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P. T. Dorsher, MD 1; J. Fleckenstein, MD 2
Trigger Points and Classical Acupuncture Points
Part 1: Qualitative and Quantitative Anatomic Correspondences*
Trigger-Punkte und klassische Akupunkturpunkte
Teil 1: Qualitative und Quantitative Anatomische Beziehungen
Abstract
Background: Data from a recently published study sug-
gest that substantial anatomic, clinical, and physiologic
overlap of myofascial trigger points (mTrPs) and acupoints
exists in the treatment of pain disorders.
Objective: To evaluate the anatomic relationships between
classical acupoint locations and those of mTrPs both qua-
litatively and quantitatively.
Methods: Graphics software was used to demonstrate the
different muscle layers of a virtual, digitized human ca-
daver. The locations of 255 “common” mTrPs described in
the Trigger Point Manual were superimposed as a separate
layer to these graphics as were the locations of the 361
classical acupoints and the meridians they exist on. The
relationships of the anatomic locations of acupoints and
meridians to those of muscles and common mTrPs could
then be directly visualized. Classical acupoints and mTrPs
that entered the same muscle regions and were physically
closest to each other, as confirmed by acupuncture and hu-
man anatomy references, were termed “anatomically cor-
responding” point pairs. A quantitative analysis of these
anatomically corresponding mTrP-acupoint pairs was also
performed.
Results: Of 255 common mTrPs, 238 (93.3 %) had anato-
mically corresponding classical acupoints. Quantitatively,
89 (37 %) of these 238 corresponding mTrP-acupoint pairs
were estimated to be within 1 cm of each other, 107 point
pairs (45 %) within 1–2 cm of each other, and another 32
point pairs (13 %) within 2–3 cm of each other. Trigger-
acupuncture point correspondences would rise to 95.7 %
if six other common mTrPs are considered anatomically
corresponding.
Conclusions: Analysis of the relationships of the anatomic
locations of mTrPs and acupoints while adhering to the
modern conceptualization of myofascial pain as a regional
muscle disorder demonstrates ≥ 93.3 % anatomic corre-
spondence of common mTrPs to classical acupoints.
Keywords
Acupuncture, acupuncture points, acupuncture meridian,
myofascial pain, pain, trigger point therapy
Peter T. Dorsher, MD 4500 San Pablo Road
Department of Physical Medicine and Rehabilitation Jacksonville, FL 32224
Mayo Clinic dorsher.peter@mayo.edu
1 Department of Physical Medicine and Rehabilitation, Mayo Clinic, Jacksonville, Florida
2 Interdisciplinary Pain Center, Department of Anesthesiology, Ludwig Maximilians University of Munich
* This is a shortened version of the article. The full article, with an additional table covering point correlations with anatomic references of Chen´s Cross-Sectional Anatomy of Acupoints
may be found on the DZA website at www.elsevier.de/dza.
Deutsche Zeitschrift für
Zusammenfassung
Hintergrund: Eine mögliche Überschneidung myofaszi-
aler Triggerpunkte (mTrPs) mit Akupunkturpunkten in Be-
zug auf deren anatomische, klinische und physiologische
Eigenschaften in der Behandlung von Schmerzsyndromen
ist Gegenstand neuester Publikationen.
Zielsetzung: Die anatomischen Beziehungen zwischen
klassischen Akupunkturpunkten und mTrPs sollten quali-
tativ und quantitativ analysiert werden.
Methodik: Es wurde ein spezielles Bildprogramm eines
virtualisierten, digitalisierten menschlichen Leichnams
zur Darstellung der verschiedenen Muskelschichten ver-
wendet. Die Lokalisation der 255 im Trigger Punkt Ma-
nual beschriebenen und häufig gebräuchlichen mTrPs
wurden ebenso wie die 361 klassischen Akupunkturpunkte
mit ihren dazugehörigen Meridianen als zusätzliche Bild-
ebenen in dieses Programm aufgenommen. Somit konnten
die anatomischen Lagebeziehungen von klassischen Aku-
punkturpunkten und Meridianen zu Muskeln und mTrPs
bildhaft gemacht werden. Klassische Akupunkturpunkte
und mTrPs, die, wie auch durch Literaturquellen gesichert,
in derselben Muskelgruppe lagen und die engste räumliche
Zuordnung hatten, wurden als anatomisch entsprechende
Punkte definiert. Zusätzlich wurde eine quantitative Ana-
lyse dieser anatomisch korrespondierenden mTrP Aku-
punkturpunktpaare durchgeführt.
Ergebnis: 238 der 255 gebräuchlichen mTrPs (93,3 %) ent-
sprachen anatomisch klassischen Akupunkturpunkten. 89
dieser 238 entsprechenden mTrP-Akupunkturpunktpaare
(37 %) lagen näher als 1 cm, 107 Punktpaare (45 %) zwi-
schen 1 und 2 cm, und weitere 32 Punktpaare (13 %) zwi-
schen 2 und 3 cm voneinander.
Schlussfolgerung: Das gegenwärtige Konzept myofaszi-
aler Schmerzen hält an der Vorstellung einer pathophysio-
logischen Störung des regionalen Muskels fest. Die Analyse
der anatomischen Lagebeziehungen zwischen mTrPs und
Akupunkturpunkten zeigt eine anatomische Beziehung
von über 93,3 % der gebräuchlichen mTrPs zu klassischen
Akupunkturpunkten.
