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. The patient should be placed in a comfortable or recumbent position to produce muscle relaxation. Subscribe to Drugs.com newsletters for the latest medication news, new drug approvals, alerts and updates. Trigger point injections are used to treat chronic pain in the: Lower back Neck Arms Legs Chronic pain in the areas mentioned above is typically associated with: Poor posture Injury to the muscle Poor mechanics that lead to stress of the muscle Joint disorders 3. low sperm count. Written by Cerner Multum. Copyright 2023 American Academy of Family Physicians. Periarticular calcifications are described in the literature, but they are rare. For therapeutic injections, the procedure should be performed when acute or chronic symptoms are present, after the diagnosis and therapeutic plan have been made, and after consideration has been given to obtaining radiographs. One-month outcomes were . Tell your doctor if you are pregnant or breastfeeding. Any physician familiar with the localization of trigger points and the use of therapeutic musculoskeletal injections may perform TPIs. doi: 10.7759/cureus.16856. Low-solubility agents, favored for joint injection, should not be used for soft tissue injection because of the increased risk of surrounding tissue atrophy. Tell your doctor about any illness or infection you had within the past several weeks. Federal government websites often end in .gov or .mil. Sometimes it is not safe to use certain medications at the same time. A prospective randomized controlled trial of injection of dexamethasone versus triamcinolone for idiopathic trigger finger Find patient medical information for dexamethasone sodium phosphate injection on WebMD including its uses, side effects and safety, interactions, pictures, warnings and user ratings. Medically reviewed by Drugs.com on Aug 24, 2021. 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). Arch. Identification of trigger points is required before performing these injections and is generally performed with a thorough manual and orthopedic examination. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP. Pen - clicking type; Gloves . 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). The physiology of trigger points themselves is controversial, and therefore the mechanism of action through which injections aimed at trigger points may relieve pain is unknown. Ask your doctor before stopping the medicine. See permissionsforcopyrightquestions and/or permission requests. Patient positioning should be comfortable to minimize involuntary muscle contractions and facilitate access to the painful areas. Follow the steps for site preparation. Always consult your healthcare provider to ensure the information displayed on this page applies to your personal circumstances. Necessary equipment for joint and soft tissue injection or aspiration is listed in Table 4. 16 Dry needling, a technique that involves multiple advances of a needle into the muscle at the region of the trigger point, provides as much pain relief as an injection of lidocaine. If there is strong resistance while injecting, the needle may be intramuscular, intratendinous, or up against bone or cartilage, and it should be repositioned. After the close of the study, there were 8 recurrences among patients with documented absence of triggering in the triamcinolone cohort and 1 in the dexamethasone cohort. Detailed Dexamethasone dosage information. 20552 Injection(s); single or multiple trigger point(s), 1 or 2 muscle(s) 20553 Injection(s); single or multiple trigger point(s), 3 or more muscles Injections for plantar fasciitis are addressed by 20550 and ICD-10-CM M72.2. Various modalities, such as the Spray and Stretch technique, ultrasonography, manipulative therapy and injection, are used to inactivate trigger points. Generic name: dexamethasone (injection) [DEX-a-METH-a-sone] The first documented epidural medication injection, which was performed using the caudal approach (see the image below; see also Approaches for Epidural Injections) was performed in 1901, when. Specific medications such as Botox are only approved for other indications and are thus used off-label for TPIs with CLBP. Remember, keep this and all other medicines out of the reach of children, never share your medicines with others, and use this medication only for the indication prescribed. Seigerman D, McEntee RM, Matzon J, Lutsky K, Fletcher D, Rivlin M, Vialonga M, Beredjiklian P. Cureus. A trigger point injection can help soothe myofascial pain, especially in your neck, shoulder, arms, legs and lower back. 2021 Aug 3;13(8):e16856. The site is secure. The patient should keep the injection site clean and may bathe. Dexamethasone is injected into a muscle or a vein. Dexamethasone is a synthetic glucocorticoid used in the treatment of inflammatory and immune conditions in children and adults. Contraindications Known Bleeding Disorder Anticoagulation (includes Aspirin in last 3 days) Local or systemic infection Acute Trauma at Muscle site Anesthetic allergy The two main types of trigger points are active and latent. It can be injected into a joint, tendon, or bursa. Available for Android and iOS devices. The German anatomist Froriep referred to tender spots occurring in muscles as muscle calluses in 1843; these points were called myalgic spots by Gutstein in 1938.39 Many other eponyms have been used to describe the same phenomenon. Ann Rheum Dis. Decadron is also used to treat certain types of cancer and occasionally, cerebral edema. Trigger point injection, which is commonly used to treat other pain conditions, has been shown to improve symptoms in women with chronic pelvic pain, with efficacy similar to that of physical. Search Bing for all related