Learn How to Manage Your Trigger Points

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What is a Trigger Point (TrP)? A trigger point is a hyperirritable spot located in a taut band of skeletal muscle. They may form

following a sudden trauma or may develop on a more gradual basis. Trigger points can be classified as either active or latent.

Active Trigger Points Latent Trigger Points Starts with some impact to the

muscle, such as injury. Can develop gradually without

being active first; often times, you don’t even know they are there.

Typically caused by poor posture, poor body mechanics, repetitive use, nerve root irritation.

Present in most people, and can be easily converted to active trigger points.

Will refer pain or other sensations, leading to decreased range of motion

No pain will be present, however, may have decreased range of motion and weakness

At some point, may stop referring pain and become latent.

The more frequent and intense pain, the greater number of active trigger points present.

The following factors are the main causes for trigger points to occur: - Mechanical stresses caused by improper ergonomics, body mechanics, and clothing - Injuries- Nutritional problems- Emotional factors- Sleep problems- Acute or chronic infections- Other medical conditions

Characteristics of a Trigger Point: Tenderness, knots, and tight bands in the muscle

- When pressed, trigger points are very tender. - Typically, the pain is variable, depending on the amount of stressed placed on the muscles

Weakness, muscle fatigue, joint stiffness - The presence of trigger points can lead to weakness and loss of coordination. May lead to

inability to use the muscle. Referred pain

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- Pain may be evident at both the area in which the trigger point is located as well as in other areas of the body. This is known as referral patterns.

- Approximately 55% of found trigger points are not located with the area of referred pain.

Managing Trigger Points1. First, figure out what you are doing to aggravate or cause the TrP. Even if it was originally caused

by an injury, if that injury was more than 6 weeks ago, there must be habits or postures that aggravate the muscle, preventing it from healing.

2. Next, don't try to strengthen the muscle, even though it might be weak. TrP are weak because of the neuromuscular problem, not because the muscle has atrophied. Attempting to strengthen the muscle without first treating the TrP will typically cause the muscle to stay weak, or even to get weaker. When the TrP subsides, much of the strength will usually come back without any strengthening exercise, and it is then safe to do more strengthening.

3. Use ice or heat. While heat always feels better when it is on, think about whether your muscle feels better after you take the heat off; if not, consider switching to ice. While ice does not always feel as comfortable when it is on, it often relieves the muscle spasm much more effectively than heat. Make sure you are applying the ice or heat to the source of the pain (the TrP) rather than the referred pain distribution. TENS can also be helpful.

4. Use pressure point treatment – sometimes called 'ischemic compression' by applying localized pressure to the TrP for 30-90 seconds; you should feel the spasm 'melt' away. You can use your thumbs, a special cane (e.g., a TheraCane) with knobs, tennis balls or special bumpy balls or various knobby gadgets.

5. Stretch the muscle slowly and carefully. 6. Strengthen only after the TrP pain has resolved.7. Physical therapists can use a variety of manual therapy techniques to help resolve TrP.8. Finally, physicians can do trigger point injections if nothing else works. You still need to learn to

manage your TrP so that they do not keep returning.

DOs and DON’Ts for Applying Self-Pressure

DOs: Use a variety of equipment such as tennis balls, golf balls, baseballs, theracanes, reflex balls,

your elbows, hands, and fingers. Apply pressure for adequate time An uncomfortable pain is normal, but it should not be so painful that it would cause you to hold

your breath or tense up. Search entire muscle for tender points to locate areas of maximum tenderness Be sure to address both sides of the body to treat and relax the muscles symmetrically, but

spend the most time on the areas that need attention more. Work in the direction of the referral pattern. Start directly over the trigger point and work

towards location of pain. If only limited time is available, work on one areas thoroughly rather than rushing through Perform stretching after working on your trigger points Try to work on your trigger points at least once per day. If you have questions, if your symptoms worsen, or you are sore for more than one day stop

your current self-care and seek guidance from a therapist.

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Have trigger point equipment readily available while traveling, as many trigger points are irritated when sitting for long periods of time.

DON’Ts: Apply pressures over locations such as varicose veins, open wounds, infections, herniated

disks, blood clots Overdo self-help techniques. Although you may think that more is better, you can actually

worsen your symptoms by not following the basic guidelines.