Schlüsselwörter
Akupunktur, Akupunkturpunkt, Leitbahn, Meridian, Myo-
faszialer Schmerz, Schmerz, Trigger Punkt Therapie

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Introduction
The major contents of The Medical Classic of the Yellow
Emperor, which first enunciated the tenets of Traditional
Chinese Medicine (TCM), date from the Warring States Pe-
riod (475 BC–221 BC) [1] though this seminal work may
reflect as much as 2500 years of prior theoretical and clin-
ical developments. [2] Acupuncture has been in clinical
use for at least 3000 years. [3] The 361 classical (channel)
acupuncture points, 95 % of which had been described by
the 3 [rd] century [3], reflect the most clinically impor-
tant acupoints found during millennia of use. Acupuncture
continues to be widely used in clinical practice. One survey
in China reported approximately 28 % of respondents still
used TCM as first line treatment for illness [4]; and in the
United States, 1 % (~ 2.1 million) of surveyed individuals
reported having recently received acupuncture treatment
[5]. Nearly 30 % of the acupuncture literature explores its
use in treating pain disorders. [6]
Trigger point therapy for treating pain disorders is wide-
ly used in contemporary medical practice. [7] Myofascial
trigger point (mTrP) injections were the second most com-
mon procedure (behind epidurals) performed by anesthe-
siologists treating chronic pain in Canada. [8] The tenets
of trigger point therapy for myofascial pain syndromes,
which reflect decades of clinical research and experi-
ence, were first comprehensively presented in the 1983
and 1992 volumes of the Trigger Point Manual. [9, 10]
Dry needling of mTrPs is discussed in that authoritative
text, and contemporary myofascial pain syndrome train-
ing courses utilize acupuncture needles to deactivate (treat)
trigger points. [11] Though there has been a contemporary
drive by some myofascial pain theorists to view mTrPs as
potentially occurring throughout muscles or in regions of
muscles rather than relatively fixed anatomic locations,
the Trigger Point Manual [9,10] delineates approximately
255 “common” trigger point locations in the studied mus-
cles that reflect the authors’ extensive clinical experience.
Further, other myofascial researchers including Kelly, Sola,
Kellgren, Kennard, and Haugen [12] independently found
mTrP locations that are anatomically similar to those of
the common mTrPs described in the Trigger Point Manual
[9,10]; and Simons [13] has been focusing on motor end-
plate regions (which are not uniformly distributed in mus-
cles) as the potential sites of mTrPs. This suggests that the
common mTrPs do occur in consistent anatomic locations
in muscles.
Thus, though separated by over 2000 years in development
through markedly different methodologies and concepts of
human physiology, both the acupuncture and myofascial
pain traditions use dry needling of specially designated
anatomic locations (acupuncture points and trigger points,
respectively) to treat pain disorders.
Melzack et al. [12] published the first study that compared
acupuncture with trigger point therapy for musculoskeletal
pain. They reported a 100 % anatomic correspondence of
the studied acupuncture points and trigger points, and a
71 % clinical correspondence in treating pain syndromes.
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Their study had some important limitations, however. Only
48 (< 20 %) of the most common mTrPs subsequently de-
scribed in the Travell and Simons text [9, 10] were examined
for comparison with a limited number of classical acupoints
that are typically used for major pain syndromes or dis-
crete pain locations. The study by Melzack et al. [12] also
used a large (3 cm) separation distance between mTrPs and
acupoints to define their anatomic correspondence, with no
determination if the acupoints actually entered the same
muscle of their anatomically corresponding trigger points.
The purpose of the present study is to re-examine the
findings of Melzack et al’s study [12] that acupoints and
trigger points have anatomic and clinical similarities,
and extend those findings by examining the anatom-
ic, clinical (pain and somatovisceral), and physiologic
(myofascial referred-pain to acupuncture meridian) rela-
tionships between all the 255 common mTrPs delineated
in the Trigger Point Manual [9, 10] and classical acu-
points. This paper (part 1) will examine their anatomic
relationships both qualitatively and quantitatively. The
clinical and physiologic correspondences between mTrPs
and classical acupoints that follow from their anatomic
correspondences will be the subjects of parts 2 and 3,
respectively, of this study.
Methods
Classical acupuncture points have been well described for
nearly 2000 years and are clinically the most important
class of acupoints [3], so the locations of the 361 classical
acupoints were examined for their anatomic similarities
to the locations of 255 common myofascial trigger points
described in the Trigger Point Manual [9, 10], the authori-
tative myofascial pain reference.
Trigger-acupoint anatomic correspondences were studied
both qualitatively and quantitatively. The qualitative com-
parison of classical acupoint locations to those of common
trigger point regions permits analysis of their anatomic
correspondences while adhering to the modern concep-
tualization of mTrPs as potentially occurring throughout
muscles or in muscle regions. The quantitative comparison
of the 255 common mTrP locations to those of classical
acupoints allows estimates of the distances between them
to be calculated.
