Journal of Bodywork & Movement Therapies xxx (2017) 1e6

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Journal of Bodywork & Movement Therapies

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Test-retest reliability of myofascial trigger point detection in hip and

thigh areas*
E. Rozenfeld, BPT a, b, A.S. Finestone, MD c, U. Moran, BPT a, E. Damri, BPT a, b,
L. Kalichman, PT, PhD b, *
a
Israel Defense Force, Medical Corps, Israel
b
Department of Physical Therapy, Recanati School for Community Health Professions, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer
Sheva, Israel
c
Assaf HaRofeh Medical Center, Zeriffin, Affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Israel

a b s t r a c t
Keywords: Background: Myofascial trigger points (MTrP's) are a primary source of pain in patients with musculo-
Myofascial trigger points skeletal disorders. Nevertheless, they are frequently underdiagnosed. Reliable MTrP palpation is the
Reliability study
necessary for their diagnosis and treatment. The few studies that have looked for intra-tester reliability of
Evaluation
MTrPs detection in upper body, provide preliminary evidence that MTrP palpation is reliable. Reliability
tests for MTrP palpation on the lower limb have not yet been performed.
Objective: To evaluate inter- and intra-tester reliability of MTrP recognition in hip and thigh muscles.
Design: Reliability study.
Subjects: 21 patients (15 males and 6 females, mean age 21.1 years) referred to the physical therapy
clinic, 10 with knee or hip pain and 11 with pain in an upper limb, low back, shin or ankle.
Methods: Two experienced physical therapists performed the examinations, blinded to the subjects'
identity, medical condition and results of the previous MTrP evaluation. Each subject was evaluated four
times, twice by each examiner in a random order. Dichotomous findings included a palpable taut band,
tenderness, referred pain, and relevance of referred pain to patient's complaint. Based on these, diagnosis
of latent MTrP's or active MTrP's was established. The evaluation was performed on both legs and
included a total of 16 locations in the following muscles: rectus femoris (proximal), vastus medialis
(middle and distal), vastus lateralis (middle and distal) and gluteus medius (anterior, posterior and
distal).
Results: Inter- and intra-tester reliability (Cohen's kappa (k)) values for single sites ranged from
0.25 to
0.77. Median intra-tester reliability was 0.45 and 0.46 for latent and active MTrP's, and median inter-
tester reliability was 0.51 and 0.64 for latent and active MTrPs, respectively. The examination of the
distal vastus medialis was most reliable for latent and active MTrP's (intra-tester k ¼ 0.27e0.77, inter-
tester k ¼ 0.77 and intra-tester k ¼ 0.53e0.72, inter-tester k ¼ 0.72, correspondingly).
Conclusions: Inter- and intra-tester reliability of active and latent MTrP evaluation was moderate to
substantial. Palpation evaluation can be used for clinical diagnosis of MTrP's in the hip and thigh muscles.
Significance: This study provides evidence that MTrP palpation is a moderately reliable diagnostic tool in
the hip and thigh muscles and can be used in clinical practice and research.
© 2017 Elsevier Ltd. All rights reserved.

1. Introduction

A myofascial trigger point (MTrP) is defined as a hyperirritable

spot within a palpable taut band of a skeletal muscle that is painful
*
on compression, stretch or overload, and that give rise to referred
Results of this study were presented during 7th Conference of International
Academy of Manual Musculoskeletal Medicine, Brussels, Belgium, November 2015.
pain pattern (Simons et al., 1999). MTrP's may develop anywhere in
* Corresponding author. the body as a response to overload, injury or repetitive
E-mail address: kalichman@hotmail.com (L. Kalichman).

http://dx.doi.org/10.1016/j.jbmt.2017.03.023
1360-8592/© 2017 Elsevier Ltd. All rights reserved.

