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Tender Points are Mostly MTPs

Both Hong-You Ge, M.D., Ph.D., and Cesar Fernandez de las Penas, Ph.D., successfully showed that 90 percent of the tender point areas that were used to diagnose fibromyalgia are actually myofascial trigger points or MTPs. In addition, these MTPs significantly contribute to the overall pain of fibromyalgia. More details on their findings and the implications for treatment are provided in the article below.

The Mirror Image of Normal?

You hear it all the time, you look just fine. Even when the doctor conducts an exam and standard tests, nothing shouts out that you have pain all over. So why are your muscles tender to the touch? What could be going on beneath the surface that is causing you so much grief but leaves you looking so normal?

Perhaps a physical therapist has told you that some of your muscles feel ropy, that your range of motion is poor. Or maybe you have visited a massage therapist who can zero in on your most painful areas, like a marksman at target practice. Is there something that these hands-on specialists are detecting that others aren’t picking up on? Perhaps.

New research points to a very fine distinction in the muscles between healthy pain-free people and those with the widespread tenderness of fibromyalgia. It has to do with myofascial trigger points (MTPs), the areas that hurt and radiate pain elsewhere in fibromyalgia patients. But the explanation is not what you might think, because most everyone has MTPs—even people who don’t have pain.

Turned On

The presence of MTPs does not distinguish your achy fibromyalgia muscles from people who feel healthy, according to a study by Hong-You Ge, M.D., Ph.D., of Denmark. He found an average of 11 MTPs in a group of fibromyalgia patients and an equal number in a pain-free control group.1 Ge even discovered that the MTPs tended to occur more commonly in the same areas of the musculature, but there was one very important difference: the state of the MTPs.

Your MTPs are turned on (they are active), while everyone else’s are in a dormant state (they are latent). You could be trying to relax, and your active MTPs will be causing you pain. No one has to press on your active MTPs for them to hurt. In healthy people (pain-free), their latent MTPs are not turned on, so they don’t produce any discomfort.

“The large number of latent MTPs in the healthy volunteers for our study was surprising, but true,” says Ge. What could these tiny, difficult-to-find nodules in the muscles be doing if they don’t produce noticeable symptoms? “These latent MTPs may serve as a potential source of pain and fatigue in healthy subjects following acute and sustained muscle overload, trauma, or other adverse events.”

Does this mean that multiple latent MTPs in people are just lying in wait, ready to be turned on to produce the widespread pain of fibromyalgia? Not quite. Ge says that only when MTPs have been chronically activated for prolonged periods of time, do they have the potential to contribute to the pain and other symptoms of fibromyalgia. In other words, latents are generally “silent” in everyone. When activated by daily movements that strain the muscle, they will cause temporary discomfort, but then revert back to latents and do not lead to the widespread muscle aches of fibromyalgia.

Reflections of Pain

If the latent MTPs don’t cause any pain, how could Ge locate them in healthy people in the first place? He mapped the active MTP locations he found on the fibromyalgia patients onto healthy height-weight-matched controls. It’s somewhat like reflections in a mirror, which enabled Ge to examine these regions for the painless nodules known as latent MTPs.

For starters, the 30 fibromyalgia patients shaded in their pain locations onto the front and back sides of a body drawing. Based on each person’s pain drawing (representing their spontaneous pain at rest), an examiner palpated the shaded areas for the presence of active MTPs. Not only do these regions feel like little knots in a tight muscle band, pressing on them causes a magnification of the pain that also radiates to other areas. These active MTPs were also confirmed by intramuscular needle electrodes that can detect the electrical activity generated by MTPs.

Ge did not use the American College of Rheumatology diagnostic tender points to identify the active MTPs in the fibromyalgia patients. Although he has previously shown that more than 90 percent of these areas contain active MTPs, he let the fibromyalgia patients’ pain drawings guide his search for MTPs.2 This method allowed Ge to identify the most likely areas where active MTPs will develop in people with fibromyalgia. He discovered that a few of the most common spots are not even included in the tender point exam, such as the quadratus lumborum in the low back.

