cervical trap points at the base of the neck about 4 fingers off the midline. I believe these are well described. Also, the tissues just overlying the PSIS. I have had varying degrees of success injecting these with my techniques ranging from complete durable relief to none at all. Getting immediate improvement with the anesthetic is common, but durable relief occurs maybe 40-50% of the time.

I hope this helps to explain why those of us who use ultrasound are so adamant about it's benefits. In my opinion any pain doc who isn't learning to do these procedures is a dinosaur.
 
  • Like
Reactions: 4 users
Powermd. I applaud your efforts. Your post is pseudoscience, jargon, and personal experience. Your passion to help is as likely to get the results as anything going on with a needle. For anything you are doing to be useful for us dinosaurs you would need to establish dx based on valid criteria and at least a series of patients that responded to treatment so we could reproduce results.
 
Powermd. I applaud your efforts. Your post is pseudoscience, jargon, and personal experience. Your passion to help is as likely to get the results as anything going on with a needle. For anything you are doing to be useful for us dinosaurs you would need to establish dx based on valid criteria and at least a series of patients that responded to treatment so we could reproduce results.

Steve, just buy an ultrasound machine.

I would love to do clinical research, but I just... can't... find.. the motivation.

Could my good results ALL be a placebo response, sure.

But then again, what if I'm actually on to something. Open your mind Quaid... Open your mind.
 
Nice post Power. I do similar injections with excellent results as well. The supraspinatus tendon at its insertion, the abs at their insertions, the various points at the GT that represent the external rotator insertions, vastus lateralis insertion, etc. I have similar experiences as you. The thing is these aren't trigger points you are injecting, but the enthesis. Its not placebo at all.
 
  • Like
Reactions: 1 user
Nice post Power. I do similar injections with excellent results as well. The supraspinatus tendon at its insertion, the abs at their insertions, the various points at the GT that represent the external rotator insertions, vastus lateralis insertion, etc. I have similar experiences as you. The thing is these aren't trigger points you are injecting, but the enthesis. Its not placebo at all.

That's why I'm reluctant to call these "trigger points", but to those who don't know what else to call it, that's what it appears to be. Like I said before, it might be an origin/insertion/sheath injection, bursa, nerve entrapment, etc.

I'm glad you seem to have REPLICATED my experience.

Have you tried iliopsoas bursa injections in patients with post-THA hip pain? I get a lot of referrals for this from a local orthropod. Basically they have provocation with resisted hip flexion, or simply attempting to lift the leg at the hip. I identify the hip HW as best I can just as I would for a normal hip joint, then slide the probe slightly cephalad to reveal the bony iliopectineal eminence. The round muscle above it is the iliopsoas, and your target is the tissue plane between the muscle and bone. These can work beautifully if you get good tissue separation. The cases that fail seem to be the ones where visualization sucks due to scar tissue.
 
  • Like
Reactions: 1 user
Hip flexor tendonitis is common. I have in-office fluoro too so I just go AP down to the lesser troch, hit bone, and inject. I have had one or two patients over the years who have had a THA for hip pain, still had the pain post-surgery, and the HF injection resolved the issue. Fluoro is quicker than US here.
 
I used to use a 1.5 inch 27 ga in fellowship. Now I use no needle at all. I just fill up a 10 cc syringe with lidocaine and spray it all over their back. It takes 10 seconds, no bandaids, I bill for more than three muscle groups AND I see no change in outcome between the two methods. I haven't dropped any lungs with my new method.

Unfortunately I do not have any studies supporting my new technique but I'm working on it.
 
I used to use a 1.5 inch 27 ga in fellowship. Now I use no needle at all. I just fill up a 10 cc syringe with lidocaine and spray it all over their back. It takes 10 seconds, no bandaids, I bill for more than three muscle groups AND I see no change in outcome between the two methods. I haven't dropped any lungs with my new method.

Unfortunately I do not have any studies supporting my new technique but I'm working on it.


LOL. Great thread.
 
This is the best thread EVER!!!

Actually, I recently purchased a bed of nails and an iron maiden. Enrolling patients now in a noninferiority study. Please refer.
 
By the way: Trigger point injections have shown promise in a non-blinded study, to promote world peace on a global scale. Final RCT confirmation pending.
 
Trigger points...anticonvulsants...antidepressants...creams...ESI...SIJ injections...much of PT... etc.
Some days I feel like I'm fighting a war with BB guns. Really expensive BB guns.
 
Trigger points...anticonvulsants...antidepressants...creams...ESI...SIJ injections...much of PT... etc.
Some days I feel like I'm fighting a war with BB guns. Really expensive BB guns.
I wish the BB guns were more expensive.
 
Amen to that


Sent from my iPhone using SDN Mobile
 
  • Like
Reactions: 1 user
Top