Sources of more information about Trigger Points The Trigger Point Therapy Workbook: Your Self-Treatment Guide for Pain Relief, by Clair

Davies & Amber Davies. When Movement Hurts: A Self-Help Manual for Treating Trigger Points, by Barbara J.

Headley. Pain Relief with Trigger Point Self-Help by Valerie DeLaune

Helpful I-pad Applications Trigger Points by Real Bodywork - $2.99 (Provides info on common trigger points, referral

patterns, recommendations on management) Trigger Point Charts – Free (Provides muscle specific trigger points and referral patterns)

Gadgets for working trigger points: TheraCane, info available at http://www.theracane.com/. The TheraCane is $39.95; the site

includes a complete manual of how to get at almost every TrP. You cannot order from them by phone, but can contact OTPT at 1- 888- 819- 0121.

Pressure Pointer at http://www.mypressureproducts.com/ or 1-888-729-3053. The Pressure Pointer is $54, but the web site also has excellent information about different trigger points under their Pain Reference Chart

Backnobber at http://www.pressurepositive.com/ or 800-603-5107. Just the Backnobber is $39.95. The Trigger Point Kit ($57.95) includes Davies book, cane, and hand-held knobber.

Fenix system has paddles that you can attach knobs to and lean against; allows you to not use your hands. At http://www.fenixstopspain.com/ or 1-888-299-6647. Basic device costs $49.95.

Reflexball is a knobby ball you can lie on or roll into. At http://www.bodytrends.com/ or 1-800-549-1667. Balls start at $7.99. Also available at www.optp.com ((888) 819-0121)

Some web pages that have useful information about TrP, such as TrP diagrams and stretches, include:

http://www.coventrypainclinic.org.uk/musclepain-backhipbuttockleg.htm TrP diagrams at www.trigger-point-injections.com/where.htm Pictures of using pressure point devices at www.fenixstopspain.com/finding_tps.html

Face/Head Trigger Points

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Masseter Muscles This muscle clenches the teeth. Pain located: over eyebrow, deep in the ear, over cheek and jaws. The masseter

can cause tension-type headaches. Other symptoms:

Limited range of mouth-opening Pain in the upper and lower molar teeth Teeth hypersensitive to pressure and temperature Ringing in one ear (tinnitus), earache Temporomandibular (jaw) pain

Aggravating factors: Clenching or grinding the teeth, or teeth not meeting

properly Chewing: constant gum chewing, forceful biting,

chewing pens or instrument mouthpieces Forward head posture Mouth breathing (as with sinus congestion) Emotional tension Overstretch during dental procedure; excessive jaw mobility

Prevention Correct forward head posture Correct mouth position, with tongue on roof of mouth, teeth slightly apart Avoid excessive chewing, clenching teeth, using a mouth guard to prevent grinding teeth

at night Correct dental problems that prevent proper closing of teeth Decrease muscle tension due to stress

Recommended trigger point release technique:1. Using the hand opposite to the side you are working on, insert your thumb inside your mouth but

outside your gums and relax your jaw. 2. With your index and middle fingers, press on the outside of your cheek between your fingers and

your thumb. 3. Work all the way from the bottom of the jaw to your cheek bone and up towards your ear.

Temporalis Muscles This muscle also clenches the teeth. Pain located: over the temple, over eyebrow, behind ear. The temporalis can cause tension-type headaches on one or both sides of the head.

Other symptoms: Pain in upper teach; sensitivity to hot/cold

Temporomandibular (jaw) joint pain Inability to open jaw far enough to fit 2 knuckles in Teeth do not seem to meet correctly

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Aggravating factors Long periods of holding jaw in one position, either open or closed, as during dental

work Clenching jaw (bruxism), grinding teeth at night, chewing gum, biting instrument

mouthpieces, or temporomandibular problems Muscle tension from stress Exposure to cold draft when muscle fatigued Posture with head forward Trigger points in other muscles, such as

sternocleidomastoid or upper trapezius Neck traction using a chin strap

Prevention Same as for masseter muscle, above

Recommended Technique:1. Use your finger tips to apply pressure to areas above temple

and the ear. 2. While pressing against the tender points, slowly open and close your jaw.

Lateral Pterygoid This muscle is used to open the mouth; it can be overused if the clenching muscles (masseter and temporalis) are overactive or if you use a musical instrument held down with your chin and you hold your teeth apart. Part of this muscle attaches to the disk inside the joint and, when in spasm, pulls the disk out of place causing clicking or locking.