For the qualitative analysis, Adobe Photoshop software
(Adobe Software, Palo Alto California) was used to modify
graphic images from Primal virtual human anatomic ren-
derings [14] to demonstrate trigger point anatomic regions
and 255 common mTrPs existing within these regions, as
described in the Trigger Point Manual [9, 10] myofascial
pain reference. Additional graphic layers were superim-
posed on these images to demonstrate the 14 Principal
acupuncture meridians and the 361 classical acupoints
that exist on them, as described by the Deadman et al.
[15] acupuncture reference. A physician (AJ) with over ten
years’ acupuncture experience confirmed the accuracy of
each classical acupoint and meridian placement in these
 Originalia | original articles
P. D o r s h e r Trigger Points and Classical Acupuncture Points

graphics. These graphics allow direct visual comparisons
of the locations of muscles, muscle regions, and their com-
mon mTrPs to the locations of classical acupoints and their
associated Principal meridians.
Common mTrPs and classical acupoints that the study’s
graphics demonstrated to be anatomically located in the
same muscle regions and physically closest to each other
were considered to be potential “anatomically correspond-
ing” trigger-acupuncture point pairs, but the present study
required independent validation of those anatomic rela-
tionships by anatomy references before defining mTrP-
classical acupoint pairs as anatomically corresponding.
The cross-sectional anatomic study of acupuncture points
by Chen [16], and the Netter [17] and Clemente [18] human
anatomy references were the principal resources used for
these validations. A representative example of the qualita-
tive analysis results are presented for the head region in
Table 1 and Figure 1. Note that human anatomy refer-
ences [17, 18] demonstrated that the Chen [16] acupoint
anatomy descriptions contained inaccuracies in 27 of the
acupoints examined in this study and incomplete anatomic
descriptions for another 15 acupoints.
The complete dataset of the present study, including all
graphics, was independently validated by the second author
(JF) at another academic institution in another country, us-
ing the same anatomy, myofascial pain, and acupuncture
references. His initial data review verified 233/255 (91 %)
of those mTrP-classical acupoint anatomic correspondenc-
es. Approximately half (45 %) of the remaining 22 contro-
verted point correspondences were due to minor anatomic
differences (e. g. correlation of a rhomboid trigger point
with BL-42 versus BL-43) which were readily resolved by
consensus (Table 2). Twelve major changes in anatomic
correspondence results resulted from the review, with nine
positive mTrP-acupoint anatomic correspondences chang-
ing to “no correspondence”. These changes did not result
from the inability of a needle entering those acupoints to
reach the muscle of the initially correlated common mTrPs,
but rather the depth or direction of needle insertion to do so
would not adhere to acupuncture references’ [3, 15] guide-

Table 1 Common Trigger Point-Classical Acupuncture Point Anatomic Correspondences for Anterolateral Head with Anatomic
Validation Results
Common Trigger Point Location, per
Trigger Point Manual [9]
superficial layer of upper portion of
masseter, anterior
superficial layer of upper portion of
masseter, posterior
superficial layer of mid-belly of
masseter, anterior
superficial layer of mid-belly of
masseter, posterior
superficial layer of lower portion of
masseter, anterior
superficial layer of lower portion of
masseter, posterior
upper portion of deep layer of
masseter
temporalis, anterior fibers
temporalis, middle fibers, anterior
temporalis, middle fibers, posterior
temporalis, posterior fibers
medial pterygoid
lateral pterygoid, superior division
lateral pterygoid , inferior division
orbicularis oculi, orbital portion
zygomaticus major
frontalis
Classical Acupoint Chen [16], Netter [17], and Clemente [18] Validation of Anatomic
Correlation Correspondence Results
SI-18 all 3 references confirm anatomic correspondence
ST-7 all 3 references confirm anatomic correspondence
ST-6 all 3 references confirm anatomic correspondence
ST-6 all 3 references confirm anatomic correspondence
ST-5 all 3 references confirm anatomic correspondence
ST-5 all 3 references confirm anatomic correspondence
ST-7 all 3 references confirm anatomic correspondence
TE-23 Chen incomplete, Netter plates 31/48 and Clemente Figure 507/539 de-
monstrate fibers of temporalis and orbicularis oculi muscles overlap
thus TE-23 will enter this region of the temporalis muscle
GB-3 all 3 references confirm anatomic correspondence
GB-7 all 3 references confirm anatomic correspondence
TE-20 Chen incorrect, Netter plate 48 and Clemente Figure 507/535 demons-
trate TE-20 will enter the posterior fibers of the temporalis muscle
No Correlation no classical acupuncture point enters this muscle
ST-7 all 3 references confirm anatomic correspondence
ST-7 all 3 references confirm anatomic correspondence
TE-23 all 3 references confirm anatomic correspondence
ST-3 all 3 references confirm anatomic correspondence
GB-14 all 3 references confirm anatomic correspondence

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lines for those acupoints. Thus, overall, the review of the

entire trigger-acupuncture point correspondence data dem-
onstrated that 243/255 (95.3 %) of these common mTrP-
classical acupoint anatomic correspondence findings were
fundamentally sound in the initial dataset, reflecting the use
of multiple acupuncture and human anatomy references to
validate each mTrP-acupoint anatomic correspondence.
