Trigger Point Workshop Phillip Snider, RD, DO Bon Secours Medical Associates Virginia Beach, VA

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

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

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 (Ameritox) is a must – Drug monitoring system – eg pill counts HA Meds (BB, CCB, Antiepilectics)

Trigger Point Injections 0.25% Lidocaine – 1cc into each muscle – 30ga 1.5 inch needle – Avoid use in face and forearm Dry Needling (Acupuncture needle) – My favorite: Lhasa OMS ( – Name brands: Seirin Hwa-to

Trigger Point Injections Needle Diameter Hypodermic Gauge

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

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

IHS Migraine Criteria 4+ HA lasting 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

Trapezius

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

Levator Scapulae

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

Sternocleidomastoid

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 lots of ENT-like symptoms

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

Quadratus Lumborum

QL Needling Patient on side May need pillow under opposite side ID muscle using midpoint of iliac crest and ½ way b/w there and rib 12 Insert.30 x 50mm or.30 x 60mm needle lateral to medial toward middle of spinous process

QL Stretch

Iliopsoas

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

Iliopsoas

Iliopsoas Stretch

Multifidus

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

Multifidus Origin – Posterior surface of the sacrum – Articular processes of the lumbar vertebrae – Transverse processes of the thoracic vertebrae – Articular processes of C3-7 Insertion – Each part of the muscle inserts into the spinous process 2-4 vertebrae higher than its origin Actions – Extension, lateral flexion and rotation of the spine

Iliocostalis & Longissimus

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

Gluteus Medius

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

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

Supinator

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

Brachioradialis

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 1 st MTP Mimics scaphoid pain

ECRL

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

Extensor Digitorum

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

Triceps

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

Anconeus

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

Supraspinatus

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

Infraspinatus

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

Serratus Posterior Superior

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

Serratus Posterior Superior Needling You may get the best access with 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

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

Runners Injuries result from – Overuse (volume, intensity) – Biomechanical imbalance Treatment includes – PRINCE – Identify and address the imbalances – Calm down the injured muscles & joints – Structured return to running

Piriformis

Piriformis Needling Patient prone.30 x 50mm needle Avoid middle portion of piriformis to avoid sciatic nerve Have pt ext rotate leg to ID muscle

Gluteus Maximus

Glute Max Needling Patient prone or on side.30 x 50mm Avoid sciatic nerve Have pt extend hip to ID muscle

Gluteus Medius

Gluteus Minimus

Glute Minimus Patient side lying.30 x 50mm needle Muscle twitch ranges from barely noticeable to fairly strong Can mimic greater trochanteric bursitis

Rectus Femoris

Rectus Femoris Needling Patient supine 30ga x 1.5” or.30 x 50mm Muscle twitch is usually strong

Vastus Medialis, Intermedius & Lateralis

Vastus Muscles Patient supine 27ga x 1.5” or.30 x 50mm (I prefer the hypodermic needle) Muscle twitch can be very strong Have pt extend knee and slightly lift leg to ID muscle

Adductors aDDUCTORaDDUCTOR

Adductor Needling Patient supine or side lying Pincer grasp of muscle 30ga x 1.5” or.30 x 50mm needle Muscle is twitch fairly strong

Hamstrings

Hamstring Needling Patient prone.30 x 50mm needle Angle away from midline to avoid sciatic nerve Muscle is twitch fairly strong and trigger point feels particularly crampy

Soleus and Gastroc Needling Patient prone 30ga x 1.5” or.30 x 50mm needle Muscle is twitch strong Only do one side per treatment session

Nutritional or Metabolic Considerations Vitamin D deficiency: – Goal = 40+ – 50,000 IU/week – 5,000 IU/day Hypothyroid: – Goal = TSH < 3.5 – Some may need optimization of T3 Fe-def anemia – Goal = Ferritin > 40 – Ferrous Gluconate 27 mg BID

Post Treatment Instruct patient to go to get CXR if any SOB, chest pain or cough developing within 24 hours Ice several times a day for 1 st 24 hr and then heat Stretch affect muscles twice a day Manual treatment daily using – The Trigger Point Therapy Workbook by Claire Davies

Post Treatment Warn patient that pain may temporarily increase after the treatment. Treat with: – Ice – NSAID – Rest If no better after 4 or 5 treatments, verify that patient is doing their part, keep looking for other reasons including Vit D, Thyroid or Iron status Botox may be another treatment option

Common Musculoskeletal CPT Codes OMT: 9892x – Billed by number of regions treated – 1-2, 3-4, 5-6, 7-8, 9-10 Trigger Point Injection – 20552: 1-2 muscles (Medicare or private insurance) – 20553: 3+ muscles (Private insurance only) x=5,6,7,8 or 9

CPT Codes - cont ’ d Tendon Injection: Joint/bursa Aspiration or Injection – Small (finger/toes): – Medium: – Large (shoulders/hips/SI/knee): 20610

ICD-9 Codes for TPI – Myofascial pain, fibromyalgia – Medicare or private insurance – Muscle spasm – Private insurance

Modifiers - 24 Used on E/M code only Appends office visit if occurring during the global time period of a surgery and the visit is unrelated to that surgery Example – Pt had TPI or OMT and returns 1 week later for reassessment of the symptoms that prompted the treatment and possible retreatment – Your billing sheet Circle (established patient office visit) Circle the 24 modifier, assigning it to the Write in or 9892x Circle TPI or OMT CPT code

Modifiers - 25 Used on E/M code only Separate and distinct procedure Example: New non-Medicare Pt seen for LBP and you diagnose them with QL and multifidus trigger points – Your billing sheet Circle (new patient office visit) Circle the 25 modifier, assigning it to the Write in Circle (1-2 muscle TPI) You’ve just added $160 to your billing Used for anything else you do other than lab & x-ray – EKG, nebulizer, TPI, OMT, etc

Modifiers - 50 Used on the procedure code Bilateral procedure (joint/tendon injection) Example: New patient presents c/o bilateral shoulder pain You diagnose bilateral subacromial bursitis (726.19) You inject each subacromial bursa (20610) Your billing sheet – Circle 99203, attach 25 modifier to it – Write in – Circle and attach the 50 modifier to it

Modifiers - 59 Used on the procedure code Prevents bundling of multiple procedures Based on the National Correct Coding Initiative In above example, the patient also had a SD of the C-spine, T-spine and First ribs: – You add 739.1, & to the dx list – You also circle for the OMT – You link the 59 modifier to the OMT* *Attach the 59 to the less expensive procedure (OMT - $80)

Charges: OMT (1 – 2 regions) $ (3 – 4 regions) $ (5 – 6 regions) $ (7 – 8 regions) $ ( regions) $140

Charges: Trigger Point Trigger Point Injection – or 20553$160

Documentation Because injections are considered surgical procedures, they require a procedure note. The procedure note should include a signed consent, documentation of the anatomic location, preparation of the site, local anesthetic administration, name and dosage of drug administered, and patient reaction to procedure. Documentation should also include all postoperative instructions related to the procedure.

Online Resources -procedures http//emedicine.medscape.com My