Fibromyalgia Trigger Points: Locations, Diagnosis, and Treatment

If you have fibromyalgia, you are probably all too familiar with painful spots scattered across your body. For decades, these tender points were the defining feature of a fibromyalgia diagnosis. Doctors would press on 18 specific spots, and if 11 or more hurt, you got the label. That diagnostic approach has changed significantly, but the pain itself has not gone anywhere.

Understanding the difference between tender points and trigger points, where they occur, and how to treat them gives you real tools to manage one of the most frustrating aspects of this condition.

Tender Points vs. Trigger Points: They Are Not the Same Thing

These two terms get used interchangeably, but they describe different phenomena. The distinction matters because it affects treatment choices.

Tender Points

Tender points are spots that hurt when pressed but do not radiate pain elsewhere. Press on a tender point and the patient says “ouch” at that exact location. The pain stays local. Tender points are a hallmark of fibromyalgia and reflect the central sensitization (amplified pain processing in the brain and spinal cord) that defines the condition.

Tender points do not contain palpable muscle knots or taut bands. The tissue itself may feel normal. The problem is not in the tissue. It is in the way the nervous system processes signals from that area.

Trigger Points

Trigger points are hyperirritable spots within a taut band of skeletal muscle. You can often feel them as a small, hard knot under the skin. The defining feature of a trigger point is referred pain: press on a trigger point in your upper trapezius, and you feel pain shooting up into your head or down into your shoulder blade. The pain pattern is predictable and reproducible.

Trigger points are found in anyone with musculoskeletal pain, not just fibromyalgia patients. However, fibromyalgia patients tend to develop trigger points more easily and in greater numbers, likely because their sensitized nervous systems amplify the muscle dysfunction.

The Original 18 Tender Point Locations

The 1990 American College of Rheumatology (ACR) criteria identified 18 specific anatomical points arranged in 9 bilateral pairs. A doctor would apply approximately 4 kilograms of pressure (roughly the amount needed to blanch the thumbnail) to each point. Pain at 11 or more points, combined with widespread pain lasting at least 3 months, constituted a fibromyalgia diagnosis.

The 18 points are located at:

Head and Neck (4 points)

• Occiput (2 points): At the base of the skull where the suboccipital muscles attach. These points, one on each side, are located just below the bony ridge at the back of the head.
• Low cervical (2 points): At the front of the neck, at the level of the C5-C7 vertebrae. Located at the anterior aspect of the intertransverse spaces.

Shoulders and Upper Back (4 points)

• Trapezius (2 points): At the midpoint of the upper trapezius muscle, the thick muscle that runs from the neck to the shoulder tip. This is one of the most commonly tender points in fibromyalgia.
• Supraspinatus (2 points): Above the scapular spine, near where the supraspinatus muscle originates. Located at the medial border close to the top of the shoulder blade.

Chest (2 points)

• Second rib (2 points): At the second costochondral junction, where the second rib meets its cartilage near the upper breastbone. This is slightly lateral to the sternum on each side.

Arms (4 points)

• Lateral epicondyle (2 points): On the outer elbow, about 2 centimeters below the bony prominence. This is the same area affected in tennis elbow, though the mechanisms are different.

Lower Body (4 points)

• Greater trochanter (2 points): At the bony prominence on the outer hip. This is where several hip muscles attach and is a common area of complaint in fibromyalgia.
• Knee (2 points): At the medial fat pad, just above the joint line on the inner knee. This point is proximal (above) to the actual joint space.

Lower Back and Buttocks (2 points if counting gluteal)

• Gluteal (2 points): In the upper outer quadrant of the buttocks, in the anterior fold of the gluteus medius muscle.

Why the Tender Point Exam Was Replaced

The 18-point tender point exam served its purpose for years, but it had several problems that became increasingly apparent:

• Examiner variability. The amount of pressure applied varied between doctors. One physician’s “4 kilograms” could be another’s 6 or 3. This inconsistency meant the same patient could test positive with one doctor and negative with another.
• Gender bias. Women generally have lower pressure pain thresholds than men, which contributed to the disproportionate diagnosis of women. The exam may have been measuring pain sensitivity in general rather than fibromyalgia specifically.
• Binary thinking. The 11-of-18 cutoff created an artificial line. A patient with 10 tender points and debilitating symptoms was technically “negative,” while someone with 11 points and milder symptoms was “positive.”
• It missed the full picture. Fibromyalgia is far more than pain. Fatigue, cognitive dysfunction, sleep disturbance, and numerous other symptoms are central to the condition. The tender point exam ignored all of them.
• Many doctors did not perform it correctly. Studies found that primary care physicians frequently did not know the exact point locations or did not apply proper pressure, leading to widespread misdiagnosis in both directions.

The 2010 Diagnostic Criteria: A Better Approach

In 2010, the ACR published updated criteria that eliminated the tender point exam entirely. The new approach uses two self-reported scales:

Widespread Pain Index (WPI)

Patients indicate which of 19 body areas have been painful in the past week. Areas include: left shoulder girdle, right shoulder girdle, left upper arm, right upper arm, left lower arm, right lower arm, left hip, right hip, left upper leg, right upper leg, left lower leg, right lower leg, left jaw, right jaw, chest, abdomen, upper back, lower back, and neck. Each painful area counts as one point (score range: 0 to 19).

Symptom Severity Scale (SSS)

Three symptoms are rated on a 0 to 3 severity scale: fatigue, waking unrefreshed, and cognitive symptoms. Additional somatic symptoms (headaches, irritable bowel, depression, etc.) add 0 to 3 more points. The total SSS ranges from 0 to 12.