Finally, a quantitative analysis of the resulting anatomi-
cally corresponding trigger-acupuncture point pairs was
then performed. The locations of the 255 common trig-
ger point locations were measured from the Trigger Point
Manual [9, 10] texts’ graphics and converted to the Chinese
cun system used for acupoint localization. This allowed
quantitative comparison of the approximate body surface

Table 2 Common Trigger Point-Classical Acupuncture

Point Anatomic Correspondence Changes
Following Independent Review
MINOR CHANGES
Figure 1: Oblique View of Head Region Demonstrating the Common Trigger
Common Trigger Point mTrP-Acupoint Corres- Points, Classical Acupoints, and Acupuncture Meridians (masseter in black,
pondence Change temporalis in white, and frontalis, orbicularis oculi, and zygomaticus
major in gray)
lower trapezius BL-42 to BL-43
middle trapezius BL-41 to BL-42
sternal head SCM TE-16 to GB-12
Table 3 Common Myofascial Trigger Point Locations
That Have No Anatomically Corresponding
superficial layer lower portion ST-6 to ST-5 Classical Acupuncture Point
sternalis CV-19 to CV-18 Number Common Trigger Point Location, per Trigger Point
Manual [9, 10]
vastus lateralis distal GB-33 to GB-32
posterior superior 1 medial (internal) pterygoid
vastus lateralis distal GB-33 to GB-32 2 digastric, anterior belly
posterior inferior
3 cervical multifidus
biceps femoris inferocentral BL-38 to BL-37
4 scalenus posterior
biceps femoris lower BL-38 to BL-37
5 subscapularis, superolateral
soleus middle BL-57 to BL-58
(“humeral attachment”)
MAJOR CHANGES
6 subscapularis, inferolateral (“second most frequent
Common Trigger Point mTrP-Acupoint Corres- TrP location”)
pondence Change
7 subscapularis, superomedial
anterior digastric CV-23 to no correlation (“least common TrP location”)
multifidus BL-10 to no correlation 8 anconeus
posterior scalene SI-14 to no correlation 9 palmaris longus
subscapularis HT-1 to no correlation 10 iliacus, proximal
medial biceps brachii no correlation to HT-2 intrapelvic obturator internus, anterior
11
anconeus TE-9 to no correlation
12 intrapelvic obturator internus, posterior
palmaris longus PC-4 to no correlation
13 lateral gluteus medius (“rare”)
gluteus medius medial BL-27 to BL-53
14 gracilis, superior
gluteus medius lateral BL-53 to no correlation
15 gracilis, inferior
mid vastus lateralis anterior GB-31 to ST-32
quadratus plantae KI-2 to no correlation 16 quadratus plantae

adductor hallucis (transverse portion) KI-1 to no correlation 17 transverse head adductor hallucis

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P. D o r s h e r Trigger Points and Classical Acupuncture Points
Figure 2: Trapezius’ Three Anatomic Regions and Its Seven Common Trigger
Points along with Acupuncture Points and Acupuncture Meridians (com-
mon trigger points shown as X’s, Bladder meridian in blue, Gallbladder
meridian in green, Large Intestine meridian in pink, and Triple Energizer
meridian in orange)
positions of each common mTrP and its anatomically cor-
responding classical acupoint (if any). The cun distances
between anatomically corresponding point pairs were con-
verted to centimeters using the conversion that 1 cun is
approximately 2 cm (Dorsher, unpublished data).
Results
Of 255 common trigger points delineated in the Trigger
Point Manual [9, 10], 238 (93.3%) were determined to have
definite anatomic correspondence to classical acupunc-
ture points. This means anatomy references [16, 17, 18]
confirmed that for each of these point pairs, the classical
acupoint enters (or is capable of entering) the muscle re-
gion that its anatomically corresponding trigger mTrP is
described [9, 10] to exist in.
The 17 common trigger points that had no anatomically
corresponding classical acupuncture points are presented
in Table 3. Four of those mTrPs’ muscles are anatomical-
ly inaccessible, five have a meridian course directly over
them but have no proximate classical acupoint, and eight
muscles lay between meridians. In terms of the anatomi-
cally inaccessible muscles, no classical acupoint enters the
medial pterygoid muscle, which is deep within the oral
cavity. The other three muscle mTrP regions that are in-
accessible for needling or injection are deep within the
pelvic cavity (one in the proximal iliacus and two in the
medial portion of the obturator internus) [10]. Five of the
non-corresponding common mTrPs do have anatomic and
physiologic relationships to acupoints and/or meridians.
Acupoint SI-14 piquered deeper than acupuncture refer-
ences [3, 15] recommend will enter the scalenus minimus
muscle [14, 17, 18] but risks penetrating the cupola of the
lung. No classical acupoint enters the common mTrP re-
Originalia | original articles
Figure 3: Posterior Neck and Upper Back with Trapezius and Latissimus
Dorsi Removed Showing from top to bottom Occipitalis, Splenius Capitis,
Levator Scapulae, Rhomboid Minor, and Rhomboid Major Common Trigger
Points along with Acupuncture Points and Acupuncture Meridians (com-
mon trigger points shown as X’s, Bladder meridian in blue, Gallbladder
meridian in green, Small Intestine meridian in red, and Triple Energizer
meridian in orange)
gion described in the C4-5 level cervical multifidus muscle
[9], but the Bladder meridian courses directly over this re-
gion. Similarly, no classical acupoint enters the anconeus
muscle but the Triple Energizer meridian courses over it.