Please cite this article in press as: Rozenfeld, E., et al., Test-retest reliability of myofascial trigger point detection in hip and thigh areas, Journal of
Bodywork & Movement Therapies (2017), http://dx.doi.org/10.1016/j.jbmt.2017.03.023
2 E. Rozenfeld et al. / Journal of Bodywork & Movement Therapies xxx (2017) 1e6
List of abbreviations
ASIS anterior superior iliac spine
MTrPs myofascial trigger points
PNeg proportion of negative agreements
PPos proportion of positive agreements
PSIS posterior superior iliac spine
VMO vastus medialis oblique
microtrauma (Nice et al., 1992). Various studies have shown that
MTrP's were the primary source of pain in 30%e85% of patients
presenting in a primary care or pain clinic because of pain (Fishbain
et al., 1986; Fricton et al., 1985; Gerwin, 1995; Nielsen et al., 2007;
Skootsky et al., 1989). MTrP's were the primary source of pain in 74%
of 96 patients with musculoskeletal pain seen by a neurologist in a
community pain medical center (Gerwin, 1995). Fishbain et al.
found that MTrP's were the primary source of pain in 85% of 283
patients consecutively admitted to a pain center (Fishbain et al.,
1986). Despite this, MTrP's are often underdiagnosed by both
physicians and physical therapists, leading to chronic conditions
(Feinberg and Feinberg, 1998; Tay et al., 2000).
MTrP's are subdivided into active and latent. An MTrP is
considered active if the referred pain it evokes during its
compression is relevant to the patient's complaints, whereas it is
considered latent if the evoked referred pain is not relevant to
patient's complaints (Simons et al., 1999). There are some new
diagnostic methods for visual demonstration of MTrP's such as
sonoelastography and magnetic resonance elastography, but these
methods have many problems (low reliability, low availability and
high cost) and are therefore not yet in clinical use (Ballyns et al.,
2011; Chen et al., 2008; Sikdar et al., 2008). Palpation is currently
the only method available for clinical diagnosis of MTrP's and it is
performed following the diagnosis criteria established by Simons
et al. (1999) and by Gerwin et al. (1997):
 The presence of a palpable taut band in skeletal muscle
(necessary sign).
 The presence of a hypersensitive tender spot within the taut
band (necessary sign).
 Reproduction of referred pain in response to MTrP compression
(necessary sign).
 Local twitch response elicited by the snapping palpation of the
taut band (confirmatory sign).
Reliable MTrP palpation is the necessary prerequisite to
considering myofascial pain as a valid diagnosis (Gerwin and
Shannon, 2000). Published inter-rater studies have reported poor
to good reliability for MTrP's palpation (Gerwin et al., 1997; Hsieh
et al., 2000; Nice et al., 1992; Njoo and Van der Does, 1994).
Gerwin et al. (1997) found good to very good kappa levels
(k ¼ 0.65e0.95), whereas Nice et al. (1992) showed only fair kappa
levels (k ¼ 0.29e0.38). These studies indicate that while referred
pain was the most reliable criterion for palpatory diagnosis, finding
the taut band associated with the MTrP is the most important
aspect of the physical examination. Without the taut band, the
MTrP cannot be reliably located. As a result of this, it is crucial to
perform a training session for any examiner as was done by Hsieh
et al. (2000). Whilst these studies provide some indication
regarding the inter-tester reliability, they do not consider intra-
tester reliability, which could be more important considering that
assessment of interventions is usually made by the same person.
Please cite this article in press as: Rozenfeld, E., et al., Test-retest reliability of myofascial trigger point detection in hip and thigh areas, Journal of
Bodywork & Movement Therapies (2017), http://dx.doi.org/10.1016/j.jbmt.2017.03.023
The few studies that have looked for the intra-tester reliability of
MTrP detection in upper body quadrant provide preliminary evi-
dence that MTrP palpation is reliable and, therefore, a potentially
useful diagnostic tool (Al-Shenqiti and Oldham, 2005; Bron et al.,
2007) k ¼ 0.75e1 and k ¼ 0.12e0.72, respectively. Recently, Zuil-
Escobar et al. (Zuil-Escobar et al. (2016) performed a reliability
test for latent MTrPs palpation in lower limb muscles in 206
asymptomatic subjects. This study presents very high intra-tester
reliability in all evaluated muscles, much higher than found in
previous reliability studies (k ¼ 0.762e1).
The aim of this study was to evaluate inter- and intra-tester
reliability of MTrP recognition in hip and thigh muscles. Our hy-
pothesis was that palpation is a reliable method of MTrP evaluation.
2. Methods
2.1. Design
Reliability study.
2.2. Setting
Physical Therapy Department, Military outpatient clinic, Nathan
military base, Beer Sheva, Israel.
2.3. Subjects
We recruited 21 soldiers and officers (15 men and 6 women) that
were referred for physical therapy due to various medical conditions.
Ten were referred because of complaints in the knee and hip. The
remaining 11 recruited subjects were referred due to upper limb
(N ¼ 2), low back (N ¼ 5), shin (N ¼ 2) and ankle (N ¼ 2) pain. Inclusion
criteria were age between 18 and 30 and referral to physical therapy
by a medical doctor due to any musculoskeletal pain condition in any
part of the body. Exclusion criteria included any medical condition
that could be a contraindication for physical treatment, participation
in another interventional clinical trial, history of major psychiatric or
neurological illness, fibromyalgia or other systemic rheumatic dis-
eases, and pregnancy. None of the subjects had met the examiners
before the study. All subjects received an explanation about the study
and signed informed consent. The study was approved by Israel De-
fense Forces ethical review board (No. of approval 1427e2014).
2.4. Evaluation procedure
Each subject completed the demographic questionnaire and had
a physical examination. Demographic data collected included sex,
age, height and weight to calculate the Body Mass Index (BMI,
weight (kg) divided by height (meters) squared), type of military
service (desk job, support troops or combatants) and area of the
main complaint.
The examiners were physical therapists with at 4 and 6 years of
clinical experience and three years of day-to-day experience in
evaluation and treatment of MTrP's. Before the beginning of the
study, both examiners had a coordination session with two expert
practitioners in myofascial pain evaluation. During this session, the
examiners came to a clear agreement on the above definitions and
how they should be summarized on paper. The training included
palpation skills practice, surface anatomy, subject's positioning, etc.
At the end of the training, a detailed protocol sheet for the MTrP
evaluation was prepared.
During the MTrP evaluation, examiners were blinded to the
subjects' identities, medical condition (site of symptoms) and re-
sults of previous examinations carried out, both by themselves and
by the second examiner.
 E. Rozenfeld et al. / Journal of Bodywork & Movement Therapies xxx (2017) 1e6 3

