By Mary Biancalana, MA, CMTPT, LMT

This article is an overview of the very interesting paper, “International Consensus on Diagnostic Criteria and Clinical Considerations of Myofascial Trigger Points, a Delphi Study”, published in 2018 in Pain Medicine Journal. The study, undertaken by C. Fernandez-de-lasPenas, PT and J. Dommerholt, PT is very much overdue.  

 It is true that there is tremendous variability in diagnostic criteria for Myofascial Trigger Points (MTrPs) and the referred phenomenon they trigger. This paper brings a much-needed consensus to the way we acknowledge and chart how patients describe referred phenomenon. I am sure each clinician reading this article can agree that their own patients have unique, individual experiences with the referred phenomenon whether it be pain, tingling, numbness, burning, heaviness, aching, shooting, or any of the other describable sensation phenomena. 

Let’s discuss first what is a Delphi Survey? A Delphi process attempts to achieve a convergence or consensual response of opinion among chosen experts on a specific topic over a series of rounds. Thus, Delphi Survey allows the bringing of consistency of view into a complex clinical topic. 

Now to the study itself. The authors noted that there was huge variability in the way myofascial pain and trigger points were described, evaluated and diagnosed. They found within previous review studies that their authors did not specifically report on the reliability of trigger point identification using a common set of diagnostic criteria. So, the authors of this study saw a great need in a consensus as well as detection of the reliability of each individual diagnostic criteria.

Current thinking has the examination of trigger points not based on just one criteria, but rather on a cluster of criteria. Thus, standardizing diagnostic criteria becomes the first step in the evaluation process and it ultimately will result in improvements in treatment of Myofascial Pain Syndrome.  

The Delphi survey was designed and conducted by Fernandez-de-las-Penas and Dommerholt to achieve an international consensus on: 

1. A basic cluster of evaluation criteria needed for the diagnosis of myofascial trigger points, and Myofascial Pain Syndrome

2. To reach a consensus on the clinical characteristics of active and latent trigger points

3. To clarify clinical criteria about the location of myofascial trigger points.

4. To reach common ground in regard to development and location of areas of referred pain developed secondary to the presence of active trigger points. 

The authors were guided by a systematic literature review on physical examination for MTrPs. Within the Delphi study, experts on Myofascial TrPs were sent a series of 3 questionnaires in which first they were asked to select from a series of potential criteria for confirming the presence of TrPs, and were asked to designate the criteria as “Essential‘ or “Confirmatory” for diagnosis of TrPs. 

In the second round, the authors used only criteria to choose from that garnered a 70% consensus from the previous questionnaires. In the third and final round, the authors only included the responses there were chosen less than 70% in the second round. They then assessed their gathered data and formed conclusions. The study coordinators were aiming to “get the highest representation, so they selected experts based on established knowledge and familiarity with Myofascial Pain Syndrome and trigger points and their ability to influence policy related to Myofascial Pain Syndrome.” They selected physical therapists and physicians who regularly teach trigger point courses as they were considered potential experts with substantial knowledge of the topic. They also considered authors of peer-reviewed articles to be experts within the profession.   

For this study the authors contacted 65 international experts from 12 countries. 60 participated with a mean age of 45 years plus or minus 9 years. The vast majority of responders were physical therapists (53) and the remaining included medical doctors (4) and Osteopaths (3). Total years in clinical practice varied from 18 to 23 years with 13 to 18 years of experience in the diagnosis and treatment of trigger points.

While I can understand how the authors wanted to get a world-wide view, I feel they missed a huge group of highly trained manual therapists who trained and work within the Board Certified Myofascial Trigger Point Therapists, many of whom were trained by myself and successfully help patients, as well as the Medical Massage Therapists trained by Dr. Ross Turchaninov. Perhaps a criteria could have been added to include those who spend a designated number of hours in their practices in hands-on treatment and assessment, of which 100% would be the number found in MTPTs in the USA. 

A very interesting to note from the Delphi study was that 42 of the 60 experts said that “they did not expect a particular referred pain pattern for a muscle, but they agreed that the Dr. Travell and Dr. Simons illustrations from Trigger Point Manual textbook represent a most common pattern.” Also, very interesting was that “52 of the experts (86.5%), did not consider a particular location of trigger points, meaning they did not look for the “X” as found in the Trigger Point Manual (or other publications).”   

As a full-time, Board Certified Myofascial Trigger Point Therapist, I find this absolutely surprising. I rely on the “x” marked illustrations every day to support my overall clinical reasoning. I can attest to the accuracy of the illustrations after having treated thousands and thousands of people over the past 19 years. I appreciate having at least a general idea of where to start palpating based on the Dr. Travell and Dr. Simons illustrations. This helps to reduce the time I might spend randomly looking around for palpable taut bands over the full length of any given muscle.