No classical acupoint enters the gracilis muscle, which has
2 common mTrP regions described [10], but the Kidney
meridian courses over this muscle [3, 15, 17, 18]. Note that
the myofascial referred-pain patterns described for each
of these 5 mTrP regions [9, 10] are largely in the distribu-
tions of the acupuncture meridians that course over them.
Eight muscles examined exist between the distributions of
adjacent acupuncture meridians. No classical acupoints
enter the common trigger point regions described for the
palmaris longus, lateral gluteus medius (“rare”), or quad-
ratus plantae muscles [9, 10], which anatomically are be-
tween the Heart and Pericardium, Bladder and Gallbladder,
and Kidney and Bladder meridians, respectively [3, 15].
The referred-pain pattern described for the palmaris longus
muscle [9] is largely in the Pericardium meridian distribu-
tion and that of the lateral gluteus medius muscle [10] is
largely in the Bladder meridian distribution. No classical
acupoints enter the anterior belly of the digastric muscle
which anatomically courses slightly lateral to the Concep-
tion Vessel meridian [3, 15], though that muscle region’s
referred-pain pattern [9] follows the distribution of that
meridian. No classical acupoint enters the transverse head
of the adductor hallucis muscle, but the Kidney merid-
ian does cross its lateral fibers [3, 15]. Finally, the study’s
graphics suggested that HT-1 might anatomically corre-
spond to the subscapularis muscle, but anatomic referenc-
es [3, 15–18] demonstrate that the acupoint does not enter
the subscapularis. If the modern conceptualization of trig-
ger points as potentially occurring throughout a muscle or
region of a muscle is considered, then 6 of these 17 mTrP
regions described by the Trigger Point Manual [9, 10] could
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Figure 4: Posterior Neck and Upper Back With Deltoids, Splenius Capitis, &
Rhomboids Removed Showing from top to bottom Semispinalis Cervicis,
Infraspinatus, Teres Minor, and Multifidi Common Trigger Points along with
Acupuncture Points and Acupuncture Meridians (common trigger points
shown as X’s, Bladder meridian in blue, Gallbladder meridian in green,
Small Intestine meridian in red, and Triple Energizer meridian in orange)
be considered anatomically corresponding to acupuncture
meridians, as outlined above. This would increase the ana-
tomic correspondence level of trigger points to acupoints
to 244/255 (95.7 %).
Figures 2–7 demonstrate representative examples of the
qualitative graphic results. These figures demonstrate the
relationships of the acupuncture meridians and the clas-
sical acupoints described to exist on them to the body’s
muscles and their common mTrPs. As a generalization, the
acupuncture meridians course mostly parallel to the ori-
entation of muscles in the extremities; while in the trunk,
except for the rectus abdominis and paraspinal muscles,
meridians course mostly perpendicular to the orientation
of the muscles there. Four progressively deeper muscle
layers of the posterior neck and upper back are demon-
strated in figures 2–5, while the last figures 6 and 7 show
the anterior torso with arms and the anterior lower ex-
tremities, respectively. Note that the scapulae in figures
2–5 are slightly abducted from their standard anatomic
positioning, so this should be considered when evaluating
the mTrP-acupoint anatomic correspondences in those im-
ages. These six figures serve to demonstrate the depth and
breadth of the anatomic relationships of muscles and their
common mTrPs [9,10] to acupuncture meridians and clas-
sical acupoints. These same figures will be used in the third
part of this study to demonstrate the close relationships of
these trigger point regions’ referred-pain patterns to acu-
puncture meridian distributions. That is, the referred-pain
patterns the Trigger Point Manual [9, 10] describes for each
muscle (or region within it) almost always follow the dis-
tribution of the acupuncture meridian that courses over
that muscle (or region of the muscle).
In terms of the distances between common mTrPs and
their anatomically corresponding classical acupoints, 37 %
(89/238) of point pairs were estimated to be within 1 cm of
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Figure 5: Posterior Neck and Upper Back With Teres Major, Teres Minor, & Se-
mispinalis Cervicis Removed Showing from top to bottom Suboccipital, Cervical
Multifidi, Supraspinatus, and Iliocostalis Thoracis Common Trigger Points along
with Acupuncture Points and Acupuncture Meridians (common trigger points
shown as X’s, Bladder meridian in blue, Gallbladder meridian in green, Small
Intestine meridian in red, and Triple Energizer meridian in orange)
each other, and 82 % (196/238) were within 2 cm (~1 cun)
of each other. Another 32 (13 %) corresponding point pairs
involving 27 discrete classical acupoints were estimated
to be 2–3 cm apart. Acupuncture texts [3,15] allow needle
insertion at least this far for 22 (82 %) of those acupoints.
Discussion
The present study found that 93.3 % of 255 common trig-
ger points described in the Trigger Point Manual [9,10]
have an anatomically corresponding classical acupuncture
point, which is slightly lower than the 100% anatomic cor-
respondence of trigger points and acupoints reported by
Melzack et al. [12] The lower percentage of corresponding
points in the present study likely relates to its stricter crite-
ria for determining mTrP-acupoint anatomic correspond-
ence, namely the requirement that anatomic references
document that for each point pair, the classical acupoint
enters the muscle region of its anatomically corresponding
common trigger point.
The present study also differed from that of Melzack et al.
