If no LTR was observed after 10 attempts, the needling was stopped and a mixture solution was injected. The needling was repeated to elicit as many LTRs as possible. The physiatrist observed the LTRs on the US while performing the trigger-point injections.
#Travell and simons neck pain skin#
With the use of an out-of-plane method, we could see the needle passing through the skin and adipose tissue to penetrate the muscle. No more injections were done once all the prepared solution of 5 mL had been used up (at most, there could be 10 injections per treatment session) or when no more palpated tender point were found.
The injection volume per tender point was 0.5 mL. The sequence of the injection sites was determined at each treatment period in terms of the decreasing order of pain severity in the tender points when palpated. In the case of multiple tender spots in one muscle, the injections were repeated for all tender spots. Under US guidance, a 25-gauge, 2.6-cm needle connected to a 5-mL syringe containing a mixture of 4 mL of 0.5% lidocaine and 1 mL of 40 mg of triamcinolone was inserted into the infraspinatus muscle at the region where the tender spot was palpated.
Color Doppler images were used to avoid the neurovascular bundle. By positioning the probe on the marked points and turning the probe for the best view, we obtained the image of the target area ( Figs. We differentiated the infraspinatus muscle from the deltoid, trapezius, teres major, teres minor, and latissimus dorsi muscles by US scanning and marked the tender points on the skin by palpating the muscle.