Each subject was evaluated four times, twice by each examiner.
There were at least 15 min between evaluations by two examiners
and at least one hour between repeated evaluations by the same
examiner. Subjects were briefed to answer the question on rele-
vance to the complaint without regards to whether their complaint
was present in the upper extremity or lower extremity. Subjects
entered the evaluation room in a random order. The randomization
was performed using a random sequence generator (“Generator
random sequence”, 2014). They were asked to refrain from any
physical activity during and between the evaluations.
The examiners performed evaluation of MTrP's using a flat
palpation technique, according to the diagnosis criteria established
by Simons et al. (Simons et al., 1999) to identify the following: 1)
the presence of a taut band; 2) the presence of a tender spot during
palpation; and 3) reproduction of the referred pain during MTrP
compression.
All criteria were scored dichotomously, as presence or absence
of each criterion. If the examiner was unsure of the result, he was
instructed to score that specific criterion as absent. Definition of the
active and latent MTrP's was made by summarization of the diag-
nosis criteria. A point was considered an MTrP when a taut band,
tenderness, and referred pain were present. If the subject answered
that the referred pain was relevant to his complaints, the MTrP was
labeled as active. If not, the MTrP was considered latent.
The evaluation was performed on four muscles in both legs and
each muscle was subdivided into different areas, therefore a total of
sixteen areas were evaluated (Fig. 1).
2.4.1. Rectus femoris (subject supine)
After identifying the anterior superior iliac spine (ASIS) and the
patella, the thigh was visually divided into three parts. Palpation
was performed approximately four fingers distally to the ASIS and
down to an upper third of the thigh.
femur and divided the thigh into thirds. Examination areas were
over the lateral thigh at the middle and distal thirds.
2.4.4. Gluteus medius (subject lay on the contralateral side with the
knee slightly flexed and supported by a pillow)
The examiner identified the greater trochanter, ASIS and pos-
terior superior iliac spine (PSIS). The muscle was divided into three
areas: anterolateral, approximately three fingers posterior and
inferior to ASIS; posterior, approximately three fingers anterior to
PSIS; and distal, approximately three fingers superior to the greater
trochanter.
2.5. Statistical analysis
All statistical analysis was performed using SPSS statistical
package (Version 17). Significance levels were set at P < 0.05.
Frequencies were calculated for the subject demographic in-
formation. To calculate inter- and intra-tester reliability, we used
both Cohen's kappa-values (k) grading (Landis and Koch, 1977), and
positive and negative agreements (PPos and PNeg). Calculation of
kappa based on the difference between actual agreement and
agreement expected by chance alone. Kappa is a coefficient of
agreement occurring beyond the chance, presented on a
1 to 1
scale, where 1 is perfect agreement, 0 is exactly what would be
expected by chance, and negative values indicate agreement less
than chance (Viera and Garrett, 2005). Landis and Koch (Landis and
Koch, 1977) suggested that kappa k < 0.00 represents poor reli-
ability, 0.001e0.20 minor, 0.21e0.40 fair, 0.41e0.60 moderate,
0.61e0.80 substantial or good, and 0.81e1.00 very good reliability.
3. Results

