Tender Points

Understanding Fibromyalgia Trigger Points and Tender Points

Fibromyalgia Trigger Points

Fibromyalgia is a massively misunderstood disorder characterized by a range of symptoms but most commonly associated with widespread musculoskeletal pain throughout the body. Other common effects of fibromyalgia include chronic fatigue and/or insomnia; mild to moderate loss of cognitive function; memory and mood disorders; major depressive disorder; and more.[1]
In this article, I will focus on one particular symptom that is specific to fibromyalgia. Unlike many other symptoms, it is not associated with the myriad additional disorders that are often confused with, misdiagnosed as, or presenting in addition to fibromyalgia. This symptom is a series of “trigger points” or “tender points” located in multiple specific areas across a fibromyalgia patient’s body.

1. What is a trigger point/tender point?

Trigger points associated with fibromyalgia—also called “tender points” so as not to be confused with the trigger points that characterize myofascial pain syndrome —are regularly presenting local pain points. (Due to the aforementioned confusion about/conflation of symptoms,[2] I will refer to fibromyalgia-symptomatic pain points strictly as “tender points” for the entirety of this article. When discussed, “trigger points” refer to those pain points associated with myofascial pain syndrome.) Tender points are quite small and often occur in superficial areas, seemingly just under the surface of the skin: though a fibromyalgia patient might feel severe soreness and pain around and associated with a specific joint, for example, tender points do not occur within the joints themselves.[1]
Though fibromyalgia patients experience widespread pain throughout the body, tender points are notably different from other fibro-related pain: they are significantly more sensitive and painful when touched than other nearby areas. A doctor’s application of firm but not ordinarily painful pressure (just enough pressure to turn a fingernail white[2]) to a tender point may cause the patient to flinch or jerk back involuntarily. Note that the name, “tender point,” is misleading: a patient presenting with fibromyalgia-related tender points must actually feel pain, not just “tenderness,” on those points’ palpitation. The pain associated with tender point palpitation should feel similar to that of pressing on a serious bruise in the stages of healing.[2]

2. Where are these “tender points?”Tender Points

Perhaps the most notable feature of fibromyalgia-related tender points is that they do not occur at random. There are 18 points in total (nine bilateral pairs) that have been identified across fibromyalgia patients: [2], [3], [4]
occiput: suboccipital muscle insertions
(bilateral tender points located at the back of the neck, near the base of the skull)

low cervical region: anterior aspects of intertransverse spaces at C5-C7 vertebrae
(bilateral tender points located at the front/sides of the neck, on either side of the larynx, well above the collarbone)

trapezius muscle: midpoint of upper border
(bilateral tender points at the top of the upper back/shoulder; neck and upper back muscles between the shoulder blades)

supraspinatus muscle: above medial border of scapular spine
(bilateral tender points where the back muscles connect to shoulder blades in the upper back; slightly below the trapezius points)

second rib: upper lateral to second costochondral junction
(bilateral tender points on either side of the sternum, below the collarbone—near the second rib)

lateral epicondyle: two cm distal to the epicondyles
(bilateral tender points just below the crease of the elbow toward the outer side of the forearm)

gluteal: anterior fold of muscle in upper outer quadrants of buttocks
(bilateral tender points where the very top of the buttocks meets the bottom of the lower back)

greater trochanter: posterior to greater trochanteric prominence
(bilateral tender points where the buttock muscles curve to meet the thigh—near the hip but not in the hip joint as in e.g., osteoarthritis)

knee: medial fat pad proximal to joint line

3. Problems with trigger points as a symptom and as a diagnostic tool

Five years ago (and for at least 20 years prior), tender points were a necessary component of a clinical diagnosis of fibromyalgia (FM): in addition to widespread pain on both sides of the body lasting for at least three months, a patient needed to demonstrate sufficient pain (not just tenderness) in at least 11 of the aforementioned 18 tender point sites in order to receive a diagnosis.[5]
However, tender point exams can be too subjective and prone to error. There is not enough consistency across diagnosticians in the way exams are performed, nor is there enough consistency in patients’ reportability of pain. In addition, it is easy to mistake tender points for other issues (such as trigger points) or vice versa. One must note, for example, that tender point pain is local: even on palpitation, tender point pain should not spread to other parts of the body or trigger additional symptoms: e.g., cause nausea or a migraine headache.[2] This reaction is associated with trigger points, a symptom of myofascial pain syndrome. Myofascial trigger points often respond well to treatments such as massage and physical therapy; FM tender points, on the other hand, tend to worsen with pressure.

