Understanding Tender Points For The Diagnosis Of Fibromyalgia

One of the two major criteria for the diagnosis of fibromyalgia, according to the American College of Rheumatology, is the presence of tender points. Tender points are specific areas of the body that, when pressed, produce pain that is often reported as similar to pressing on a bruise or an area of inflammation. They are not swollen or even detectable as hot, inflamed or irritated areas under the skin.

In contrast, trigger points, which are not present with a diagnosis of fibromyalgia but are associated with myofascial pain syndrome, produce hard nodules that can be felt under the skin. They are extremely painful and, when pressed, can trigger pain elsewhere in the body. Since they are found along muscles, the pain tends to radiate outward to the extremities of the body and can be felt when the muscle stretches or contracts. This may lead to severe limitations in the range of motion of the limb or body part.

Tender points, which are associated with fibromyalgia, are found over the entire body. In order for the diagnosis of fibromyalgia using the American College of Rheumatology criteria, the person must have experienced widespread pain on all four quadrants of the body for at least three months.1 The four quadrants are the waist up and the waist down on the right and left sides of the body.

In addition, the individual must have at least 11 of the 18 possible tender points that are established in the criteria. The test is completed using a physical examination where the medical professional applies uniform pressure to the specific recognized tender points on the body. Each of the 18 possible points are tested during the examination and, at the same time, the doctor checks to ensure there is no visible irritation, inflammation, swelling or redness. If these symptoms are present the doctor will first rule out other conditions that may include arthritis, inflammation and different possible autoimmune conditions or related diseases.

Tender Point Location

Although the location of the tender points are established based on their location on the body, it is possible for some individuals to have slightly different locations. In general, the majority of patients will have sensitivity to the pressure even if the medical professional is not completely accurate as to the specific location of the tender point on an individual.

The tender points are usually tested from either the head to the toes or from the toes to the head. Starting at the knees, the doctor will press just above the kneecap on the inside of the leg. The lower outer sides of the buttocks are the next points, one on each leg just below the outside point of the hip bone. Two additional pressure points are located just above the buttocks on the right and left side of the lower back. These are usually between the outside of the waist and the spine, but they can be more inward or outward. The elbows, on the inside of the arm, are the next two tender points that will be tested moving from the lower to upper body.

There are several tender points around the neck area. These include four different points; two on each side just behind the spine to the left and the right and just at the top of the shoulder blade down from the indentation caused when you raise your arm.  The final two on the back of the body are on either side of the spine just below the hairline.

The front of the body is also tested in this area with one tender point on each side of the body just above the collar bone and midway between the shoulders and the center of the body. The same area is tested above the collarbone to determine if those two tender points exist.

Tender Point Concerns

There is some concern or controversy in the medical profession about the use of tender points in a diagnosis of fibromyalgia. Most of the controversy is in the subjective way in which the tests are administered. The physician is to press into the tender point using 4kg/cm2 of pressure and the patient must report feeling pain, not just a sensation of tenderness. This can lead to significant bias that can be altered by physical or psychological stress or distress, some which can be influenced by the testing itself.4

In addition many researchers indicate that the multiple symptoms associated with fibromyalgia are not restricted to just tender points and widespread pain. As such, in 2010 the American College of Rheumatology presented an alternative set of guidelines to diagnose fibromyalgia that does not use tender points in the criteria. This test involves scoring a Widespread Pain Index and the Symptom Severity scale score. These two tests rely on the patient reporting their symptoms in areas such as pain, fatigue, and sleep difficulty. Because it does not involve testing the tender points, it may be more reliable than the previous diagnostic system. Time will tell if this new scoring system will be widely adopted to help make the diagnosis of fibromyalgia easier.


1 Wolfe, F., Smythe, H., Yunus, M., et al. (1990). The American College of Rheumatology 1990 criteria for the classification of fibromyalgia. Report of the Multicenter Criteria Committee. Arthritis and Rheumatism , 160-172.

2 Tastekin, N., Uzunca, K., Sut, N., et al. (2010). Discriminative Value of Tender Points in Fibromyalgia Syndrome. Pain Medicine , 466-471.

3 Harden, R. N., Revivo, G., Song, S., et al. (2007). A Critical Analysis of the Tender Points in Fibromyalgia. Pain Medicine , 147-156.

4 Harth, M., & Nielson, W. R. (2007). The Fibromyalgia Tender Points: Use Them or Lose Them? A Brief Review of the Controversy. The Journal of Rheumatology , 914-916

This article was originally published on July 11, 2012 and last revision and update of it was 9/7/2015