Other symptoms: Sinus pain or congestion Popping, clicking or locking in the TMJ Ringing in the ear

Aggravating factors Tension held in the jaw TrP in the masseter or temporalis Holding the jaw open for prolonged

periods, such as dental work or playing a wind instrument

Opening against resistance, such as holding a violin or viola under the chin Protruding the jaw (poking it out) playing a wind instrument Mouth breathing

Prevention Correct forward head posture Correct mouth position, with tongue on roof of mouth, teeth slightly apart, jaw relaxed Avoid excessive chewing, clenching teeth, using a mouth guard to prevent grinding teeth

at night Decrease muscle tension due to stress

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Recommended trigger point release technique 1. Place your finger between the cheek and the upper molars and slide it all the way to the back,

behind the last molar and press toward your nose.2. Isolating the entire muscle is difficult, therefore, may be impossible to entirely eliminate all

trigger points.

Medial Pterygoid This muscle is located deep inside the mouth. Primary function: closing the mouth and jutting out the jaw

Common symptoms: Pain referred to back of month, tongue and throat, around TMJ, and deep in the ear Difficulty swallowing Pain with chewing or clenching jaw Pain with opening jaw Jaw may deviate to one side

Causes: Clenching or teeth grinding, chewing gum Improper bite alignment Head-forward posture Nutritional deficiencies

Management: Learn relaxation and coping techniques to eliminate

stress Do not chew gum and avoid foods requiring a lot of

chewing Use a pillow that adequately supports the jaw Perform exercises to correct forward head posture Attend to nutritional deficiencies if applicable.

Recommended Technique1. Use the opposite index finger to reach inside your mouth, inside your teeth, and behind

top set of molars. 2. Sweep downward behind your molars to the floor of your mouth3. One a tender spot is located, press and hold that spot.

Neck/Upper Back Trigger PointsSternocleidomastoidFunction:

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1. When using only one side, rotates head and tilts head upward2. When both sides used together, brings the head and neck down in front

Common Symptoms Tension headache Headaches on the forehead Muscle sore to the touch Persistent, dry cough Referred pain to top of head, back of head,

the cheek, behind eye Sinus congestion on affected side Tearing and reddening of the eyes, blurred

vision Earaches Dizziness, disturbed balance Nausea, loss of appetite Sweating and cool sensation on forehead

Causes Overhead activities Looking up for long periods of time Poor neck postures such as forward head posture Traumatic injuries that have caused whiplash, a fall on the head, etc. Improper breathing Chronic cough or infection Injury or deformity that restricts upper body movement

Management Avoid overhead work and prolonged periods of looking up Practice good posture and body mechanics Seek proper breathing techniques (ex. diaphragmatic breathing) Prevent excessive infection Seek specialist if body asymmetries exist

TrapeziusFunction: Moves the shoulder girdle and shoulder blade in various directions.

Common Symptoms Upper trapezius

Headaches Facial, temple, jaw pain

Pain behind the eye Neck pain Dizziness Limited range of motion

Middle trapezius Mid back pain Headaches at base of skull Burning sensation near spine

Shoulder pain

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Lower trapezius Mid back, neck, upper shoulder pain Referred pain to shoulder blade, inside of arm Headaches at base of skull Ache and tenderness over top of shoulder

Causes: Poor posture and ergonomics Clothing or anything that places constricting pressure on the muscle (ex. backpack,

purse, etc.) Certain sports with sudden one-sided movements Structural abnormalities such as asymmetrical leg length, pelvis height, etc.) Fatigue Traumatic injuries such as whiplash, fall to the head.

Management Improvements in ergonomics in the workplace Postural alterations Practice relaxation techniques Minimize direct pressure on the muscle Modification or decreased participation in sports that provoke symptoms Address fatigue problems

Splenius Capitus and Splenius Cervicis Function: Rotates the head and brings head back up from forward position; provide stabilization

Common Symptoms Referred pain to top of head (Capitis) Referred pain throughout inside of head Pain behind the eye Pain in back of skull Pain at the junction of the neck and top of shoulder Decreased neck range of motion Blurred vision

Causes: Poor posture

- Prolonged awkward positions- Prolonged looking up

Poor ergonomics during work Forward head posture Structural problems (ex. kyphosis) Exposure to cold temperatures while muscle is fatigued Traumatic injuries Sports activities that involve rotating of the head Restrictive clothing Depression

Management Practice proper posture

- Sit upright, with head held directly over trunk and back well supported- Invest in pillows or other objects that would facilitate proper spine alignment

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Postural retraining exercises Correct body asymmetries Avoid cold drafts; try to keep neck warm Avoid head rotating activities, modification of sport activities as necessary Be aware of restrictive clothing Seek counseling for depression if applicable.

