Fig. 121.1 Most frequent locations of myofascial trigger points.

Fig. 121.2 Location of nine bilateral (18) tender point sites for the American College of Rheumatology criteria for the classification of fibromyalgia. 1, Suboccipital muscle insertions; 2, cervical, at the anterior aspects of the intertransverse spaces at C5 to C7; 3, trapezius, at the midpoint of the upper border; 4, supraspinatus, at the origin, above the scapular spine near the medial border; 5, second rib, at the costochondral junction; 6, lateral epicondyle, 2 cm distal to the epicondyle; 7, gluteal, in the upper outer quadrant of the buttock; 8, greater trochanter, just posterior to the trochanteric prominence; 9, knee, at the medial fat pad proximal to the joint line.

Fig. 121.3 Suboccipital muscle. Injection of trigger point (x) in the obliquus capitis superior muscle with the patient in the prone position. Injection is localized directly over the trigger point and the superior portion of the occipital area to avoid the vertebral artery. The occipital triangle and vertebral artery are noted. The pain pattern is shown by stippling.

Fig. 121.4 Posterior cervical muscles (semispinalis and multifidi). Injection of trigger point in the right posterior cervical muscles (x). The greater occipital nerve is visualized. Anatomic landmarks are noted in addition to visualization of the left vertebral artery. Avoid the vertebral artery by injecting above or below the vertebral artery area. Aspirate prior to injection. The pain pattern is shown by stippling.

Fig. 121.5 Splenius capitis and splenius cervicis. Injection of trigger points (xs) in the right splenius capitis and cervicis with the patient lying on the uninvolved side. Avoid the vertebral artery. Aspirate prior to injection. Anatomic landmarks are noted. The trigger point pattern is shown by stippling.

Fig. 121.6 Scalene muscles. Injection of the scalenus medius muscle trigger points (xs). The patient is supine, the head turned away from the area of pain. Anatomic landmarks are noted, including axillary artery and lateral chord. The referred pain pattern is shown by stippling.

Fig. 121.7 Supraspinatus. Injection of trigger points (xs) in the right supraspinatus with the patient prone. The needle is placed directly over the supraspinous fossa of the scapula to avoid penetrating the rib cage. Anatomic landmarks are noted. The pain pattern is shown by stippling.

Fig. 121.8 Serratus posterior superior. Injection of trigger point (x) in the right serratus posterior superior. Localize the trigger point by palpation and direct the needle in the direction of a rib and tangentially in relation to the chest wall to avoid entering the intercostal space. Aspirate before injection. Trigger points in the region of muscle insertion are more easily palpated with abduction of the right scapula. Observe precautions to prevent pneumothorax. Inset, Trigger point pain pattern is shown by stippling.

Fig. 121.9 Trapezius. Injection for trigger points (xs) in the left trapezius with the patient prone. The upper portion of the left trapezius is grasped between the thumb, index, and middle fingers and is elevated to avoid penetrating the apex of the lung. Several entries are usually necessary to treat all trigger points that are present. Aspirate prior to injection. The pain pattern is shown by stippling.

Fig. 121.10 Gluteus maximus. Injection of trigger points (xs) in the gluteus maximus. Anatomic landmarks are noted. Avoid the sciatic nerve. The pain pattern is shown by stippling. Injection may be performed with the patient in the prone or side-lying position.

Fig. 121.11 Gluteus medius. Injection of trigger points in the right gluteus medius. Multiple trigger points (xs) are noted. Anatomic skeletal landmarks are shown together with the sciatic nerve. The patient is positioned lying on the uninvolved side. Injection may also be performed with the patient prone. The pain pattern is noted by stippled area.

Fig. 121.12 Rectus femoris. Injection of trigger points (xs) in the right rectus femoris. Note trigger points in the area of origin and distally toward the area of insertion. The patient is supine. The trigger point pain pattern is shown by stippling. Anatomic landmarks are noted.

Fig. 121.13 Quadratus lumborum. Injection of trigger points (xs) in the right quadratus lumborum with the patient in the prone position. Injection may also be performed with the patient lying on the uninvolved side. The trigger point pain pattern is shown by stippling. Direct the needle tangentially or parallel to the frontal plane of the patient.

Fig. 121.14 Piriformis. Injection of trigger points in the right piriformis muscle (xs). The sciatic nerve is shown in addition to anatomic details. Injection is performed with the patient lying on the uninvolved side. A pillow is placed between the knees. The hip is flexed. The pain pattern is shown by stippling.