Forty areas for MTPs, 20 on each side in a symmetrical pattern, were identified in the group of fibromyalgia patients. On average, each fibromyalgia patient had 11 active MTPs, with the most common locations shown on the mannequins to the right.

When Ge looked at each healthy control subject who had the mirror image markings of the MTPs locations from a fibromyalgia patient with a matched body build, he did not find any active MTPs. This was no surprise because the healthy subjects did not have pain. Yet, Ge was still able to identify an average of 11 latent (not active) MTPs per healthy subject. In addition, these latents in the various locations happened to mirror what he found for the active MTPs in the fibromyalgia patients.

Of course, if the fibromyalgia patients were used as a guide to look for potential MTPs on the healthy subjects, wouldn’t you expect to find the latents there? No. People who do not have pain have always been presumed to not have any MTPs, or at most, maybe an occasional one here or there. Certainly, not 11.

“At the time I designed the study, I thought there may be some mapped locations on the healthy subjects with latents,” says Ge. He confirmed the latents with intramuscular electrodes to pick up the electrical activity that even latents give off (it’s much less than active MTPs). And because his sample size was large enough, Ge says,” Our findings of multiple latents is valid for middle-aged healthy subjects.”

So, the difference between you and healthy, pain-free folks is not that you have more MTPs or that they are in different locations. The only distinction is that your MTPs are turned on, they are in a sustained active state and they produce a larger knot, while the MTPs of your healthy counterparts are dormant (or latent), they are just present for good measure, and nothing more.


The number of key active MTPs on the right side of the body for fibromyalgia patients appears to match those found on the left side. Even the active spots in each location matched the number on both sides of the body. Why the symmetry?

“This is likely due to dual activation of the muscle groups for performing most physical activities,” Ge says. Or it could be caused by the spreading of pain from one side of the spinal cord to the other. Either way, this is an important clue when identifying and treating active MTPs in people with fibromyalgia.” For example, if an active MTP is found in the right forearm one inch below the elbow, the treating specialist should also examine this same area on the left side (typically the non-dominant arm).

More Active MTPs
Greater Pain

The greater number of active MTPs, the greater the pain severity in people with fibromyalgia. This direct correlation was found in Ge’s study as well as another one conducted by Cesar Fernandez de las Penas, P.T., Ph.D., of Spain.3 So if you have more active MTPs, your fibromyalgia pain will be worse. And, your sensitivity to painful stimuli may also be increased by a greater number of active MTPs.

In a group of 45 fibromyalgia patients, Fernandez de las Penas found that “the higher the number of active MTPs, the lower the pressure pain threshold levels.” The pressure pain thresholds were assessed at multiple regions on the body (not over the MTPs), so the results reflect a generalized enhancement of your body’s ability to detect pain. Similar to Ge, Fernandez de las Penas also found an average of 10 active MTPs in his fibromyalgia group, while only latents could be detected in the healthy group of 50 subjects.

Both studies found that the greater the number of active MTPs, the greater the patient’s pain severity.

Fibromyalgia Reproduction

Once the active MTPs were identified in each fibromyalgia patient, both research teams looked at the ability of these areas to produce your fibromyalgia pain. After each active MTP was pressed, patients were asked to shade on a body diagram where they felt the pain. A composite pain drawing that represented all the active MTPs was generated for each patient. The same was done for the latent MTPs in the healthy group, which led to only a negligible amount of discomfort.

“The local and referred pain elicited from widespread active MTPs fully reproduced the overall spontaneous fibromyalgia pain pattern,” says Fernandez de las Penas. Ge’s research produced the same results—your active MTPs are responsible for generating your body-wide pain pattern. However, your pain intensity is not uniform throughout your body.