[12] in not setting an arbitrary distance between a mTrP–
acupoint pair as a criterion to define anatomic correspond-
ence. This aspect of the present study’s methodology was
chosen for three reasons. First, the Trigger Point Manual
[9, 10] does not provide precise descriptions of the loca-
tions of common mTrPs but rather their approximate sites
in muscles are illustrated. The common mTrPs illustrated
do, however, provide anatomic anchors within muscles for
muscle sub-regions that may have differing clinical ef-
fects and referred-pain patterns (e.g. the trapezius muscle
has 7 trigger point regions having differing referred-pain
patterns and some of which have somatovisceral effects
described [9]). Similarly, the cun location system for acu-
 Originalia | original articles
P. D o r s h e r Trigger Points and Classical Acupuncture Points

Figure 6: Anterior Chest and Arms Showing from top to bottom Anterior
Deltoid, Coracobrachialis, Medial Aspect of Medial Head of Triceps, Biceps,
Brachioradialis, Pronator Teres, & Flexor Digitorum Superficialis Common
Trigger Points along with Acupuncture Points and Acupuncture Meridians
(common trigger points shown as X’s, Heart meridian in red, Large In-
testine meridian in purple, Lung meridian in pink, and Triple Energizer
meridian in orange )
Figure 7: Anterior Thighs and Legs Showing from top to bottom Tensor
points does not define the exact position of acupoints, only Fascia Latae, Gluteus Minimus, Rectus Femoris, Adductor Longus, Vastus
Medialis, Tibialis Anterior, Abductor Hallucis, and First Dorsal Interosseus
their approximate insertion sites. [3] Therefore, it seems Common Trigger Points along with Acupuncture Points and Acupuncture
more appropriate to provide an estimate of how far apart Meridians (common trigger points shown as X’s, Gallbladder meridian in
anatomically corresponding common mTrPs and classical green, Kidney meridian in yellow, Liver meridian in purple, Spleen meri-
acupoints are than to attempt to define a distance that the dian in red, and Stomach meridian in pink)

separation between point pairs must fall within. Second,

the present study’s methodology is also consistent with the ger points cannot (should not) be compared or have cor-
modern conceptualization of trigger points as occurring in respondence to classical acupoints. There are fundamental
muscle regions rather than precisely definable anatomic conceptual as well as data presentation and analysis defi-
sites. Finally, the guidelines from acupuncture references ciencies in Birch’s study [19], however, that render its sup-
[3, 15] for needle insertion may allow 1.5–3 cun (~3–6 porting data incorrect and therefore its conclusions invalid.
cm) depth of entry at some acupoints. Furthermore, the Birch’s conceptual opinion that mTrPs should only be com-
depth of trigger point needling is not rigidly defined in pared to ashi acupoints [19] because only those acupoints
the Trigger Point Manual [9, 10]. Despite these issues, it are defined by tenderness ignores the fact that acupuncture
is remarkable that the quantitative analysis of the present references [3, 15] document that tenderness is a fundamen-
study produced estimates that 82 % of anatomically cor- tal clinical characteristic of all acupoints (“when locating
responding common mTrP-classical acupoint pairs are
within 2 cm of each other, and that 95 % of point pairs are
within 3 cm of each other.
Figure 8 presents a conceptualization of why anatomic
and clinical similarities of corresponding mTrPs and clas-
sical acupoints are present. Simply put, the anatomic site
stimulated by the acupuncture needle tip is unknown,
as is the anatomic site treated by trigger point needling.
Even though acupuncture needles are initially inserted
into planes between muscles, tendons, and/or bones, and
trigger point needles are inserted into muscles, they could
both ultimately be stimulating the same anatomic substrate
to produce similar clinical (pain and somatovisceral) and
physiologic (referred-pain and meridian) effects.
Birch’s 2003 study [19] re-examined the data of Melzack et
al. [12] that found substantial anatomic and clinical pain
correspondences of trigger points and classical acupoints, Figure 8: Comparison of Trajectories of Trigger Point Injections versus Acu-
but his conceptual and clinical analysis concluded that trig- puncture Point Piquering

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the precise position of an acupoint, the most important sin-
gle guide is sensitivity”—Shanghai College of Traditional
Medicine text, p. 122 [3]). Birch [19] offered a second con-
ceptual reason of why only ashi points should be compared
to mTrPs: that ashi points “are associated with the jing-jin
system, which have as associated symptoms muscle pain/
spasms, and joint pain — mTrPs’ principal symptoms.” This
claim ignores the fact that all but 2 (BL-8 and ST-17) of 361
classical acupoints do have pain indications described [3,
15], which almost always are for proximate musculoskel-
etal pain conditions. Further, Birch’s conceptual reasoning
implies that ashi points are clinically and anatomically con-
fined to Muscle channels and acupoints to Principal chan-
nels, which acupuncture references literally contradict. The
Shanghai reference [3] states that “Muscle channels are not
viewed as distinct anatomic entities but rather represent an
early description of the structure and function of the body’s
musculature within the overall framework of the traditional
channel system … because of the intimate relationship be-
tween the Primary channels and Muscle channels, an acu-
point on the related Primary channel may be selected … to
treat a local Muscle channel symptom” (pages 99–100). Ma-
ciocia’s authoritative text on the acupuncture channels [20]
states (page 285) that “Muscle channels are called ‘Jing Jin’
in the Spiritual Axis, which could be translated as ‘channel-
like muscles’ or ‘muscles of the channels’.” The intimate ana-
tomic relationship of the Primary and Muscle channels (that
is, no anatomic boundary between them) is thus established
by these references as is the use of classical acupoints to
treat Muscle channel conditions.