Diagnostic Thresholds

A fibromyalgia diagnosis requires:

• WPI of 7 or higher AND SSS of 5 or higher, OR
• WPI of 3 to 6 AND SSS of 9 or higher
• Symptoms present at a similar level for at least 3 months
• No other disorder that would explain the pain

This approach captures the multidimensional nature of fibromyalgia and does not require an examiner to press on your body. It also produces a score that can track disease severity over time, which the tender point count never did well.

Treating Trigger Points in Fibromyalgia

While the overall management of fibromyalgia requires a multifaceted approach (medication, exercise, sleep optimization, stress management), targeted treatment of trigger points can provide meaningful relief. Here are the most evidence-supported options.

Manual Therapy

Skilled manual therapy from a physical therapist, osteopath, or massage therapist trained in myofascial release can deactivate trigger points effectively. Techniques include:

• Myofascial release: Sustained pressure applied to the trigger point until the tissue releases. The therapist holds pressure for 60 to 90 seconds (or longer) while the muscle gradually softens.
• Spray and stretch: A vapocoolant spray is applied to the skin over the trigger point, followed by gentle stretching of the involved muscle. The cold temporarily reduces pain signaling, allowing a deeper stretch.
• Ischemic compression: Firm, sustained pressure directly on the trigger point to temporarily cut off blood flow. When pressure is released, a flush of fresh blood enters the area, helping to break the metabolic cycle that maintains the trigger point.
• Strain-counterstrain: The muscle is placed in a shortened, comfortable position for 90 seconds, then slowly returned to neutral. This technique is particularly useful for fibromyalgia patients because it involves minimal pain during treatment.

A key consideration for fibromyalgia patients: overly aggressive manual therapy can trigger a pain flare. Start with gentler techniques and lower pressure. More is not better here. A skilled therapist will adjust their approach based on your pain response and central sensitization status.

Dry Needling

Dry needling involves inserting a thin filiform needle (similar to an acupuncture needle) directly into a trigger point. The needle creates a local twitch response, which is an involuntary contraction of the taut muscle band. This twitch response is both diagnostic (confirming you are in the right spot) and therapeutic (it appears to reset the dysfunctional motor endplate).

Research supports dry needling for trigger point pain. A 2013 systematic review in the Journal of Orthopaedic and Sports Physical Therapy found that dry needling significantly reduced pain and improved function in patients with myofascial trigger points. For fibromyalgia specifically, the evidence is more mixed but generally positive when dry needling is combined with other treatments.

What to expect: the needle insertion is usually not very painful, but the twitch response can be intense and somewhat startling. Soreness at the needling site for 24 to 48 hours afterward is normal. Most patients need multiple sessions (6 to 8) to see lasting benefit.

Shockwave Therapy

Extracorporeal shockwave therapy (ESWT) delivers acoustic pressure waves to the affected tissue. Originally developed for kidney stones, shockwave therapy has found increasing use in musculoskeletal conditions, including trigger point treatment.

The mechanism appears to involve several effects: disruption of the trigger point’s metabolic crisis, increased local blood flow, stimulation of tissue healing factors, and modulation of pain signaling. A 2020 meta-analysis found that shockwave therapy was effective for myofascial trigger points, with benefits in both pain reduction and pressure pain threshold improvement.

For fibromyalgia patients, shockwave therapy has an additional potential benefit: it may help modulate the central sensitization that amplifies pain. Some studies have shown decreased substance P levels (a pain-related neuropeptide) after shockwave treatment.

Treatment typically involves 3 to 6 sessions, spaced 1 to 2 weeks apart. Each session lasts about 10 to 15 minutes. The intensity is adjusted based on patient tolerance, and fibromyalgia patients generally start at lower energy levels than other patients.

Other Treatment Options

• Trigger point injections: A physician injects a small amount of local anesthetic (lidocaine) or saline directly into the trigger point. Some practitioners use corticosteroids, though evidence for steroid injection into trigger points is weak.
• TENS (transcutaneous electrical nerve stimulation): Electrodes placed over trigger points deliver low-voltage electrical stimulation that can reduce pain through the gate control mechanism.
• Heat therapy: Moist heat applied to trigger points for 15 to 20 minutes can increase blood flow and reduce muscle tension. Simple, free, and effective for many patients.
• Self-myofascial release: Using foam rollers, lacrosse balls, or specialized tools (Theracane, etc.) to apply pressure to your own trigger points. This gives you a daily management tool between professional treatments.

The Bigger Picture: Trigger Points Are Part of the Puzzle

Treating trigger points provides real relief, but it addresses a peripheral contributor to fibromyalgia pain rather than the central cause. The underlying issue in fibromyalgia is central sensitization: the brain and spinal cord amplify pain signals, turning normal sensory input into painful experience. Trigger points feed into this system, and reducing their activity helps dial down the overall pain volume. But they are not the whole story.

The most effective fibromyalgia management plans combine trigger point treatment with strategies that address central sensitization directly: regular aerobic exercise (shown to normalize pain processing over time), sleep optimization, stress management, and in some cases medications like low-dose naltrexone, duloxetine, or pregabalin.

Think of trigger points as amplifiers plugged into an already overloaded sound system. Unplugging those amplifiers (treating trigger points) makes things quieter. But if you also turn down the master volume (addressing central sensitization), the overall improvement is much greater.

Related Reading

• Fibromyalgia: Causes, Symptoms, and Evidence-Based Treatment
• Shockwave Therapy: How It Works and What It Treats
• Chronic Pain Management: A Practical Guide
• Dry Needling: What to Expect and Does It Work?