“Looking at the patient’s pain drawings,” says Ge, “it is easy to understand that the pain of fibromyalgia is not necessarily diffuse throughout all areas of the body. Rather, it consists of regional pains that are most concentrated in the neck, shoulders, arms, low back, and gluteal/hip regions. These areas likely correspond to regions of the body which the muscles are more prone to becoming over-used or over-strained.”

Treatment Approach

The 18 areas of tenderness (e.g., the tender points) are important for diagnosis, but of limited value for treatment. “Most fibromyalgia patients have key active MTPs in other muscle areas besides those used for diagnosis,” says Ge. “If these active MTPs in other muscles are not treated, fibromyalgia pain will persist.” Ge suggests that “pain drawings provide a great aid for locating key active MTPs.”

Pain drawings can identify your most intense regions of pain and serve as a tool to help your provider prioritize which areas to treat first. However, an understanding of the referred pain patterns produced by MTPs is essential. For example, Ge comments that an MTP in a back shoulder muscle could likely shoot pain to the front of the shoulder. So, while your pain drawings form the basis for your individualized care, someone on your team must be capable of interpreting your pain diagrams and understand how MTPs refer pain to other muscle groups.

Physical therapists and deep-tissue massage experts may possess the talent needed for treating your painful MTPs. Some physicians, particularly physical medicine specialists or physiatrists, are also skilled at pinpointing MTPs and applying techniques to alleviate the discomfort that they produce. David Simons, M.D., and Janet Travell, M.D., published a two-volume manual illustrating the location of all known MTPs. 4 If your provider does not refer to these two famous physicians, even when prompted, ask if they work with a hands-on specialist who does.         

Spotlight on Back Pain

One muscle that was most likely to contain an active MTP in fibromyalgia patients and a latent in healthy subjects was the quadratus lumborum. Surprisingly, this muscle is not even part of the diagnostic exam for fibromyalgia. Yet, Ge confirms that MTPs in this muscle are the most common cause of low back pain and referred pain to the hips and gluteal muscles (e.g., buttocks). This muscle attaches at the back ridge of your pelvic bone and fans out into multiple sections, each one attaching to a different level of the vertebrae in your low back or lumbar region.

What are some of the signs that your quadratus lumborum might have an active MTP? Turning over in bed, standing upright, bending over to lift objects, or twisting the trunk can all amplify the pain produced by MTPs in this muscle.4 Getting up out of a chair can be agonizing unless one is able to use strong support from the upper arms.

  1. Ge HY, et al. Arthritis Res Ther 13(2):R48, Mar 22, 2011. Free Journal Report
  2. Ge HY, et al. J Pain 11(7):644-51, 2010. Free Journal Report
  3. Alonso-Blanco C, Fernandez-de-las-Penas C, et al. Clin J Pain 27(5):405-13, 2011.
  4. Travell JG, Simons DG. Myofascial Pain and Dysfunction: The Trigger Point Pain Manual; Vol. 2., The Lower Extremities, Lippincott Wiliams & Wilkins, 1992.

A journal report on MTPs in fibromyalgia that documents the high prevalence of MTPs in the trapezius muscle (the upper back shoulder muscle that attaches at the back of the neck, out to the shoulder joint and down to the middle of the back) is below and it was also part of the AFSA-funded study to Dr. Ge.

Ge HY, et al. Contribution of the local and referred pain from active myofascial trigger points in fibromyalgia syndrome. PAIN 147(1-3);233-40, 2009. Abstract

A journal report showing that a fatiguing muscle contraction of the trapezius occurs more rapidly in fibromyalgia patients because of the presence of MTPs. In addition, the MTPs give off electrical activity, sending signals into the central nervous system and causing reduced pain threshold in a distant muscle in the leg. This study explains why exercising one muscle can lead to more pain in other distant muscles in the body and it was also part of the AFSA-funded study to Dr. Ge.

Ge HY, et al. Descending pain modulation and its interaction with peripheral sensitization following sustained isometric muscle contraction in fibromyalgia. Eur J Pain 16(2):196-203, 2012. Abstract