Levator ScapulaFunction: Shrugs shoulder and helps rotate head

Symptoms: Neck, shoulder, & shoulder blade pain Limited neck flexion or rotation Tension headache

Other diagnoses with similar symptoms: Stiff neck Neck (cervical) strain Neck disc disease

Causes: Prolonged shoulder tension Holding phone between ear and shoulder Carrying heavy purse or book bag Emotional stress, tension, anger, or fear Prolonged posture with head turned, as in typing Respiratory infection

Management: Take breaks when working at computer; use armrests Face forward without head rotated Carry less weight Learn stress reduction techniques

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ScalenesFunction: Stabilizes the cervical spine and elevates the first and second ribs during inhalation

Common symptoms: Referred pain to chest, mid back, and/or over the outside, back, and front of the arm and

into the wrist and hand Pain may interrupt sleep, relieved by sleeping sitting up Decrease range of motion when turning and bending the head Numbness, tingling, and loss of sensation in fingers

and hand Finger stiffness

Causes: Excessive pulling or lifting activities Breathing in against resistance Poor body mechanics when carrying large objects Traumatic injuries Trigger points in SCM and levator scapula Improper breath techniques Asymmetries of body structures (legs, pelvis,

spine, ribs) Management:

Avoid activities that require lifting and pulling heavy objects

Prevent excessive turning of the head to one side Learn proper breathing techniques Address surround trigger points Seek specialist if structural asymmetries exist.

RhomboidsFunctions: Stabilizes the shoulder blade and brings it toward the spine

Common symptoms Localized pain in upper/mid back, between edge of shoulder blade and spine Discomfort is typically superficial and achy Symptoms aggravated by lying on the same side or by reach forward Snapping noises upon movement of the shoulder blade Rounded shoulders

Causes Poor posture

- Constantly leaning forward for long periods of time- Rounded shoulders

Tight pectoral muscles Persistent discouragement or sad (leads to

slumping of the shoulders) Structural problems

- Scoliosis

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Management Learn proper ergonomics and body mechanics Address additional trigger points in pectoral muscle if applicable Practice proper breathing techniques Learn ways to control degree of depression/sadness if applicable Address structural abnormalities with appropriate specialist

Back, Hip and Lower Extremity Trigger Points

Serratus Posterior Inferior Function: Assists with trunk rotation and forward bending at the waist

Common symptoms Achy feeling on the back near the bottom of the rib cage Decreased trunk rotation

Causes Straining of the back during activities that involve lifting, twisting, reach overhead Improper ergonomics and body mechanics Improper breathing techniques or coughing One leg longer than the other

Management Practice proper lifting techniques

- Bend with your knees, not with your back

- Hold objects close to body Learn proper breathing techniques

(diaphragmatic breathing) Seek a specialist to address any structural

abnormalities

Quadratus Lumborum

Function:1. When only one side is used, it assists with stabilization and side-bending at the waist 2. When both sides are used, assists with assuming standing from the bending position, assists

with forced breath exhalation

Common symptoms Referred pain to hip joint, groin area, lower abdomen, gluteal area Pain is deep and achy at rest, but can be sharp upon movement Pain is aggravated by climbing stairs, rotating trunk, leaning to opposite side

Decreased forward bending

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Painful when rolling onto side, getting up, or raising from a chair Pain may be unbearable when standing or sitting up straight

Causes Awkward movements that involves trunk rotation (ex. lifting and object while turning

simultaneously) Repetitive strains from frequent bending Sitting with malaligned pelvis Activities and positions that require excessive

forward lean Management

Be mindful of body positioning during heavy lifting, assuming standing position, dressing oneself.

