9.08 Fibromyalgia (Trigger Points)
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agk's Library of Common Simple Emergencies

Presentation
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The patient, generally between 25 and 50 years 
old, will be troubled with the gradual onset of 
fibromuscular pain that at times can be 
immobilizing. There may be a previous history 
of acute strain, muscle spasm or nerve root 
irritation (e.g., whiplash injury of the neck 
or low back strain). The areas most commonly 
affected include the posterior muscles of the 
neck and scapula, the soft tissues lateral to 
the thoracic and lumbar spine, and the 
sacroiliac joints. The patient is often 
depressed or under emotional or physical stress 
and often has associated fatigue with disturbed 
sleep as well as sensations of numbness or 
swelling in the hands and feet. Cold weather 
may be one of the precipitating causes of pain. 
There should be no swelling, erythema or heat 
over the painful areas, but applying pressure 
over the site with an examining finger will 
cause the patient to wince with pain . This 
tender "trigger pont" is usually no larger than 
your finger tip and when pressed will cause 
local pain, referred pain, or both.

What to do:
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- When you find a trigger point, map out its 
    exact location (point of maximum tender- 
    ness) and place an X over the site with a 
    marker or ball point pen. If the trigger 
    point is diffuse there is no need to 
    outline its location.
- Obtain a careful history and perform a 
    general physical exam to help exclude the 
    possibility of a serious underlying 
    disorder such as rheumatoid arthritis or 
    cancer.
- With any suspicion that an underlying problem 
    exists, obtain an x-ray or an erythrocyte 
    sedimentation rate. These studies should 
    both be normal in fibromyalgia.
- Where trigger points are diffuse, prescribe a 
    nonsteroidal anti-inflammatory such as 
    naprosen (Anaprox) 275mg two tablets stat 
    then one qid or ibuprofen (Motrin) 800mg 
    stat then 600mg qid x 5 days. A muscle 
    relaxant like cyclobenzaprine (Flexaril) 
    may also be helpful.
- When a focal trigger point is present you can 
    suggest to the patient that he may get 
    immediate relief with an injection. Inject 
    2-5ml of l% xylocaine or loger-acting 0.5% 
    bupivacaine along with 20-40mg of 
    methylprednisolone (Depomedrol) or 2-5mg of 
    triamcinolone (Aristospan) through the mark 
    you placed on the skin, directly into the 
    painful site. Be sure you are not in a 
    vessel and then "fan" the needle in all 
    directions while injecting the trigger 
    point. In addition, to insure total 
    coverage, massage the area after the 
    injection is complete. The patient will 
    often get complete or near-complete pain 
    relief, which helps to confirm the 
    diagnosis of fibromyalgia. The beneficial 
    effect of this injection may last for weeks 
    or months. A supplementary five day course 
    of non-steroidal anti-inflammatories is 
    optional.
- Moist hot compresses and massage may also be 
    comforting to the patient after discharge.
- Inform the patient that after trigger point 
    injection there may be a transient painful 
    rebound. Anti-inflammatory analgesics will 
    help to reduce this potential discomfort.
- Provide followup care for patients in the 
    event their symptoms do not clear and they 
    require further diagnostic evaluation and 
    therapy. For example, hypothyroidism and 
    polymalgia rheumatica coexist with or 
    predispose to fibromyalgia, or the patient 
    may develop dermatomyositis.

What not to do:
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- Do not attempt to inject a very diffuse 
    trigger point (more than one square 
    centimeter). Results are generally 
    unsatisfactory.
- Do not prescribe narcotic analgesics or 
    systemic steroids. They are no more 
    effective and add side effects and the risk 
    of dependence.

Discussion
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Although the pathophysiology of fibromyalgia is 
unknown it is a very real syndrome. Treatment 
may provide only partial symptomatic relief. 
True fibromyalgia syndrome is a chronic 
condition requiring long term management that 
may include physical therapy, exercise, patient 
education and reassurance along with sleep- 
enhancing medications like low dose tricyclic 
antidepressants.

Emergency physicians often see trigger points 
associated with simple self-limiting regional 
myofascial pain syndromes which appear to arise 
from muscles, muscle-tendon junctions, or 
tendon-bone junctions. Myofascial disease can 
result in severe pain, but typically in a 
limited distribution and without the systemic 
feature of fatigue. When symptoms recur or 
persist after the basic therapy above, or are 
accompanied by generalized complaints, refer 
the patient to a rheumatologist or primary care 
physician.

When the quadratus lumborum muscle is involved 
there is often confusion as to whether or not 
the patient has a renal, abdominal, or pulm-
onary ailment. The reason for this is the 
muscle's proximity to the flank and abdomen as 
well as its attachment to the 12th rib, which 
when tender, can create pleuritic symptoms. A 
careful physical exam, with palpation, active 
contraction, and passive stretching of this 
muscle reproducing symptoms, can save this 
patient from a multitude of laboratory and x-
ray studies.

Illustration
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img/cse0908.gif

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 from Buttaravoli & Stair: COMMON SIMPLE EMERGENCIES
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