Trigger Point WorkshopTrigger Point Workshop
Phillip Snider, RD, DO
Amelia Medical Associates
Bon Secours Medical Group
Norfolk, 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 contTreatments cont’’dd
NSAIDs – po, gel, drops, patch Lidoderm patch Tylenol Narcotics
– Short term use is best– Narcotic contract is a must– Urine drug testing – Drug monitoring system – pill counts, PMP
HA Meds (BB, CCB, Antiepilectics)
Trigger Point InjectionsTrigger Point Injections
0.25% Lidocaine w/ NaHCO3
– 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 glutes in 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 many 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 side, affected side upMay need pillow under unaffected side1 – 2” posterior of iliac crest apex, approx
½ way b/w there and rib 12Insert .30 x 50mm or .30 x 60mm needle
lateral to medial toward midshaft 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
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
Patient side-lying, affected side downArm internally rotated with hand behind
backPull scapula away from ribsInsert .30 x 50mm needle parallel to rib
cage and scapulaAlso 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 x 16 weeks, recheck– 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 327 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/Medicaid)– 20553: 3+ muscles (Private insurance only)
x=5,6,7,8 or 9
CPT Codes - contCPT Codes - cont’’dd
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/Medicaid
728.85– Muscle spasm– Private insurance
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
Enter 99203 (new patient office visit) Enter the 25 modifier, attaching it to the 99203 Enter dx of muscle spasm 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 - 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
Code 99213 (established patient office visit) Enter a 24 modifier, attached to the 99213 Enter a 25 modifier as the 2nd modifier, attached to the 99213 Write in 728.85 or 9892x Enter the appropriate TPI or OMT CPT code
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– Enter 99203, attach 25 modifier to it– Enter 726.19– Enter 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 enter 98926 for the OMT– You link the 59 modifier to the OMT*
*Attach the 59 to the less expensive procedure (OMT - $80)
Typical charges: OMTTypical charges: 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: [email protected]