3.1. Subject characteristics

2.4.2. Vastus medialis oblique (VMO) (subject supine with the
examined leg supported by a pillow)
Study sample characteristics are summarized in Table 1.
The examiner asked the subject to perform an isometric
Twenty-one subjects (15 males and 6 females; mean age 21.1 ± 1.8;
contraction of the quadriceps and then to relax. The examiner
(95% CI 20.2e21.9) and BMI 24.5 ± 2.5; (95% CI 23.3e25.7)) met the
located the vastus medialis at the anteromedial aspect of the thigh
inclusion criteria and agreed to participate in this study.
from the medial patellar border to the anterior midline of the thigh.
The muscle was examined in two areas: middle and distal.
3.2. Inter- and intra-tester reliability
2.4.3. Vastus lateralis (subject lay on the contralateral side with
knee slightly flexed and supported by a pillow) Tables 2 and 3 present the data (Cohen's kappa values, PPos and
The examiner identified the ASIS and the lateral condyle of the PNeg) on MTrP diagnostic criteria from 42 thighs of 21 subjects. The
tables present the data according to intra- and inter-tester results
and divided to eight muscle areas.

Table 1
Characteristics of studied sample (n ¼ 21).a

Characteristics n (%) mean ± SD (95% CI)

Age (years) 21.1 ± 1.8 (20.2e21.9)

Gender (males) 15 (71.4)
Complaints
Upper limb 2 (9.5)
Low back 5 (23.8)
Hip 2 (9.5)
Anterior knee pain 8 (38.1)
Shin pain 2 (9.5)
Ankle 2 (9.5)
BMI 24.5 ± 2.5 (23.3e25.7)
Service type
Desk job 9 (42.9)
Support troops 8 (38.1)
Combatants 4 (19.0)
Fig. 1. MTrP palpation areas in the evaluated muscles.
a
a. Rectus femoris (proximal); b. Vastus medialis oblique (middle and distal); c. Vastus Data collected from demographic questioners. BMI - body mass index; CI -
lateralis (middle and distal); Gluteus medius (ante-lateral, posterior and distal). confidence interval; SD - standard deviation.

