Trigger Point WorkshopTrigger Point Workshop

Phillip Snider, RD, DO

Bon Secours Medical Associates

Virginia Beach, VA

Common ComplaintsCommon Complaints

Headaches Low Back Pain Tennis Elbow Post-surgical Neuropathic Pain Runners

– Glutes– TFL– Hamstring– Gastroc / Soleus– FDB

TreatmentsTreatments

OMTTPI (trigger point injections)Neural TherapyPT

– Posture education– Watch for trigger point irritation

Muscle relaxants

Treatments cont’dTreatments 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 InjectionsTrigger 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 InjectionsTrigger Point Injections

.30 30

.20 36

.14 42

.12 44

NeedleDiameter

HypodermicGauge

Trigger Point InjectionsTrigger 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

HeadachesHeadaches

Migraines– IHS Criteria– Anyone can get one– Triggers often include MSK component

Most Common Offenders– Traps

– SCM

– Levator Scapulae

IHS Migraine CriteriaIHS 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

TrapeziusTrapezius

Trapezius NeedlingTrapezius Needling

Patient supine Pincer grasp of muscleInsert needle anterior to posterior30ga x 1.5” or .30 x 50mmMuscle twitches can be significant

Levator ScapulaeLevator Scapulae

Levator Scapulae NeedlingLevator Scapulae Needling

Patient proneInsert needle at shallow angle toward

superior angle of scapula.30 x 50mm or 30ga x 1”DO NOT insert needle posterior to anteriorMuscle twitch is moderate

SternocleidomastoidSternocleidomastoid

SCM NeedlingSCM 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 PainLow Back Pain

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

Quadratus LumborumQuadratus Lumborum

QL NeedlingQL Needling

Patient on sideMay need pillow under opposite sideID muscle using midpoint of iliac crest and

½ way b/w there and rib 12Insert .30 x 50mm or .30 x 60mm needle

lateral to medial toward middle of spinous process

QL StretchQL Stretch

IliopsoasIliopsoas

Iliopsoas NeedlingIliopsoas 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

IliopsoasIliopsoas

Iliopsoas StretchIliopsoas Stretch

MultifidusMultifidus

Multifidus NeedlingMultifidus Needling

Patient supineSafety zone is 1 finger width lateral to

spinous processInsert .30 x 50mm needle from posterior

lateral to anterior medial; aim for base of transverse process and lamina

MultifidusMultifidus

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 & LongissimusIliocostalis & Longissimus

Iliocostalis & Longissimus Iliocostalis & Longissimus NeedlingNeedling

Patient prone.30 x 50mm needleIdentify trigger pointUse index and middle fingers to block the

adjacent intercostal spacesInsert needle using shallow angle

Gluteus MediusGluteus Medius

Glute Medius NeedlingGlute Medius Needling

Patient on side.30 x 50mm needle into trigger pointMuscle twitch ranges from barely

noticeable to fairly strongCan mimic greater trochanteric bursitis

Tennis ElbowTennis Elbow

Don’t Forget - Joint Above and Below– Shoulder– Radial head– Wrist

Myofascial Pain Referral PatternsTrigger Point Injection/needling

– Don’t use Lidocaine near the radial nerve

SupinatorSupinator

Supinator NeedlingSupinator Needling

Have patient supinate forearm to identify muscle

.20 x 25mm needle

BrachioradialisBrachioradialis

Brachioradialis NeedlingBrachioradialis Needling

Pincer grasp of muscle.20 x 25mm needleInsert needle only through portion of

muscle you’re holdingMimics OA pain in the 1st MTPMimics scaphoid pain

ECRLECRL

ECRL NeedlingECRL Needling

.20 x 25mm needleMuscle twitch is strong

Extensor DigitorumExtensor Digitorum

ED NeedlingED Needling

.20 x 25mm needleMuscle twitch is strong

TricepsTriceps

Triceps NeedlingTriceps Needling

Pincer grasp of muscle.30 x 50mm needleInsert needle only through portion of

muscle you’re holdingReview anatomy to avoid median nerve and

radial nerveMuscle twitch is strong

AnconeusAnconeus

Anconeus NeedlingAnconeus Needling

.20 x 25mm needleMuscle twitch is vague to moderate

SupraspinatusSupraspinatus

Supraspinatus NeedlingSupraspinatus Needling

Pt seated or prone30ga x 1.5” or .30 x 50mm needleYou must identify the spine of scapulaInsert needle anterior to posterior and

medial to lateralMuscle twitch is vagueVery common trigger point in shoulder pain

