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Acupuncture Points as Tender Points
For the diagnosis of the upper quadrant pain, particularly for the clarification of the connections, it is recommended to start with the acupuncture point LI 4 (Fig. 1). This can already be established in the course the first handshake. In most cases the patient will draw his hand back, if the point is painful on palpation. If the patient does not draw his hand back, respectively there is no expression of pain, it is very probable that there is no disturbance of the Large Intestine of the right side. It must then be clarified whether the patient is left-handed or not. It is recommended to ask the patient about all the regions he is in pain. If the patient is leaving out certain areas belonging to the Large Intestine and to its neighbouring meridians, the patient must be asked specifically.
Due to his contact to many physicians of various fields, the patient might unintentionally conceal from the orthopedist that he suffers of pain in the jaw and from the ENT specialist or dentist that he also has pain in the shoulder, etc. As a consequence of the various conceptions relating to fibromyalgia and fibromyalgetic sensations, the clinical picture is not viewed as a whole neither by the patient nor by the physicians.

Acupressure Diagnostics of the Quadrant Pain of the Upper Extremity
The issue that trigger points are synonymous with acupuncture points is now being discussed already since the beginning of the 80s (9). Acupuncture points are based on a definite structure: a nerve-vessel bundle which is wrapped in a sheet of lose and easy inflammable connective tissue and penetrates a small perforation (perforation of fascias, channels in bones, aponeuroses and so on {13, 5, 7, 11It must not be ignored in this context, that the nerves of the acupuncture bundle are connected with cuti-myogenous, cuti-visceral and cuti-neuronal reflex pathways. The sympathicus joins over the nerve plexus of the vascular wall.Every prolonged disturbance of the reflex pathways mentioned above leads, among others, to the release of the phlogogenous substance P ("neurogenous inflammation"). As a consequence, it is possible that the acupuncture perforations will inflame. The collagen occlusion will cause the inflammations to turn into the painful walling in of the corresponding nerve-vessel bundle, together with an intensification of the pain symptoms of particular points (8). This is a matter of pathological afferences which start with the sealed up acupuncture points and are represented centrally and projected into other regions by the ego. This is a kind of phantom pain.The required puncture depth must be observed, if the actual functional perforation, for instance LI 10, should be reached. This point is on its part marked by a finer nerve-vessel bundle which perforates the surfacing corporal fascia (here fascia brachialis) and branches off from the deep nerve-vessel bundle (1).In case of pain in the arm, shoulder or neck and head region, the Meridian of the Large Intestine is disturbed, in some cases the Lung Meridian as the neighbouring meridian as well, and now and then even other neighbouring meridians.
The Lung Meridian causes the tenderness on pressure of the front side of the shoulder joint. This explains why there is pain in the region of the upper extremity, which can simulate a shoulder pain to the patient and an affection in the region of the rotator cuff of the shoulder to the examiner.The Meridian of the Large Intestine crosses the Meridian of the Gall Bladder in the region of the lateral triangle of the neck and can thus transmit the disturbance to the Meridian of the Gall Bladder. It starts in the lateral corner of one's eye, runs to the ear, to the mastoid bone, and from there over the scalp to the forehead and then returns to the back of the neck. This fact explains why patients with sensations in the region of the Large Intestine complain about headaches and neck pain or that one eye, namely the one on the homolateral side of the disturbance, is getting swollen.
Even a typical facial pain can be explained this way, migraine with pain attacks in the forearms during the aura also.
The end of the Large Intestine is situated in the region of the contralateral side above the canine tooth and the corresponding maxillary sinus. It thus becomes understandable why some patients which demonstrate a disturbance of the Large Intestine complain of tooth aches and/or pain in the jaw (1, 2, 9) or of sensations in the region of the masticatory joints.

After the acupuncture point LI 4 has been examined (this applies to both upper extremities), the Large Intestine is followed in central direction. Particular attention should be given to the possible pain on pressure in the region of LI 5, Lu 7 to Lu 10. Lu 7 and Lu 8 correspond to the pain on pressure considered by hand surgery to be a an indication of tendovaginitis of the first ad second extensor tenor. For this reason, acupressure diagnostics should be not be applied exclusively, but in addition, and all examination points known from hand surgery must be tested for snapping fingers, capsular ligament instability, tendovaginitis, ski thumb, etc., as well.Above that, attention must be paid to whether LI 7, 8, 9, 10, 11, 12, 13 and 14 are painful on pressure. The points Lu 6, Lu 5 and Pe 3 must subsequently be examined. It is recommended to ask the patient in the course of the acupressure of the Lung Meridian whether he suffers from pain in the shoulder joint or at the front of the shoulder. In addition, it should be clarified whether the patient ever had chest pain, thorax pain or even noticed unclear heart sensations.
The shoulder level should be palpated next. Particularly important are LI 15 and 16. As a rule, the points in the neck region are not painful to pressure. Considering all the clinical characteristics which could appear in connection and as a result of their relation with already mentioned meridians, it should be established: if there is pain in the region of the mandibular angle or of the upper jaw, toothaches or jaw sensations, if the eye or both eyes swell up, if visual disturbances appeared, if the intra-ocular pressure is increased, if there are subjective noises in the ear, possibly tinnitus or a pain in the back of the head.
The typical findings of a patient with quadrant pain are as follows: painful on pressure are the points LI 4, 7, 8, 9, 10, 11, 12, 13, Lu 6 and Lu 5, potentially painful are LI 14, 15, Lu 1, 2, LI 19, 20, Gb 1, 14, 20 and 12.If exact acupressure diagnostics is performed, it will demonstrate that, as a rule, the points LI 7-12 and Lu 6 are painful on pressure. If this is the case, we have a quadrant pain that can be traced back to the irritation of these important sections of the Large Intestine (1).

