What Are Fibromyalgia Tender Points?

Common Symptom Associated With Fibromyalgia

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Fibromyalgia is a chronic pain condition involving widespread musculoskeletal aches and pains --  primarily of the muscles, tendons, and connective tissue. It is sometimes referred to as muscular rheumatism or rheumatic syndrome. Unlike some types of arthritis and rheumatic conditions, fibromyalgia is not associated with joint damage or joint deformity. The diagnosis of fibromyalgia can involve a physical examination for tender points.

Since routine laboratory tests do not detect fibromyalgia, tender points have been part of the diagnostic process. What are tender points?

Diagnosing Fibromyalgia

According to the diagnostic criteria for fibromyalgia (based on The American College of Rheumatology Diagnostic Criteria for Rheumatology 1990), a patient must have:

  • widespread pain in all four quadrants of the body for at least 3 months
  • at least 11 of 18 specific tender points

Tender points are specific places on the body (18 specific points at 9 bilateral locations) that are exceptionally sensitive to the touch (digital palpation) upon examination by a doctor. The 9 bilateral muscle locations are:

  • Low Cervical Region: (front neck area) at anterior aspect of the interspaces between the transverse processes of C5-C7.
  • Second Rib: (front chest area) at second costochondral junctions.
  • Occiput: (back of the neck) at suboccipital muscle insertions.
  • Trapezius Muscle: (back shoulder area) at midpoint of the upper border.
  • Supraspinatus Muscle: (shoulder blade area) above the medial border of the scapular spine.
  • Lateral Epicondyle: (elbow area) 2 cm distal to the lateral epicondyle.
  • Gluteal: (rear end) at upper outer quadrant of the buttocks.
  • Greater Trochanter: (rear hip) posterior to the greater trochanteric prominence.
  • Knee: (knee area) at the medial fat pad proximal to the joint line.

With digital palpation, the patient is asked if the palpation is painful. A "yes" reply from the patient is the only response considered to be positive. Aside from digital palpation, the tender point examination can be performed with dolorimetry (an instrument used to measure pain tolerance).

In 2010, however, the American College of Rheumatology proposed updated criteria for diagnosing fibromyalgia. The updated preliminary criteria suggest that the tender point examination be eliminated in favor of a combination of WPI (wide pain index) and SS (severity scale of symptoms). There were inherent problems with tender points being the focus of fibromyalgia diagnosis. In fact, it requires skill to perform a tender point examination properly. Also, a tender point examination was not useful for assessing the success of treatment. Some doctors avoided the tender point exam and paid more attention to other symptoms (e.g., sleep problems, forgetfulness, mental fogginess, and decreased physical function pertaining to usual daily activities).

  Study results revealed that the updated criteria was able to identify 88% of fibromyalgia patients who met the older American College of Rheumatology criteria for diagnosing fibromyalgia. 

Tender Points and Trigger Points - Are They the Same?

Tender points and trigger points are two terms that are often used interchangeably -- but are they synonymous? Trigger points characteristically are palpable knots in taut bands (tense muscle fibers) which are associated with a pattern of referred pain. On the other hand, tender points are areas of tenderness that occur in muscle, muscle-tendon connection, bursa, or fat pad. Tender points are characteristically widespread when associated with fibromyalgia. Trigger points are typically in a restricted pattern and usually associated with myofascial pain syndrome. It is possible for both to occur together.

Sources:

American College of Rheumatology Preliminary Diagnostic Criteria for Fibromyalgia and Measurement of Symptom Severity. Wolfe F. et al. Arthritis Care and Research. May 2010.
https://www.rheumatology.org/Portals/0/Files/2010_Preliminary_Diagnostic_Criteria.pdf

Fibromyalgia. How to Perform the Tender Point Examination. Page 740. Kelley's Textbook of Rheumatology. Ninth Edition. Elsevier. Accessed 11/27/2015.

Fibromyalgia, Joseph J. Biundo, MD. The Merck Manual, February 2013.
http://www.merckmanuals.com/professional/musculoskeletal-and-connective-tissue-disorders/bursa-muscle-and-tendon-disorders/fibromyalgia

The Fibromyalgia Tender Points.Use Them of Lose Them? A brief review of the controversy. Harth and Nielson. The Journal of Rheumatology.
https://jrheum.com/subscribers/07/05/914.html

Trigger points and tender points: one and the same? Does injection treatment help? Borg-Stein J. et al. Rheumatic Disease Clinics of North America. May 1996.
http://www.ncbi.nlm.nih.gov/pubmed/8860801

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