Please cite this article in press as: Rozenfeld, E., et al., Test-retest reliability of myofascial trigger point detection in hip and thigh areas, Journal of
Bodywork & Movement Therapies (2017), http://dx.doi.org/10.1016/j.jbmt.2017.03.023
4 E. Rozenfeld et al. / Journal of Bodywork & Movement Therapies xxx (2017) 1e6

Table 2
Intra- and inter-tester reliability results.

Muscle Latent trigger point Active trigger point

Kappa p-value PPos PNeg Kappa p-value PPos PNeg

Rectus femoris Intra 1 0.533 0.000 0.571 0.961
0.040 0.743 0 0.937
Intra 2 0.475 0.002 0.500 0.975
0.024 0.874 0 0.976
Inter
0.068 0.638 0 0.923
0.040 0.743 0 0.937
Middle Intra 1 0.364 0.016 0.400 0.962 0.656 0.000 0.667 0.988
VMO Intra 2 0.549 0.000 0.615 0.930 0.774 0.000 0.800 0.973
Inter 0.540 0.000 0.571 0.961 0.644 0.000 0.667 0.974
Distal VMO Intra 1 0.276 0.060 0.364 0.904 0.533 0.000 0.571 0.961
Intra 2 0.774 0.000 0.800 0.973 0.725 0.000 0.750 0.974
Inter 0.774 0.000 0.800 0.973 0.725 0.000 0.750 0.974
Middle Intra 1
0.050 0.746 0 0.950
0.024 0.874 0 0.976
Vastus lateralis Intra 2 0.451 0.002 0.500 0.947 0.234 0.088 0.286 0.935
Inter
0.073 0.594 0 0.909
0.041 0.710 0 0.923
Distal Intra 1 0.369 0.013 0.462 0.901 0.462 0.000 0.500 0.947
Vastus lateralis Intra 2 0.725 0.000 0.750 0.974 0.641 0.000 0.667 0.974
Inter 0.493 0.000 0.545 0.932 0.632 0.000 0.667 0.960
Ante-lateral Intra 1 0.456 0.002 0.615 0.828 0.724 0.000 0.750 0.974
Gluteus medius Intra 2 0.276 0.065 0.400 0.870 0.217 0.024 0.250 0.921
Inter 0.524 0.001 0.632 0.892 0.690 0.000 0.727 0.959
Posterior Intra 1 0.442 0.003 0.556 0.879 0.462 0.000 0.500 0.947
Gluteus medius Intra 2 0.400 0.009 0.593 0.807 0.222 0.150 0.333 0.889
Inter 0.264 0.082 0.480 0.780 0.417 0.007 0.500 0.917
Distal Intra 1 0.391 0.008 0.500 0.882 0.379 0.013 0.444 0.933
Gluteus medius Intra 2 0.504 0.000 0.571 0.914 0.556 0.000 0.600 0.946
Inter 0.543 0.000 0.625 0.912 0.690 0.000 0.727 0.959

PPos - Positive agreement; PNeg - Negative agreement; VMO - vastus medialis oblique; statistically significant (p < 0.05) reliability values are marked bold.

Table 3
Intra- and inter-tester reliability results.

