Explaining the Tender Point Test

The American College of Rheumatology (ACR) published a set of criteria for the diagnosis of Fibromyalgia Syndrome (Fibro) in 1990. For this, you need to have had pain in all four quadrants of the body (i.e. on both the left and right sides and above and below the waist) for at least 3 months. For the ACR criteria, you also need to have 11 out of 18 specifically chosen tender points. The tender points are spots on the body where everyone is more sensitive and so where it is easiest to test for the hypersensitivity to pain that characterises Fibro.

There can be many more points on the body in which you are sensitive, but these were chosen as the standard 18 to test.

The location of the 18 tender points described in the 1990 ACR criteria for the diagnosis of Fibromyalgia Syndrome are as follows (note that the tender points are located in the same place on either side of the body):

1. Back of the neck, either side of the spine at the base of the skull (the Occiput Tender Points).
2. At the front of the neck, either side of the windpipe, just above the collar-bone (the low cervical Tender Points).
3. Midway between the base of the neck and the shoulder, on the back edge of the big muscle there (the Trapezius Tender Points).
4. On the upper back, just above either shoulder blade (the Supraspinatus Tender Points).
5. Either side of the breast bone, just below the second ribs (the second rib Tender Points).
6. On the inside of the elbows, 2cm down from the elbow crease (the lateral epicondyle Tender Points).
7. Just above the buttocks (the Gluteal Tender Points).
8. On the back of the upper thighs, just below the hip joint (the Greater trochanter Tender Points).
9. On the knees, just inside of the knee cap (the knee Tender Points).

The doctor examining you may also press other points of the body which are less painful, in order to judge your pain baseline.

The tender point test can be very subjective and you may have experienced that different doctors carry out the test differently – and get very different results. Some doctors do not consider the tender point test to be accurate, but the inaccuracy of the test results is often down to it being poorly understood and performed. In order for the test to have most meaning, the doctor examining you needs to follow some common-sense guidelines for doing the test:

• They need to tell you before beginning the test that you have to respond to each tender point examination and say if the point is painful (the points must be painful not just tender), because everyone responds differently in terms of grimacing and at what point they say “ouch”. Ideally the doctor doing the test should get you to rate the pain on a scale of 0 to 10, and record each response.
• They should only press each tender point once as repeated pressing on sensitive areas can affect the result. It is easier if you are in a standard, easy access hospital gown and are in a comfortable position, either sitting or lying down. The doctor doing the test should locate the tender point position visually before applying any pressure and should then apply a force equivalent to 4kg, which should be sufficient to whiten the nail bed of the thumb used. The tender point should be pressed for long enough to give you time to respond.
• They need to be able to tell the difference between tender points and myofascial trigger points which are also painful when pressed. The most obvious signs are that a myofascial trigger point, unlike a tender point, will feel like a knot in the muscle and will refer pain or other symptoms elsewhere.

As most doctors will have had no training in performing the tender point test and as there are no official NHS guidelines on performing the test, it is unfortunately not unusual to have a doctor that doesn’t know how to most accurately perform the tender point test. This doesn’t necessarily mean that the doctor is not a good doctor to manage the treatment of your Fibro, but it is worth keeping the above guidelines in mind, especially if your diagnosis is questioned simply because a poorly performed tender point test doesn’t result in you having a high “score”.