What Are Tender Points and How Do They Affect Pain Perception?

Tender points are specific areas on the body that are sensitive to pressure and are associated with pain perception. They are commonly used in the diagnosis and assessment of conditions such as fibromyalgia syndrome (FMS) and rheumatoid arthritis (RA).

In FMS, the presence of tender points is one of the criteria used for diagnosis, and they have been found to exhibit significant differences in pain pressure thresholds and subjective pain perception [1]. In RA, the presence of tender points has been shown to influence disease activity scores, particularly in patient-reported components such as tender joints and visual analog scale of global health [2].

Tender points have also been found to impact the quality of life in individuals with sickle cell disease (SCD), with associations between tender points, average pain, catastrophizing, central sensitization, anxiety, depression, and various domains of quality of life [3]. Additionally, a high tender point count has been found to predict the development of chronic widespread pain in somatising subjects, suggesting that tender points may be a marker of distress and somatization [4]. Overall, tender points play a significant role in pain perception and can have implications for diagnosis, disease activity assessment, and quality of life in various conditions.

Defining Tender Points: What Exactly Are They?

Tender points are specific areas of the body that are hypersensitive and can trigger pain or an attack in patients with certain conditions such as fibromyalgia and hysteria. These points can be identified through examination and are often associated with spontaneous painful irritation.

They can also be used as a measure of disease activity in rheumatoid arthritis, where the presence of tender points influences the Disease Activity Score. However, it is important to note that the terms “tender-point” and “ashi-point” have different connotations and experiences in acupuncture and moxibustion treatments. While “tender-point” refers to the affected site that is directly punctured or stimulated, “ashi-point” refers to the regional reactive site for treatment. The confusion and mixing up of these terms have led to generalized explanations and clinical applications. [5] [6] [7] [8]

Where Are Tender Points Typically Found on the Body?

Tender points are typically found in various regions of the body. In patients with stable angina pectoris (SAP) and coronary heart disease (CHD), tenderness spots were observed in the left and right chest, back, shoulder, and upper limb [9].

In acute whiplash injured patients, tenderness was found in the neck region and in remote areas [10]. Clinicians, including physiotherapists, often identify tender points in superficial tissue, but their characteristics and significance are still controversial [11].

The concept of “hysterogenic zones” was described by Charcot in the 19th century, which referred to specific regions of the body that were hypersensitive and could trigger hysterical attacks [12]. In a study involving osteopathic medical students, high-yield tender points were found in various body regions, including the cervical, thoracic, rib, and lumbar regions [13].

What Causes Tender Points to Develop?

Tender points can develop due to various factors such as acute whiplash injury, infections like acute infectious mononucleosis (AIM), and hepatitis C virus (HCV) infection. In acute whiplash injury, local sensitization to noxious stimuli has been observed, leading to the development of tender points in the neck region and remote areas [14].

AIM is associated with the development of tender points acutely, but fibromyalgia (FM) is an unusual long-term outcome [15]. In HCV infection, tender points are not a common finding, suggesting that HCV infection may not be related to FM [16]. The characteristics and significance of tender points in musculoskeletal conditions are still controversial, and further investigation is needed to understand their etiology and role in assessment and treatment [17].

The concept of “hysterogenic zones” proposed by Charcot in the 19th century also suggests that pressure or rubbing on specific regions of the body can lead to the development of tender points [18].

How Do Tender Points Contribute to Pain Sensitivity?

Tender points contribute to pain sensitivity in fibromyalgia by indicating regions of increased tenderness and sensitivity to pressure, heat, cold, and electrical stimulation [19]. These tender points are not unique to fibromyalgia and can be found in all individuals, but they are more widespread and sensitive in fibromyalgia patients [20].

The number of tender points identified through palpation is often used as a measure of tenderness, but it can be influenced by subjective distress and bias [21]. Other methods, such as pressure dolorimetry, provide more objective measures of pain sensitivity and are less influenced by bias or distress [22].

The presence of tender points in fibromyalgia is related to physiological and psychological features of the condition, including hormonal events and musculoskeletal disorders [23]. However, the exact role of tender points in pain perception and sensitivity is still being studied, and further research is needed to fully understand their contribution to pain sensitivity .

Are Tender Points Linked to Specific Conditions or Syndromes?

Tender points are associated with specific conditions and syndromes. Fibromyalgia syndrome (FMS) and myofascial pain syndrome (MPS) are two major non-inflammatory myalgia conditions that involve tender points [25]. FMS is often misdiagnosed as other conditions, such as tendinitis, leading to ineffective treatment [26].

Multiple tender points in FMS are strongly associated with psychological distress, somatization, and adverse childhood experiences [27]. In a group of Hispanic patients with FMS, tender point count was associated with various FMS symptoms and comorbidities, suggesting it as a tool for assessing disease severity [28]. In a study of female home care personnel, tender point score correlated with pain intensity, other symptoms, disability, and health, and was the strongest regressor of disability indices [29].

Therefore, tender points are linked to specific conditions like FMS and MPS, and are associated with psychological distress, somatization, and disease severity.

What Role Does Stress Play in Aggravating Tender Point Sensitivity?

Stress appears to play a role in aggravating tender point sensitivity. Studies have shown that individuals with psychosomatic pain, which is often associated with stress, have higher scores for both stress-related tender points and fibromyalgia tender points [30].

Additionally, high levels of pain and pain behavior tendencies have been found to be independently related to tender point scores in patients with fibromyalgia [31]. Chronic psychoemotional stress has been shown to reduce pain thresholds, indicating a weakening of central descending tonic inhibition [32].

Furthermore, chronic stress has been found to increase painful sensitivity, while acute stress has been associated with decreased painful sensitivity [33]. These findings suggest that stress can influence tender point sensitivity, potentially through changes in the nociception system and the activity of the brain’s opioid system [34] .

How Can Tender Point Management Improve Quality of Life?

Tender point management can improve quality of life by assessing and addressing the physical and mental health parameters of patients [35]. By evaluating parameters related to a patient’s health, such as tender point pain ratings and counts, a treatment program can be assigned to improve their quality of life [36].

This approach takes into account the specific needs of each individual patient, including their pharmacokinetics, pharmacodynamics, pathophysiology, and psychosocial factors [37]. By providing an objective assessment of these parameters, the method allows for targeted interventions that can lead to an improvement in the patient’s overall well-being [38].

The association between tender point pain ratings, tender point counts, and distress in people with fibromyalgia further supports the importance of addressing tender points in improving quality of life [39]. Overall, tender point management offers a comprehensive approach to enhancing the quality of life for patients by considering both physical and mental health aspects .

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