Muscle Taut band Tenderness Pain referral

Kappa p-value PPos PNeg Kappa p-value PPos PNeg Kappa p-value PPos PNeg

Rectus femoris Intra 1 0.483 0.002 0.815 0.667 0.454 0.003 0.784 0.667 0.533 0.000 0.571 0.961
Intra 2 0.176 0.209 0.818 0.333 0.520 0.000 0.636 0.871 0.475 0.002 0.500 0.975
Inter
0.25 0.061 0.688 0.000 0.150 0.128 0.400 0.571
0.068 0.638 0.000 0.923
Middle Intra 1 0.295 0.053 0.519 0.772
0.050 0.746 0.250 0.700 0.364 0.016 0.400 0.962
VMO Intra 2 0.269 0.052 0.717 0.516 0.400 0.004 0.723 0.649 0.494 0.001 0.571 0.914
Inter 0.078 0.496 0.522 0.421 0.083 0.469 0.450 0.500 0.540 0.000 0.571 0.961
Distal VMO Intra 1 0.527 0.001 0.750 0.773 0.481 0.001 0.718 0.756 0.427 0.003 0.500 0.917
Intra 2 0.331 0.014 0.651 0.634 0.261 0.040 0.605 0.585 0.806 0.000 0.833 0.972
Inter 0.222 0.114 0.622 0.564 0.328 0.014 0.667 0.615 0.774 0.000 0.800 0.973
Middle Intra 1 0.127 0.408 0.625 0.500 0.429 0.005 0.727 0.700
0.061 0.688 0.000 0.937
Vastus lateralis Intra 2 0.282 0.068 0.949 0.333 0.333 0.028 0.632 0.696 0.451 0.002 0.500 0.947
Inter 0.089 0.338 0.750 0.200 0.252 0.089 0.600 0.636
0.073 0.594 0.000 0.909
Distal Intra 1 0.182 0.237 0.873 0.308 0.305 0.037 0.651 0.634 0.369 0.013 0.462 0.901
Vastus lateralis Intra 2 0.222 0.147 0.759 0.462 0.295 0.053 0.519 0.772 0.725 0.000 0.750 0.974
Inter
0.125 0.350 0.719 0.100 0.252 0.047 0.541 0.638 0.493 0.000 0.545 0.932
Ante-lateral Intra 1
0.149 0.331 0.849 0.000 0.323 0.032 0.919 0.400 0.456 0.002 0.615 0.828
Gluteus medius Intra 2 0.103 0.131 0.829 0.143 0.427 0.003 0.917 0.500 0.276 0.650 0.400 0.870
Inter
0.041 0.710 0.923 0.000 0.171 0.268 0.921 0.250 0.524 0.001 0.632 0.892
Posterior Intra 1 0.439 0.003 0.727 0.700 0.600 0.000 0.846 0.750 0.481 0.001 0.600 0.875
Gluteus medius Intra 2 0.588 0.000 0.885 0.696 0.754 0.000 0.935 0.818 0.400 0.009 0.593 0.807
Inter 0.006 0.957 0.577 0.313 0.382 0.007 0.786 0.571 0.333 0.030 0.538 0.793
Distal Intra 1 0.302 0.042 0.772 0.519 0.353 0.017 0.820 0.522 0.391 0.008 0.500 0.882
Gluteus medius Intra 2 0.127 0.283 0.762 0.286 0.084 0.582 0.781 0.300 0.402 0.004 0.500 0.882
Inter 0.244 0.400 0.794 0.381 0.471 0.001 0.852 0.609 0.495 0.001 0.588 0.896

PPos - Positive agreement; PNeg - Negative agreement; VMO - vastus medialis oblique; statistically significant (p < 0.05) reliability values are marked bold.

3.2.1. Latent MTrP's
Kappa values for latent MTrPs ranged from
0.05 (in middle
vastus lateralis) to 0.77 (in distal VMO) with a median of 0.45 for
intra-tester reliability, while for inter-tester they ranged from

0.07 (in middle vastus lateralis) to 0.77 (in distal VMO) and the
median was 0.51 (Fig. 2).
3.2.2. Active MTrPs
Kappa values for active MTrPs ranged from
0.04 (in rectus
femoris) to 0.77 (in middle VMO) with a median of 0.46 for intra-
tester reliability, for inter-tester reliability kappa ranged from

0.04 (in rectus femoris) to 0.73 (in middle VMO) with a median
0.64 (Fig. 1).
3.2.3. Palpable taut band
The agreement on taut band recognition ranged from
0.15 (in
anterolateral gluteus medius) to 0.59 (in posterior gluteus medius)
for intra-tester reliability with a median of 0.28 and from
0.25 (in
rectus femoris) to 0.24 (in distal gluteus medius) for inter-tester
with a median of 0.04.