images, Management: Post-Procedure Instructions (Reduce postinjection flare), Roldan (2020) Am J Emerg Med 38(2): 311-6 [PubMed], Alvarez (2002) Am Fam Physician 65(4):653-60 [PubMed], Fomby (1997) Phys Sportsmed 25(2):67-75 [PubMed], Shipton (2023) Am Fam Physician 107(2): 159-64 [PubMed], Search other sites for 'Trigger Point Injection', Trigger Point Injection at trapzius insertion, Twitch response to pressure with referred pain, Unsafe injection site (e.g. Therapeutic responses to corticosteroid injections are variable.4 The patient's response to previous injection is important in deciding whether and when to proceed with reinjection. Purpose/Specific Aims Side Effects Problems with cortisone shots can range from mild to quite serious. A short-acting solution, such as dexamethasone sodium phosphate (Decadron), is less irritating and less likely to cause a postinjection flare than a long-acting dexamethasone suspension. Avoid being near people who are sick or have infections. increased appetite. Pressure is then applied to the injected area for two minutes to promote hemostasis.10 A simple adhesive bandage is usually adequate for skin coverage. Brand names: Decadron, De-Sone LA The number of trigger points injected at each session varies, as does the volume of solution injected at each trigger point and in total. The highest inter- and intra-examiner reliability for locating trigger points was achieved with pressure threshold algometry.48,49 Once trigger points are located and marked with a skin pen, the skin is generally prepared with a standard antibacterial agent such as isopropyl alcohol or betadine solution. Therapeutic injection with corticosteroids should always be viewed as adjuvant therapy.6 The improper or indiscriminate use of corticosteroids is likely to have a bad outcome. Ethyl chloride is a rapid-acting general anesthetic that becomes flammable and explosive when 4 to 15 percent of the vapor is mixed with air.10 Nevertheless, ethyl chloride remains a popular agent because of its local anesthetic action and its greater cooling effect than that of dichlorodifluoromethane-trichloromonofluoromethane.5, The decision to treat trigger points by manual methods or by injection depends strongly on the training and skill of the physician as well as the nature of the trigger point itself.10 For trigger points in the acute stage of formation (before additional pathologic changes develop), effective treatment may be delivered through physical therapy. A set of trigger point injections means injections in several trigger points in one sitting. Diagnostic indications include the aspiration of fluid for analysis and the assessment of pain relief and increased range of motion as a diagnostic tool. Neuroplastic changes in the dorsal horn may also activate neighboring neurons at lower thresholds, resulting in allodynia, hypersensitivity, and referred pain. Comparison of Different Dosages and Volumes of Triamcinolone in the Treatment of Stenosing Tenosynovitis: A Prospective, Blinded, Randomized Trial. Several precautions should be taken when using steroid injections. Before receiving TPIs, patients should first be assessed for LBP using an evidence-based and goal-oriented approach focused on the patient history and neurologic examination, as discussed in Chapter 3. Examples of predisposing activities include holding a telephone receiver between the ear and shoulder to free arms; prolonged bending over a table; sitting in chairs with poor back support, improper height of arm rests or none at all; and moving boxes using improper body mechanics.11, Acute sports injuries caused by acute sprain or repetitive stress (e.g., pitcher's or tennis elbow, golf shoulder), surgical scars, and tissues under tension frequently found after spinal surgery and hip replacement may also predispose a patient to the development of trigger points.12, Patients who have trigger points often report regional, persistent pain that usually results in a decreased range of motion of the muscle in question. Trigger point injections provide quick, long-lasting relief from trigger point pain Injections reduce the amount of referred pain Injections help to minimize the effects of other symptoms, including fatigue, stiffness, and disability Injections can be done quickly and conveniently in your physician's office or at a pain clinic They produce pain locally and in a referred pattern and often accompany chronic musculoskeletal disorders. government site. however, remained un- affected by dexamethasone throughout the time of the study. This list may not describe all possible side effects. Trigger-point injection has been shown to be one of the most effective treatment modalities to inactivate trigger points and provide prompt relief of symptoms. Epub 2008 Jan 7. Needle breakage; avoid by never inserting the needle to its hub. Patients should sign documentation that informed consent for the procedure was given and understood. 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. The main hypothesis of this study is that anti-inflammatory medications (ketorolac or dexamethasone) will provide longer-lasting and greater pain relief than just lidocaine in trigger point injections where a local twitch response is evoked at the time of the injection. Additionally, local circulation was thought to be compromised, thus reducing available oxygen and nutrient supply to the affected area, impairing the healing process. The needle size used for TPIs is typically quite small, frequently 25 or 27 gauge (G), but needles as large as 21G have been reported.10-12,14,18-20,24,26,32,50 The length of needle used is dependent on the depth of the trigger point through subcutaneous tissue, but is commonly from 0.75 inches to 2.5 inches.10,12,14,18,20,46,5052 Acupuncture needles may be used for dry needling of trigger points, using 0.16 13mm for facial muscles to 0.30 75mm for larger or deeper muscles. However, insufficient training in trigger point examination likely impedes recognition of myofascial pain, and palpation generally has poor interrater reliability. Synovial fluid evaluation can differentiate among various joint disease etiologies including infection, inflammation, and trauma. Before Taking. A more recent article on trigger point management is available. Copyright 1996-2023 Cerner Multum, Inc. A trigger point is defined as a specific point or area where, if stimulated by touch or pressure, a painful response will be induced. Some drugs can affect your blood levels of other drugs you take, which may increase side effects or make the medications less effective. 