·migraine headache
·frozen shoulder
·pseudo trigeminus neuralgia
·pain in the back of the head
·shoulder-arm-syndrome
·seized up back
·myogeloses in the region of the shoulder-blades
·cervical syndrome
·suspected intervertebral disk lesion in the region of the HWS/BWS
·impingement of the shoulder
·relapsing tendovaginitis of the forearms
·CRPS

Table 2: Diagnoses with quadrant pain of the upper extremityIn case of a comprehensive anamnesis with a variety of diagnoses, the surgical exposure of the corresponding acupuncture points is finally indicated. The diagnoses listed in Table 2 relate to the quadrant pain of the upper extremity.According to experiences gained so far, the Complex Regional Pain Syndrome (CRPS) represents a quadrant pain and is identical to stage 1 of FMS: Research on this issue is in progress.

Acupressure Diagnostics of the Quadrant Pain of the Lower Extremity

For the diagnosis of the lower quadrant pain, it is essential to follow the acupuncture points of the Kidney Meridian (Fig. 2). In this context, the examination of a compression pain of the forefoot should be performed first. Subsequently, the physician will look for a pain on pressure on the dorsal side of the spaces between the heads of the metatarsal bone (Gb 43, St 44 and Li 2) (2).

Summary
Fibromyalgia is accompanied with painful acupucture points known as tender points. This islinked to the anatomical structure of acupucture points. In principle they form a nerve vesselbundle penetrating sharp outlined perforations of fascias, ligaments and aponeuroses orchannels in bones, i.e. bones of the face and so on. The nerve vessel bundle is wrapped ina sneet of lose and easy inflammable connective tissue. The axons of the nerve bundle areconnected with cuti-myogenous, cuti-visceral and cuti-neuronal reflexes. Disturbances ofthese feedback mechanismus can cause the development of tender points starting at one qua-drant of the body spreading with time throughout the body. At the same time more and moretender points develop because of excess collagen formation with compression of the nerve-vessel bundle within an inflamed acupuncture point. We are able to demonstrate that surgi-cal mobilisation of nerve-vessel bundle of definite acupuneture-points within a body quadrant relieves fibromyalgetic pain in 90% of the patients.

Keywords: Quadrant pain, acupuncture points, acupressure, fibromyalgia, surgical intervention.

The Kidney Meridian is disturbed in case of deep pain of the back, pain in the hip region, the trochanter, the thigh, pain in the knee-joint, of the Achilles tendon, the heel and the forefoot, in some cases even the Bladder and the Gall Bladder Meridians, as there are connections these meridians. Via SP 6 there is a link-up of the Liver, Spleen and Kidney Meridians (9). The Kidney Meridian begins with Ki 1on the plantar side of the forefoot. If this point is disturbed, it is sometimes marked by a hornification of a wart resistant to therapy. Caution is advisable here. The pain on pressure of Ki 1 in case of acupressure can be simulated by a Morton neuroma.
While Ki 2 is rarely diagnosed to be painful on pressure, the points Ki 3, 4, 5, 6, 7 and 8 and SP 6 are of crucial importance for the diagnostics. The disturbance of these points represent the existence of fibromyalgia of the right or left lower quadrant. The Liver Meridian could be irritated due to the SP 6 link-up. This will become obvious as a homolateral pain in the groin, which could simulate a groin hernia (football groin).
The irritation of the Spleen Meridian could cause meteorism. 30 to 40 % of the fibromyalgia sufferers actually complain of Irritable Bowel Syndrome.

The connections from and to the Bladder Meridian lead to its disorder, which could make itself felt as pain in the knee-joint (Bl 38, 39, 40) and at the sitting line (Bl 36). Here, patients indicate that sitting down feels like they would sit on a lump of ice of the size of a tennis ball. There is further pain in the region of the iliosacral joint or iliosacral gap (Bl 27 34) expressed as deep pain of the back. Besides, many fibromyalgia patients suffer from interstitial cystitis, bladder disturbance with low urine flow.

Tab. 3: Subdivision of the fibromialgia in stages

· Convexity of degree reduced of the curve of intervertebral discs
· Light protrusion of intervertebral discs without narrowing of the durale bag
· Light stenosis with doubt interest of the nervous root
· Modest degenerate alterations, circumscribed
· Modest arthrosis of the articulation of the elbow, the shoulder, etc....
· Obvious oncoartrosi, however not a lot emphasized.
· Modest osteoporosis

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