Activity modifications that would limit excessive forward bending

Make sure your sit with proper pelvic alignment

Stand up straight

IliopsoasFunction: flexes hip

Common symptoms: Referred pain to low back region close to the spine Referred pain to front of thigh and groin Pain worse standing, or standing from sitting Pain first standing in the morning

Other diagnoses with similar symptoms: Failed low back syndrome Appendicitis Hip osteoarthritis

Causes: Walking long distances SI malalignment, Prolonged sitting Leg length difference

Management: Correct leg length difference or flat

foot; Correct imbalance of weak and tight

low back and hip muscles Trigger point pressure and stretching

PiriformisFunction: rotates hip

Symptoms:

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Pain worse with sitting, standing, or standing from sitting SI dysfunction Possible numbness, weakness, or swelling in the involved leg Chronic pelvic infections

Other diagnoses with similar symptoms: Sciatica, herniated disc, or

lumbago Sacroiliac (SI) dysfunction Facet syndrome Post-laminectomy syndrome

Causes: Catching oneself while falling, or

twisting while lifting or rotating while weight on one leg

SI malalignment, Prolonged driving or sitting Leg length difference Hip joint replacement Car accident.

Management: Correct leg length difference or flat foot; Avoid strong twisting motions; Limit driving with involved foot on accelerator Avoid sitting on involved leg Trigger point pressure and stretching

Gluteus Minimus and Medius and Tensor Fascia Latae (TFL)Function: holds the pelvis level during walking

Symptoms: Pain walking Limping Pain crossing leg over opposite

leg Difficulty straightening leg after

sitting (TFL) Other diagnoses with similar

symptoms: Trochanteric bursitis Sciatica, herniated disc, failed

low back syndrome Sacroiliac (SI) dysfunction Iliotibial band friction syndrome

(TFL)

Causes:

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Falling, SI malalignment, Strenuous walking or running, especially on soft surfaces Flat foot or leg length difference Prolonged driving, Sleeping on involved hip Sitting with wallet in back pocket.

Management: Limit standing and vigorous walking; Stand with feet wider apart; Sleep on uninvolved side with pillow between knees Trigger point pressure and stretching

Shoulder, Upper Arm, and Elbow Trigger Points

Supraspinatus Function: Stabilizes the humerus and moves the arm away from the body

Common symptoms: Deep ache in the shoulder area Referred pain to the elbow, outside of the arm, wrist Increased pain with moving arm Decreases range of motion when reaching behind Audible clicking sounds in the shoulder

Causes Carrying heavy objects with arm at your side Carrying objects above shoulder height

Management Do not life objects overhead on a continuous basis Decrease prevalence of carrying heavy objects

Infraspinatus Functions: Stabilizes end of humerus and rotates upper arm

Common symptoms Referred pain to front of shoulder, forearm, and

possibly fingers Increased pain during sleep Arm may “fall asleep” at night and during the day Decreased mobility of shoulder

Muscle fatigue and weakness

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Gluteus Medius

Tensor Fascia Lata (TFL)

Causes Activities that require arm to be held out in front of you. Pulling activities that requires you to reach behind. Overload on muscle when attempting to catch a fall.

Management Increased awareness of body mechanics Decrease activities that requires arm to be held in front for extended periods of time. Application of heat over the muscle.

Teres Minor and Major

Functions: Stabilizes the humerus and helps move the upper arm

Common symptoms Referred pain in posterior deltoid Numbness and tingling of the ring and little fingers (increased with reaching above

shoulder height)

Causes Sudden overload of the muscle, often during traumatic

accident Activities that require holding arms out in front or

above your for prolonged periods of tie. Repetitively reaching behind

Management Increase awareness of body mechanics Decrease the prevalence of activities that require arms

to be out in front and above you. Heat application at night for 15-20 minutes

Pectoralis MinorFunction: Pulls the shoulder blade and should girdle down and forward, and assists in forced inhalation

Common symptoms Referred pain over the front of the shoulder

and chest, down the inside of the arm into the middle, ring, and little fingers

Rounded forward shoulder Difficulty taking a deep breath

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Teres Minor

Teres major

Decreased range of motion when reaching forward, upward, and backward Causes

Poor ergonomics and posture Compression the muscle with straps and clothing Weakness of trapezius muscle Trauma to the ribs or front of shoulder Coughing and improper breathing

techniques Management

Improve ergonomics and posture in the home and at work

Avoid carrying backpacks or using other straps that places significant compression on the shoulder

Manage trigger points and weakness of surrounding muscles.