This issue is further compounded because many patients present with both fibromyalgia and myofascial pain syndrome—which means that identifying and classifying tender points can be extremely difficult. As a result, correctly diagnosing fibromyalgia would be incredibly difficult as well; since, according to the old criteria, lasting pain and tender point pain are the only relevant symptoms.
An additional concern is that some patients might present pain in fewer than 11 tender points, but also complain of other (e.g., cognitive or psychological) symptoms commonly associated with fibromyalgia. Under the old criteria, these patients would not receive a diagnosis. This is yet another reason that increased diagnostic attention to cognitive symptoms and decreased attention to particular pain points is an important step in working towards correctly diagnosing and helping patients.
In May of 2010, the American College of Rheumatology (ACR) proposed significant alterations to the diagnostic process for FM after Wolfe et al. performed a large-scale study of over 800 previously diagnosed fibromyalgia patients and controls. They found that, using the ACR’s old diagnostic criteria, over 25% of fibromyalgia patients would not have received a diagnosis.[6] Wolfe et al. went on to develop a new diagnostic process for the ACR that does not merely rely on tender point examinations. Instead, the two most important criteria are a widespread pain index (WPI) and a symptom severity (SS) scale. The WPI is not a tender point exam; patients are also asked about recurring, long-lasting pain in a number of different body regions. The SS scale was developed to take additional symptoms—e.g., fatigue, insomnia, cognitive problems, IBS, depression, and more—into consideration.[6]

4. Finally: what causes tender points?

The short answer: nobody knows. Doctors and researchers have come up with numerous hypotheses: genetics might pay a role; some illness and infections can trigger the onset of fibromyalgia (including tender point pain); physical or emotional trauma might also be involved. However, there are holes in each of these possibilities, and there is no established solution within the FM research and treatment community. One common explanation for fibro pain (though not tender point pain in particular) is that repetitive nerve stimulation actually alters FM patients’ brains: this alteration results in an increase in particular pain-signaling neurotransmitters, and the increase in neurotransmitter production might also cause pain receptors to become more sensitive.[1] This combined brain activity and alteration would result in a vicious cycle of pain: increasing pain-signaling neurotransmitters result in increasing sensitivity of pain receptors, meaning that the more pain signals your brain receives, the more sensitive you become to these pain signals, and so on ad infinitum. Again, though, this is only a possible explanation—and it does not account for the presence of tender points at all.
There are many possible reasons for the dearth of medical knowledge when it comes to fibromyalgia: the fact that it is far more common in women than men—that many of the associated symptoms (e.g., fatigue, “brain fog,” depression, etc.) have, for many years, been dismissed as “merely” psychological/emotional or related to other women’s issues when presented in female patients—cannot be unrelated. Still, with increased awareness of fibromyalgia, the new diagnostic criteria which place more weight on other cognitive/psychological symptoms, and similar changes, the medical community may slowly be working toward overhaul and understanding. Once fibromyalgia itself is better understood, there is hope that its symptoms—including tender points—might be explained as well.


Article Sources:

[1] Mayo Clinic: Diseases and Conditions, “Fibromyalgia.” Available: < http://www.mayoclinic.org/diseases-conditions/fibromyalgia/basics/definition/con-20019243>.


[2] National Fibromyalgia Research Association, “Fibromyalgia trigger point.” Available: <http://www.nfra.net/fibromyalgia_trigger_point.php>.


[3] Health, “18 points used to diagnose fibromyalgia.” Available: <http://www.health.com/health/gallery/0,,20345635,00.html>.


[4] About.Health, “What are tender points? Common symptoms associated with fibromyalgia.” C. Eustice. Available: <http://arthritis.about.com/od/fibromyalgia/g/tenderpoints.htm>.


[5] Massachusetts CFIDS/MA & FM Association, “Tender points might no longer be used for diagnosis of fibromyalgia.” Available: <http://www.masscfids.org/news-a-events/266-tender-points-might-no-longer-be-used-for-diagnosis-of-fibromyalgia>.


[6] Wolfe, D., et al. (2010). “The American College of Rheumatology preliminary diagnostic criteria for fibromyalgia and measurement of symptom severity.” Arthritis Care & Research 62 5, (pp. 600-610).