Trigger Point Workshop
Phillip Snider, RD, DO
Bon Secours Medical Associates
Virginia Beach, VA
Common Complaints
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Headaches
Low Back Pain
Tennis Elbow
Post-surgical Neuropathic Pain
Runners
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–
–
–
–
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
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–
–
–

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 (www.lhasaoms.com)
– Name brands:


Seirin
Hwa-to
Trigger Point Injections
Needle
Diameter
Hypodermic
Gauge
.30
30
.20
36
.14
42
.12
44
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 4 - 72 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
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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
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
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 1st 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
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You may get the best access with patient sidelying
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
a
D
D
U
C
T
O
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: 268.9
– Goal = 40+
– 50,000 IU/week
– 5,000 IU/day

Hypothyroid: 244.9
– Goal = TSH < 3.5
– Some may need optimization of T3

Fe-def anemia 280.9
– 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 1st 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: 20550

Joint/bursa Aspiration or Injection
– Small (finger/toes): 20600
– Medium: 20605
– Large (shoulders/hips/SI/knee): 20610
ICD-9 Codes for TPI

729.1
– Myofascial pain, fibromyalgia
– Medicare or private insurance

728.85
– 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
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Circle 99213 (established patient office visit)
Circle the 24 modifier, assigning it to the 99213
Write in 728.85 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
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Circle 99203 (new patient office visit)
Circle the 25 modifier, assigning it to the 99203
Write in 728.85
Circle 20552 (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 726.19
– Circle 20550 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, 739.2 & 739.8 to the dx list
– You also circle 98926 for the OMT
– You link the 59 modifier to the OMT*
*Attach the 59 to the less expensive procedure (OMT - $80)
Charges: OMT

98925 (1 – 2 regions)
 98926 (3 – 4 regions)
 98927 (5 – 6 regions)
 98928 (7 – 8 regions)
 98929 (9 - 10 regions)
$59
$80
$103
$122
$140
Charges: Trigger Point

Trigger Point Injection
– 20552 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

http://www.proceduresconsult.com/medicalprocedures
 http//emedicine.medscape.com
 www.aafp.org

My email: Phillip_Snider@bshsi.org