Birch’s clinical “evidence” [19] of why trigger points can-
not be compared to classical acupoints can also be dem-
onstrated to be invalid. His 2003 study [19] compiled the
frequency of how often the classical acupoints clinically
correlated to mTrPs by Melzack et al. [12] are mentioned
for pain or other indications in the clinical applications
sections of five acupuncture reference texts, and concluded
that trigger points and classical acupoints cannot be cor-
respondent because the acupoints correlated by Melzack et
al. [12] are not frequently used for pain (or any other indi-
cations). All of the Birch study’s [19] statistics can be dem-
onstrated to be inaccurate due to data analysis deficien-
cies (see below), which further undermines his untenable
presumption that his statistics are sufficient to invalidate
those classical acupoints’ reported [3, 15] pain indications
(which reflect thousands of years of clinical experience).
Birch’s study [19] failed to properly examine Melzack et al’s
data [12], rendering all its statistical results inaccurate. Birch
[19] failed to examine Melzack et al. data’s [12] 15 “negative”
TrP-acupoint pain correspondences, and also failed to present
that data’s evidence demonstrating TrP-acupoint somatovis-
ceral correspondences and TrP influences on distant pain sites.
At least 9 and probably 14 of those “negative” correspond-
ences were actually “positive” (comparable pain indications),
including an iliocostalis mTrP to BL-47, a hamstring mTrP to
BL-37, longissimus mTrPs to BL-18 and BL-19, a subscapu-
laris mTrP to HT-1, a gastrocnemius mTrP to KI-10, a toe
extensor mTrP to ST-37, a tibialis anterior mTrP to ST-36, a
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scalene mTrP to LI-17, first dorsal interosseus and adductor
pollicis mTrPs to LI-4, a pectoralis major mTrP to GB-22, and
adductor longus mTrPs to LR-10 and LR-11. Trigger point-
acupoint clinical pain correspondences in Melzack et al’s data
[12] then increase potentially to 98 % (49/50).
Birch’s study [19] claimed yet another clinical reason mTrPs
could not correlate to classical acupoints is that Melzack et
al’s data [12] did not present evidence of somatovisceral cor-
respondences of mTrP-classical acupoint pairs or mTrP ef-
fects on distant pain sites. The reality, however, is that Birch
[19] simply failed to report that evidence. Melzack et al’s
data [12] documented 9 common mTrP-classical acupoint
somatovisceral correspondences (all positive). These includ-
ed a trapezius mTrP that treats cardiac pain syndromes and
BL-16 used for heart pain/pericarditis [3], a pectoralis mTrP
that treats angina pectoris and KI-23 used for painful chest
obstruction [3], and a splenius capitis mTrP that treats head-
ache and TE-16 used for headache [3]. Melzack et al’s study
[12] also demonstrated 8 mTrPs having distant pain effects,
including a trapezius mTrP causing temporal pain, a scalene
mTrP causing index finger pain, multifidi mTrPs causing
periumbilical pain, and a gluteus minimus mTrP causing
lateral ankle pain. The Trigger Point Manual [9,10] provides
other examples of mTrPs that influence distant pain condi-
tions (e.g., a soleus TrP near BL-57 whose referred pain is
isolated to the lumbar spine, and another near GB-35 whose
referred pain is confined to the temple/cheek region).
Thus, Birch’s 2003 study [19] simply failed to report that
marked clinical correspondences of common mTrPs and
classical acupoints for both somatovisceral (100 %) and
pain (up to 98 %) disorders and evidence that mTrPs can
influence distal pain sites were presented in Melzack et
al’s study [12]. The sum of these multiple conceptual, data
reporting, and data analysis errors in Birch’s 2003 study
[19], all of which favor “no correspondence” of mTrPs and
classical acupoints, strongly suggests a systematic bias in
that report, which his recent editorial [21] on this topic
provides even further evidence of.
Skeptics might still question why there are classical acu-
points that do not have anatomically corresponding myo-
fascial trigger points (361 classical acupoints are described
but only 255 common TrPs). First, the Trigger Point Manual
[9, 10] reflects only about 100 years of accumulated clini-
cal data and experience, whereas acupuncture points reflect
3000+ years of clinical knowledge and experience. It fol-
lows that the myofascial pain tradition’s clinical experience
and thus its accumulated dataset on mTrPs is still (relatively)
in its infancy. Second, though the Trigger Point Manual [9,
10] is the authoritative text on myofascial pain and its treat-
ment, it does not present all available data on mTrPs. Ad-
dressing all available mTrP data is beyond the purpose and
scope of the present study. Nearly 25 % of all the “common”
mTrPs described by the Trigger Point Manual [9, 10] are
demonstrated in figures 1–7. Third, in reviewing those fig-
ures, most other classical acupoints do have anatomic rela-
tionships to muscles and muscle regions (some anatomically
also near the 255 common mTrPs [9, 10]) which could po-
tentially have mTrPs; so many potential clinically important

P. D o r s h e r Trigger Points and Classical Acupuncture Points
“common” mTrPs may simply not have been discovered yet
in the (relatively) young myofascial pain tradition. Finally,
focusing on what acupoints don’t correlate with mTrPs dis-
tracts from the fact that the present study demonstrates that
at least 93.3 % of common mTrPs that are described by the
Trigger Point Manual [9, 10] do have anatomically corre-
sponding classical acupoints!