Please cite this article in press as: Rozenfeld, E., et al., Test-retest reliability of myofascial trigger point detection in hip and thigh areas, Journal of
Bodywork & Movement Therapies (2017), http://dx.doi.org/10.1016/j.jbmt.2017.03.023
 E. Rozenfeld et al. / Journal of Bodywork & Movement Therapies xxx (2017) 1e6
Fig. 2. Kappa value (median ±standard deviation) of intra- and inter-tester reliability of active and latent MTrP's in all 16 evaluated areas.
3.2.4. Tenderness
Kappa values for intra-tester reliability ranged from
0.05 (in
middle VMO) to 0.75 (in posterior gluteus medius) with a median of
0.38, the kappa value for inter-tester was 0.47 (for antelateral
gluteus medius) while the lowest was 0.08 (for the middle VMO),
the median was 0.25.
3.2.5. Referred pain sensation
Referred pain was marked as positive when the pain was felt in
another area as well as the palpated area. The kappa value for intra-
tester reliability ranged from
0.06 (for middle vastus lateralis) to
0.81 (for distal VMO) and the median was 0.44 as for intra-tester it
ranged from
0.07 (in rectus femoris) to 0.77 (in distal VMO) with a
median of 0.49. The referred pain had the strongest level of reli-
ability of all MTrP criteria.
4. Discussion
Palpation is the only clinical method currently available for
diagnosing myofascial pain. Therefore, reliable MTrP palpation is a
necessary tool for accurate evaluation and effective treatment of
myofascial pain. This study indicates that there is moderate to
substantial reliability for latent and active MTrP's palpation, while
reliability is lower for other MTrP diagnostic criteria (taut band,
tenderness and referred pain). Referred pain was the most reliable
diagnostic criteria for MTrPs evaluation in all eight locations,
whereas palpation of the taut band had the lowest reliability.
For latent MTrP locations examined, kappa exceeded 0.5 in 9 out
of 16 locations. For active MTrPs, 10 out of 16 tests showed sub-
stantial reliability (k > 0.6). The highest overall reliability was found
in the distal VMO, while for the middle VMO, distal vastus lateralis,
and all gluteus medius locations the reliability was moderate to
substantial. The lowest reliability was found in rectus femoris and
middle vastus lateralis due to the lack of consistency on MTrP
presence in those locations, PPos ¼ 0 whereas PNeg was >90% for
these locations.
The inter- and intra-tester reliability of MTrP palpation in the
Please cite this article in press as: Rozenfeld, E., et al., Test-retest reliability of myofascial trigger point detection in hip and thigh areas, Journal of
Bodywork & Movement Therapies (2017), http://dx.doi.org/10.1016/j.jbmt.2017.03.023
5
studied thigh muscles seems to be an acceptable tool for clinical
diagnosis. In many commonly used tests in musculoskeletal med-
icine intra-tester and inter-tester agreements range from moderate
to substantial. For example, manual assessment of shoulder pain
(Neer and Hawkins-Kennedy test, k ¼ 0.38e0.40; the painful arc,
empty can, and external rotation resistance tests, k ¼ 0.45e0.67),
(Cadogan et al., 2011; Michener et al., 2009), as in common knee
examination (McMurray's inter-tester k ¼ 0.35. Lachman test, intra-
tester k ¼ 0.51, inter-tester k ¼ 0.42. valgus stress test, inter-tester,
k ¼ 0.00e0.40) (Cooperman et al., 1990; Evans et al., 1993) and the
Thomas test for assessing range of motion (intra-tester k ¼ 0.47,
inter-tester k ¼ 0.39) (Peeler and Anderson, 2007).
The reliability values in our study are slightly lower than ones
presented in MTrP palpation reliability studies of upper quadrant
muscles e.g. 70% in most locations evaluated. Gerwin et al. found
even better agreement ranging from 79% for the infraspinatus, to
98% for the extensor digitorum (Gerwin et al., 1997). We assume
that higher reliability of MTrP detection in upper quadrant muscles
is because those muscles are smaller and more convenient for
palpation. In addition, the skin and fascia layers of the upper
quadrant are thinner than ones of the lower quadrant (Standring,
2008). Certainly, it is more difficult to palpate a tight band or to
find a tender spot in a large muscle covered by thicker skin and
