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Reliability of Physical Examination for Diagnosis of Myofascial Trigger Points: A Systematic Review of the Literature

Lucas, Nicholas BSc, MHSc, MPainMed* †; Macaskill, Petra BA, MAppStat, PhD; Irwig, Les MBBCH, PhD; Moran, Robert BSc, MHSc; Bogduk, Nikolai MBBS, PhD, MD, DSc§

doi: 10.1097/AJP.0b013e31817e13b6
Review Articles

Background: Trigger points are promoted as an important cause of musculoskeletal pain. There is no accepted reference standard for the diagnosis of trigger points, and data on the reliability of physical examination for trigger points are conflicting.

Objectives: To systematically review the literature on the reliability of physical examination for the diagnosis of trigger points.

Methods: MEDLINE, EMBASE, and other sources were searched for articles reporting the reliability of physical examination for trigger points. Included studies were evaluated for their quality and applicability, and reliability estimates were extracted and reported.

Results: Nine studies were eligible for inclusion. None satisfied all quality and applicability criteria. No study specifically reported reliability for the identification of the location of active trigger points in the muscles of symptomatic participants. Reliability estimates varied widely for each diagnostic sign, for each muscle, and across each study. Reliability estimates were generally higher for subjective signs such as tenderness (κ range, 0.22-1.0) and pain reproduction (κ range, 0.57-1.00), and lower for objective signs such as the taut band (κ range, −0.08-0.75) and local twitch response (κ range, −0.05-0.57).

Conclusions: No study to date has reported the reliability of trigger point diagnosis according to the currently proposed criteria. On the basis of the limited number of studies available, and significant problems with their design, reporting, statistical integrity, and clinical applicability, physical examination cannot currently be recommended as a reliable test for the diagnosis of trigger points. The reliability of trigger point diagnosis needs to be further investigated with studies of high quality that use current diagnostic criteria in clinically relevant patients.

*School of Biomedical and Health Sciences, University of Western Sydney

† Screening and Test Evaluation Program, School of Public Health, University of Sydney, Sydney

§ Department of Clinical Research, Newcastle Bone and Joint Institute, Royal Newcastle Hospital, University of Newcastle, Newcastle, Australia

‡ School of Health Science, Unitec, Auckland, New Zealand

Sources of Support: Screening and Test Evaluation Program, School of Public Health, University of Sydney. Supported in part by the Australian National Health and Medical Research Council Program grant 402764. Conflict of interest: None.

Reprints: Nicholas Lucas, BSc, MHSc, MPain Med, School of Biomedical and Health Sciences, University of Western Sydney, Campbelltown Campus, Buildling 24, Rm 24.4.31, Locked Bag 1797, Penrith Sth DC NSW 1797, Australia (e-mail: n.p.lucas@uws.edu.au).

Received for publication March 5, 2008 revised April 22, 2008 accepted April 24, 2008

© 2009 Lippincott Williams & Wilkins, Inc.