Where Are the Tender Points in Fibromyalgia?

Roderick S. Hooker, PhD, PA


June 30, 2000


Where are the tender points of fibromyalgia and what is the correct technique in examining them?

Claudine Lilla, PA-C

Response from Roderick S. Hooker, PhD, PA

Tender points are discreet areas of pain in response to palpation on body surfaces. They are in areas of muscles and muscle insertions and do not involve the joint. Some tender points can be identified in many people, but those suffering from chronic pain disorders tend to have more. Fragmented sleep along with lack of sustained delta wave sleep is theorized to be associated with the phenomenon of tender points.

The locations of tender points in people with fibromyalgia syndrome (FMS) are fairly typical, although anecdotal evidence suggests women are more vocal in responding to tender point palpation than men. The common tender points are described in The American College of Rheumatology (ACR) 1990 criteria for the classification of fibromyalgia[1]:

Occiput: suboccipital muscle insertion

Low cervical: anterior aspects of the intertransverse spaces of C5-C7

Trapezius: midpoint of the upper border

Supraspinatus: above the medial border of the scapular spine

Gluteal: upper outer quadrants of buttocks

Greater trochanter: posterior to the trochanteric prominence

Second rib: second costochondral junctions

Lateral epicondyle: 2 cm distal to the epicondyle

Knee: medial fat pad proximal to the joint line

One of the 2 criteria for the diagnosis of FMS specifies pain on palpation in at least 11 of these 18 pairs of tender points. Digital palpation should be performed with an approximate force of 4 kg (10 lb per square inch). You can approximate this pressure by placing your thumb pad on a hard surface and pressing so the nail tip just begins to blanch. Either the pad of the thumb or the combined pads of the forefinger and middle finger can be used.

For a tender point to be considered "positive," the subject should volunteer that the palpation was painful. Pressing tender points often elicits grimacing, moaning, and withdrawal. Ethnic differences should be factored in for this subjective response. Nontender control points (such as the mid-forehead and the anterior thigh) should be included in the examination although they are not included in the ACR criteria. These control points may be useful in distinguishing FMS from a conversion reaction in which tenderness may be present virtually everywhere.[1]

The second criterion is the history of widespread pain for more than 3 months. The presence of a second clinical disorder does not exclude the diagnosis of fibromyalgia.[2]

FMS is a widespread disorder that involves at least 4% of the population.[3] Patients with FMS may be seen more frequently in primary care settings than patients with other functional disorders such as headaches and irritable bowel syndrome. Early recognition of FMS helps the patient to focus on self-management and reduces the number of unnecessary tests, because there are no helpful laboratory and imaging studies. The use of electromyelogram (EMG), magnetic resonance imaging (MRI), single photon emission computed tomography (SPECT), and muscle biopsy routinely fail to identify any pathology of muscle or alterations in blood flow. The peripheral treatment of muscle pain has not been helpful to date. Beneficial treatment probably lies in managing the central disorder and improving sleep with nonhabituating soporifics.


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