fascia. Our results are also lower then Zuil-Escobars (Zuil-Escobar
et al., 2016) results which are extremely high (k > 0.85) for all the
studied muscles except for non-dominant soleus (k ¼ 0.79).
It is important to mention that most previous studies assessed
the reliability of the different criteria of MTrPs, but not their sum-
mation which presents the presence or absence of active and latent
MTrPs as this study done, and what is highly important and clini-
cally relevant.
Kappa is the most common statistical index used to present the
dichotomous reliability. A recognized limitation of this test is that it
overestimates the chance agreement when the observation prev-
alence of positive and negative findings are not similar (50% posi-
tive and 50% negative) (Feinstein and Cicchetti, 1990). Therefore,
kappa can sometimes be low despite a high value of the percentage
6 E. Rozenfeld et al. / Journal of Bodywork & Movement Therapies xxx (2017) 1e6
of agreement. In our study, we had a very asymmetric prevalence of
findings, about 95% negative. Although we received a high per-
centage of the agreement we still receive a relatively low kappa
values. We tried to overcome this problem by presenting the pos-
itive and negative agreements, obviously not correcting for agree-
ment by chance.
In this study, the active MTrP's were relatively rare because nearly
half of the subjects were without any complaints in the evaluated
areas. Another reason was that we evaluated 16 areas, mostly
asymptomatic, which contributed to the lower relative prevalence of
MTrP's. We chose to include the heterogenic (with and without
lower limb complaints) subjects in an attempt to reduce the exam-
iner bias, where the examiner's awareness of the patient's condition
could cause the false-positive findings of MTrP's.
Due to the relative proximity between different areas in the
evaluated muscle, examiners had difficulty in distinguishing MTrPs
in some of the explored areas, mostly in the VMO, and gluteus
medius muscles. Bearing this in mind, we assume that a higher
prevalence of MTrP's would generate a more symmetric distribu-
tion of results and therefore higher kappa values. It is also possible
that the palpation during the first evaluation has acted as a treat-
ment to the evaluated MTrP's, and therefore these points were not
identified in the following evaluation.
Additional potential limitations of the study are the relatively
short period between examinations which was one hour for the
same examiner; this could cause the examiners to remember their
previous records. We tried to overcome this limitation by random
order of evaluations and similar outfit of all subjects.
5. Conclusions
Active and latent MTrP's have moderate to substantial inter- and
intra-tester reliability and may be used for clinical diagnosis of
MTrP's in the hip and thigh muscles. This conclusion is consistent
with other studies performed on the upper and lower limb muscles.
(Al-Shenqiti and Oldham, 2005; Bron et al., 2007; Zuil-Escobar
et al., 2016). The study indicates that referred pain has the high-
est agreement among all MTrP criteria.
Authors contributions
E. Rozenfeld designed the study, collected data and drafted the
manuscript as part of his Master's thesis.
A. S. Finestone & L. Kalichman developed the concept of the
study, supervised the design, analysis and interpretation of data
and revised the manuscript.
U. Moran helped design the study, took part in data acquisition
and in critical revision of the article.
E. Damri took part in data-acquisition and critical revision of the
article.
All authors approved the final version of the paper.
Funding sources
None.
Conflicts of interest
None.
Acknowledgements
We would like to thank all subjects for participating in this study
and our colleagues (Giora Khayutin, Rotem Kadosh, Daniella Lever,
Please cite this article in press as: Rozenfeld, E., et al., Test-retest reliability of myofascial trigger point detection in hip and thigh areas, Journal of
Bodywork & Movement Therapies (2017), http://dx.doi.org/10.1016/j.jbmt.2017.03.023
and Nabil Khir) for their assistance in organization, patient
recruitment, and data acquisition.
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