Learn proper breathing techniques

DeltoidFunction: Moves the arms in a variety of ways

Common symptoms Pain located over the shoulder Pain is worse when the arm is move and less intense at rest Decreased range of motion, difficulty raising arm past 90°

Causes Jerky, repetitive movements of the arm Trauma to the shoulder region Holding an object above shoulder level for a prolonged time.

Management Avoid lifting objects above shoulder level

Limit repetitive movements of the arm

Biceps BrachiiFunction: flexes the shoulder and elbow; rotates the lower arm

Common symptoms Refers superficial achy pain over the front of the

upper arm and front of the should

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Weakness and pain when raising hand above head when elbow is bent.

Causes Repetitive motion injuries Carrying heaving objects with palms facing

upward Trying to catch yourself from a fall Trigger points of the infraspinatus

Management Modification of aggravating activities Carry items with palms face-down Manage trigger points of surrounding

muscles

Trigger Points in the Forearm and Hand

Hand Extensors, Brachioradialis, and Finger Extensors

Function: 1. Hand extensors- extend the hand at the wrist and stabilize the wrist while the fingers are being

used for grasping. 2. Finger extensors- extend the hand at the wrist and extend the fingers. 3. Brachioradialis- bends the elbow

Common symptoms Pain is worse when shaking hands, and when performing motions that involves twisting

of the wrist and forearms. Trigger points in the finger extensors cause finger stiffness, pain in the back of the

forearm, hand, fingers and elbow. Trigger points in the hand extensors and brachioradialis cause

pain outside the elbow and refers pain to the wrist and hand. Decreased grip strength, loss of coordination, muscle fatigue

during repetitive motions. Numbness and tingling over the back of the hand if the radial

nerve is involves. Causes

Forcefully and repetitively griping an object. - Ex. shaking a hand, turning a doorknob, writing,

kayaking, playing the violin, etc. Trauma of the elbow joint Repetitive finger movements

- Ex. playing the piano Referred pain form trigger points in shoulder.

Management

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Avoid activities that requires twisting of the arm and grasping repeatedly

Learn to alternate hands when performing aggravating activities.

Manage trigger points that may be causing referred pain to the forearm.

Use a wrist brace at night to prevent twisting of the forearm.

Finger Flexors and PronatorFunction: Finger flexors grip & type; Pronator turns hand palm down as in typing

Symptoms: Shooting pain into wrist or hand Finger Stiffness and painful cramping Trouble with fine motor control Numbness into hand or fingers

Other diagnoses with similar symptoms: Carpal tunnel syndrome Pinched nerve in neck (C5-T1) Ulnar nerve palsy, cubital tunnel

Causes: Prolonged or forceful gripping Driving, especially in bad weather Prolonged typing/computer use, fingering an

instrument (finger flexors) playing an instrument with palms turned away (e.g., piano, pronator)

Management: Take breaks when working at computer,

instrument Avoid excessive gripping Keep grip relaxed when driving, or playing an

instrument Relax fingers fully when not in use Use devices, such as jar openers, to reduce strong

gripping

Adductor and Opponens Pollicis Function:

1. Adductor pollicis- brings the thumb toward the index finger2. Opponens pollicis- brings the thumb across the palm

Common symptoms

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Aching pain referred over the thumb, into the thumb and over the wrist Difficulty with fine motor movements that require the thumb to grasp “Trigger thumb” where the thumb locks in the closed position

Causes Grasping things with thumb and fingers Residual pain from a fracture

Management Avoid activities requiring grasping with the thumb Relax thumb fully when not in use Alternate hands, take rest breaks Use a thumb brace to support thumb in static positions

Hand Interosseous Muscles and Abductor Digiti MinimiFunction: Moves the fingers from side to side

Common symptoms Referred pain to back of palm and hand, and down fingers Finger stiffness Difficulty with fine motor movements (writing, grasping objects, making a fist Superficial numbness on one side of the finger

Causes Repetitive grasping activities with the fingers pinched

together Management

Grasps items lightly Take frequent breaks Limit amount of time of any given activity Alternate hands

All trigger point information is adopted from the following source:Delaune, V. Pain Relief with Trigger Point Self-Help. California: Lotus Publishing; 2011.

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