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. 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. Dexamethasone may also be used for purposes not listed in this medication guide. There are several proposed histopathologic mechanisms to account for the development of trigger points and subsequent pain patterns, but scientific evidence is lacking. Copyright 2002 by the American Academy of Family Physicians. 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. If additional tender points are palpable, they should be isolated, needled and injected. 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). Trigger point injections can be used to treat a number of conditions including fibromyalgia, tension headache, and myofascial pain syndrome. Steroid injections may be given every 3-4 months but frequent injections may lead to tissue weakening at the injection site and . Dosage. Fine and colleagues reported that the analgesic effects of TPIs could be reversed with intravenous naloxone.60 Mechanical disruption may play some role in breaking up trigger points.38,61 Spontaneous electrical activity, as originally observed, was later confirmed to be end-plate potentials.62 This finding was used to show that many traditional ah-shi acupuncture points corresponded to trigger points.63 Animal models also suggest the role of the autonomic nervous system related to phentolamine, an alpha-adrenergic agonist that inhibits sympathetic activation and decreases spontaneous electrical activity in rabbit myofascial trigger spots.64. Many researchers agree that acute trauma or repetitive microtrauma may lead to the development of a trigger point. Active trigger points can cause spontaneous pain or pain with movement, whereas latent trigger points cause pain only in response to direct compression. Trigger point injection to the levator ani muscles is a minimally invasive, nonsurgical treatment option for patients who have pelvic floor myofascial spasm and are refractive to physical therapy and medication. The concept of abnormal end-plate potentials was used to justify injection of botulinum toxin to block acetylcholine release in trigger points.57 McPartland has expanded on the idea of excessive acetylcholine by suggesting that congenital or acquired genetic defects in presynaptic, synaptic, or postsynaptic structures may contribute to an individuals susceptibility to myofascial pain.45. For this reason, and to monitor for allergic reactions, patients should be observed in the office for at least 30 minutes following the injection. Potency is generally measured against hydrocortisone, and ranges from low-potency, short-acting agents such as cortisone, to high-potency, long-acting agents such as betamethasone (Celestone). nausea, vomiting. Pneumothorax; avoid pneumothorax complications by never aiming a needle at an intercostal space. Description Your health care provider inserts a small needle and injects medicine into the painful and inflamed area. ), The number of trigger points injected at each session varies, as does the volume of solution injected at each trigger point and in total. Live vaccines include measles, mumps, rubella (MMR), rotavirus, typhoid, yellow fever, varicella (chickenpox), and zoster (shingles). Trigger points are first located by manual palpation with a variety of techniques (Figure 24-3). Participants were randomly . Methods: It is reproducible and does not follow a dermatomal or nerve root distribution. Roberts JM, Behar BJ, Siddique LM, Brgoch MS, Taylor KF. The dose of anesthetic varies from 0.25 mL for a flexor tendon sheath (trigger finger) to 5 to 8 mL for larger joints. We report on 68 women who underwent injections by a single physician and show an improvement in VAS pain scores in 65% of patients. Not all possible interactions are listed here. Patients are encouraged to remain active, putting muscles through their full range of motion in the week following trigger-point injections, but are advised to avoid strenuous activity, especially in the first three to four days after injection.10. The injection technique recommended by Hong and Hsueh for trigger points was modified from that proposed by Travell and Simons. The important goal is to minimize risk of infection at the site. It is used in the management of certain types of edema (fluid retention and swelling; excess fluid held in body tissues,) gastrointestinal disease, and certain types of arthritis. erythema or redness of skin or mucous membrane. Active trigger points can cause spontaneous pain or pain with movement, whereas latent trigger points cause pain only in response to direct compression.6 A pressure threshold meter, also termed an algometer or dolorimeter, is often used in clinical research to measure the amount of compression required to elicit a painful response in trigger points.7 Trigger points can be classified as central if they occur within a taut band, or attachment if they occur at a musculotendinous junction (Figure 24-1).