Just take the rectus femoris for example. In a volleyball player who may be 6ft 10 inches tall, if there were not a general starting point to look for the most probable location of TrP that could refer into the anterior knee, it could take 15 minutes to systematically palpate the length of a femur that could be 29 inches long!   

Also, a very interesting in the open question round within the Delphi study; 51 (85%) of the participants considered that “patients with acute or chronic pain who were asymptomatic at the time of the physical examination could still have active trigger points.” Yes, we may frequently observe these scenarios when

“The patient has a history of migraines, but did not have an active migraine at the moment of their visit.”

I find this really helpful and reinforces for we manual therapists the importance of a long and detailed pre-appointment history to get a broad view of the daily and monthly function of the patient/client. How do we describe referred sensation?   

Dr. Travell and Dr. Simons (1983) pointed out that the referral phenomena is a

“sensory and motor phenomena such as pain, tenderness, increased motor unit activity paresthesia, spasm, vasoconstriction, vasodilation, or hyperalgesia caused by a trigger point which can occur at a distance from the trigger point.”  

This is AWESOME! Dr. Travell and Dr. Simons allowed for a much broader view of possible clinical symptoms. In our clinical practices we should all do the same. As we ask for feedback on sensory information from the client, we need to be open ended in our allowing them to describe what they are experiencing.  According to the Delphi Study, the most common reported sensations were:

1. pain spreading to another area

2. deep pain

3. dull ache

4. tingling

5. burning pain

78% of the experts (47/60) agreed that there could be various sensations due to the presence of active TrPs. There is other research data cited in the Delphi Study to support this idea. This is an awesome validation to what I have known and have been teaching for more than 12 years after including concepts from other research and considering the fascial matrix model. Not all myofascial/soft tissue problems present as pain! 

Study Conclusions

Fernandez-de-las-Penas and Dommerholt, urge that diagnosis of trigger point should not be based on one criteria, rather, the reliability of the diagnosis should take into account the cluster of criteria presented in the Delphi panel, namely: 

1. the presence of a taut band

2. hypersensitive spot

3. presence of referred sensation.

Thus, the authors indicated that the diagnostic criteria for Myofascial Pain Syndrome as a pathology should also involve other secondary symptoms. This approach helps better evaluate and treat MPS since it is a much more complex condition. They argued that other sensory abnormalities besides the pain must be included in referred pattern developed secondarily due to presence of active TrPs. They proposed to use the term “referred sensation” instead of “referred pain,” which is still commonly used.

Finally, the authors suggested developing clear distinction between active and latent trigger points. Such distinction should be based on the therapist’s ability to recreate the patient’s symptoms and not just on the presence of spontaneous pain the patients generally complained about. Some patients can be pain-free at the moment of the examination. Thus, this study has given us a first step in standardization of referred phenomenon formed in the presence of myofascial trigger points. 

This brings us to another important subject: How will you ask your clients to describe their pain? I recommend taking into account that we all now agree that NOT all referred sensation is described as “pain.” That said, I recommend that you be open ended in your questioning. Listen, and actively allow the client to describe what is unique to them. Do not lead the client into just describing pain, rather let them describe their sensation and chart it as they report it.   

I am very grateful to the authors of this paper for their continued and tireless efforts to produce excellent research into soft tissue conditions and into the comparative efficacy of various treatment modalities. Fernandez-de-las-Penas and Dommerholt, continue to be world leaders in research and treatment of myofascial pain and we salute them on their many, many prior publications, and we look forward to many more.  


Fernández-de-Las-Peñas C, Dommerholt J. International Consensus on Diagnostic Criteria and Clinical Considerations of Myofascial Trigger Points: A Delphi Study. Pain Med. 2018 Jan 1;19(1):142-150.

Travel J.G., Simons D.G. Myofascial Pain and Dysfunction. The Trigger Point Manual. Williams&Wilkins, 1983

    Mary Biancalana, Founder of Chicago Center for Myofascial Pain Relief, Trigger Point Sports Performance and Advanced Trigger Point seminars has excelled in the wellness education field since 1983. A lifelong athlete and exerciser, Mary possesses a unique blend of manual therapy skills and clinical experience that sets her apart. She holds a B.S. from DePaul University in Physical Education and a Master’s in Education from Northeastern Illinois University. She also holds four State of Illinois teaching licenses and is an American Council on Exercise Certified Personal Trainer, a Nationally Board-Certified Myofascial Trigger Point Therapist, and a Licensed Massage Therapist.

Mary has been Vice-President and is currently President of The National Association of Myofascial Trigger Point Therapists of which she has been a serving member for 16 years and Annual National conference chair for 10 years.

Mary is currently a member of The American Academy of Pain Management, a serving Board Member of The International MYOPain Society, The American Council on Exercise, and the American Massage Therapy Association. 

To find out more about M. Biancalana’ clinic of somatic rehabilitation please visit:

Category: Medical Massage