There are theoretically an infinite number of acupuncture
points (e. g. ashi points) that may be present in clinical
practice, and the 361 classical acupoints represent clinically
common and/or important acupuncture point locations that
reflect at least a thousand years of accumulated clinical
experience [3]. Analogously, some theorists [22] state that
trigger points may occur anywhere in muscles or muscle
regions (potentially an infinite number of mTrPs), but this
does not negate that the 255 “common” trigger point re-
gions described in the Trigger Point Manual [9, 10] reflect
the most frequently seen, best described, and thus most
clinically important mTrPs seen in those authors’ decades
of clinical experience. Other myofascial researchers includ-
ing Kelly, Sola, Kellgren, Kennard, and Haugen [9, 12] in-
dependently described mTrP locations that are similar in
anatomic location to the “common” mTrPs delineated in the
Trigger Point Manual [9, 10]. Moreover, there is evidence
that other civilizations, separated from the acupuncture and
myofascial pain traditions by different eras, cultures, and
geographic locations, also found similar illness treatment
concepts. Ötzi, the 5200 year-old “Iceman” found in the Ty-
rol Alps, has tattoo marks on his knee and ankle (near acu-
points LR-8 and BL-60, respectively) postulated to represent
acupuncture-like treatment points for sciatica [23]. Imhotep,
physician to the Egyptian pharaohs ~ 2600 BC, is the prob-
able source of spine and limb injury treatments described in
the Ebers and Smith papyruses (17 [th] century BC). Some
of these treatment concepts are similar to those of TCM [24].
Mayan healers (“curanderos”) used “jup” and “tok” needling
techniques analogous to those of TCM “to move the stag-
nant blood and air” at points that anatomically and clinical-
ly overlap with those of classical acupoints [25]. Why would
all these clinicians practicing in different eras and cultures
with varying levels of scientific advancement and concep-
tualizations of human physiology all describe such similar
findings? This suggests all these traditions are describing
clinical findings that must reflect fundamental properties of
human anatomy and/or physiology. I believe there is an an-
atomic reason for this (which will be the subject of a future
report). These issues must also be addressed by myofascial
pain theorists [22] who recommend abandoning the Trig-
ger Point Manual’s [9, 10] common mTrP locations to view
trigger points as occurring throughout muscles or in muscle
regions, as well as acupuncture theorists [19] who cling [21]
to the demonstrably invalid view that classical acupoints are
anatomically and physiologically unique phenomena.
The marked anatomic correspondence (≥ 93.3 %) of the loca-
tions of the common mTrPs described in the Trigger Point
Manual [9, 10 ]and those of classical acupuncture points dem-
onstrated in this paper is only the first part of the evidence
that documents the fundamental correspondences of trigger
Originalia | original articles
Summary
• 93.3 % of 255 common trigger point regions de-
scribed by the Trigger Point Manual have anatomi-
cally corresponding classical acupuncture points.
• 37 % of anatomically corresponding common trig-
ger point-classical acupoint pairs are estimated to
be within 1 cm of each other, 82 % within 2 cm of
each other, and 95 % within 3 cm of each other.
points and acupoints anatomically and physiologically. The
second part of this study will present the marked clinical cor-
respondences of both the pain and somatovisceral indications
of these anatomically corresponding common mTrP-classical
acupoint pairs, and the third part of the study will present the
marked physiologic correspondences (myofascial referred-
pain to acupuncture meridian) of those point pairs.
Conclusion
There is at least a 93.3 % (potentially up to 96 %) anatomic
correspondence of the “common” trigger point locations de-
scribed in the Trigger Point Manual [9, 10] to the locations of
classical acupoints. Anatomic correspondence of a common
trigger point and a classical acupoint means those points
are proximate and are demonstrated by acupuncture and
anatomy references to enter the same muscle region. 82 %
of these anatomically corresponding point pairs are within
2 cm of each other, and 95 % within 3 cm of each other.
These findings provide this study’s anatomic evidence that
common trigger points and classical acupoints likely rep-
resent the same physiologic phenomena, confirming the
findings of Melzack et al. [12]. Despite being separated by
2000 years, different cultures, different conceptualizations of
physiology, and different treatment methods, the acupunc-
ture and myofascial pain healing traditions show marked
similarity in their anatomic localizations of their most clini-
cally important treatment points (the classical acupuncture
points and common trigger points, respectively).
Authors
All primary research by PD. JF, physician, with over ten
years’ acupuncture experience confirmed the accuracy
of each classical acupoint and meridian placement in the
graphics, helped drafting the manuscript.
Financial support
This study was not supported by other institutions.
Conflict of Interest
None
Acknowledgements
Thanks to Adria I. Johnson, M.D., for proofing this study’s im-
ages. Thanks to Primal Pictures Ltd; www.primalpictures.com
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