Monday, September 11, 2006

Trigger Point Injections

  • A simple and easily learned procedure for trigger point pain is a trigger point injection. If you have never performed one before, feel free to ask me for an easy demonstration. Here I'll walk you through the diagnosis and treatment of trigger point pain.
  • Trigger point pain is myofascial pain that can be due to strain or poor posture with nerve irritation.
  • Cummings and White did a review of 23 studies. They determined that none of the studies had enough quality to demonstrate or refute the benefit of this technique. From the Mattison Journal of Anectdotal Evidence, I have yet to perform a trigger point injection that didn't provide nearly total pain relief within a couple of minutes of the injection and dramatic pain relief at time of discharge.
  • Typical areas of trigger point pain are the trapezius muscle, occipital, rotator cuff, lateral epicondylitis and femoral-trochanteric pain. I for one only feel comfortable injecting the trapezius region. On average, I see patients with this kind of pain once every couple of months. Therefore, I will only discuss this particular location.
  • The easiest way to diagnose trigger point pain of the trapezius is based on history and a very simple technique. Typical historical complaints include overuse patterns, sleeping in an "uncomfortable" position, etc. Patients will have pain in their trapezius region that sometimes will refer discomfort down their shoulder/upper extremity.
  • Physical examination may reveal a "knot" or muscle spasm of the trapezius.
  • The clincher in making this diagnosis is reproduction of symptoms with the patient or physician palpating the area of question with one finger. I'll simply ask the patient to use their finger or my finger to find the one area that when palpated reproduces maximum discomfort. I then mark it with a pen. This typically is found near the mid-clavicular line deep in the trapezius.
  • The next step is to order kenalog 40 mg from the pharmacy. This is usually the longest delay.
  • I'll create a cocktail of kenalog 40 mg + bupivicaine 0.25% (usually 5 cc). I might include a little lidocaine with epi for quick acting effect. I usually create a small wheal with a 25 g needle and then switch to a 22 g in order to deliver the medicine a little deeper. I usually only go 1-2.5 cm. This may vary depending on patient's habitus, muscle mass, etc. Obviously the complication to avoid would be a pneumothorax. Other complications are infection (use aseptic techniques obviously).
  • After the injection, patients usually have pretty dramatic relief within five minutes. The bupivicaine provides longer lasting effects. The kenalog usually will provide relief for several days to weeks. Typically after this duration the patients symptoms have resolved.
  • The obvious benefit of this procedure for patients is pain relief without the need for narcotics, muscle relaxants, etc. Patients are usually very thankful and satisfied with the procedure. The benefit to us is pain relief for the patient and a simple procedure that is billable (we can't always be altruistic).
  • If you have any questions about this procedure or want to know more about it, let me know. Hope this helps.

4 Comments:

Blogger Greg said...

Very Seligsonian

1:24 PM  
Blogger Joints said...

I would advise against the skin wheal with the cocktail, as intradermal and subcutaneous injection of Kenalog may lead to irreversible dermal and subcutaneous atrophy and/or depigmentation. No need anyway, as you can get adequate skin anesthesia with an ethyl chloride spray, and the needle stick without anesthesia is less painful than the production of a skin wheal with local anesthetic.

8:33 AM  
Blogger Michelle Reyes M.D said...

Thank you for this thorough and helpful description. Agree with you Joints, kenalog 40 is pretty powerful subQ, guaranteed dermal atrophy. Also I would suggest 30gauge needle is all that is necessary and injected while squeezing up the sore muscle is literally painless.

8:28 AM  
Blogger Manjula Ramesh said...

Nice. Very useful information for readers that you have shared. Keep posting like this. Kenacort Injection 40mg/1ml in US

10:51 PM  

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