InfraspinatusInfraspinatus

Infraspinatus Needling Infraspinatus Needling

Pt seated or prone30ga x 1.5” or .30 x 50mm needleYou must identify the medial border and

inferior angle of scapulaMuscle twitch is moderateVery common trigger point in shoulder pain

Serratus Posterior SuperiorSerratus Posterior Superior

Serratus Posterior Superior Serratus Posterior Superior NeedlingNeedling

Patient prone.30 x 50mm needleIdentify trigger pointUse index and middle fingers to block the

adjacent intercostal spacesInsert needle using shallow angleMuscle twitch vague to moderate

Serratus Posterior Superior Serratus Posterior Superior NeedlingNeedling

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 Post-Surgical Neuropathic Pain Pain (729.2)(729.2)

Occurs due to surgical scarPain is burning and usually localNeural therapy

– Injection of 0.25% Lidocaine along scar – 30ga needle

RunnersRunners

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

PiriformisPiriformis

Piriformis NeedlingPiriformis Needling

Patient prone.30 x 50mm needleAvoid middle portion of piriformis to avoid

sciatic nerveHave pt ext rotate leg to ID muscle

Gluteus MaximusGluteus Maximus

Glute Max NeedlingGlute Max Needling

Patient prone or on side.30 x 50mmAvoid sciatic nerveHave pt extend hip to ID muscle

Gluteus MediusGluteus Medius

Gluteus MinimusGluteus Minimus

Glute MinimusGlute Minimus

Patient side lying.30 x 50mm needleMuscle twitch ranges from barely

noticeable to fairly strongCan mimic greater trochanteric bursitis

Rectus FemorisRectus Femoris

Rectus Femoris NeedlingRectus Femoris Needling

Patient supine30ga x 1.5” or .30 x 50mmMuscle twitch is usually strong

Vastus Medialis, Intermedius & Vastus Medialis, Intermedius & LateralisLateralis

Vastus MusclesVastus 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 Adductors

aDDUCTOR

Adductor NeedlingAdductor Needling

Patient supine or side lyingPincer grasp of muscle30ga x 1.5” or .30 x 50mm needleMuscle is twitch fairly strong

HamstringsHamstrings

Hamstring NeedlingHamstring Needling

Patient prone.30 x 50mm needleAngle away from midline to avoid sciatic

nerveMuscle is twitch fairly strong and trigger

point feels particularly crampy

Soleus and Gastroc NeedlingSoleus and Gastroc Needling

Patient prone30ga x 1.5” or .30 x 50mm needleMuscle is twitch strongOnly do one side per treatment session

Nutritional or Metabolic Nutritional or Metabolic ConsiderationsConsiderations

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 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 TreatmentPost 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 Common Musculoskeletal CPT Codes 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’dCPT 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 TPIICD-9 Codes for TPI

729.1– Myofascial pain, fibromyalgia– Medicare or private insurance

728.85– Muscle spasm– Private insurance

Modifiers - 24Modifiers - 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 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 - 25Modifiers - 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 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 - 50Modifiers - 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 - 59Modifiers - 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: OMTCharges: OMT

98925 (1 – 2 regions) $5998926 (3 – 4 regions) $8098927 (5 – 6 regions) $10398928 (7 – 8 regions) $12298929 (9 - 10 regions) $140

Charges: Trigger Point Charges: Trigger Point

Trigger Point Injection– 20552 or 20553 $160

DocumentationDocumentation 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 ResourcesOnline Resources

http://www.proceduresconsult.com/medical-procedures

http//emedicine.medscape.comwww.aafp.org

My email: Phillip_Snider@bshsi.org