Trigger point treatments

In 2015, HPRC posted an introductory article on trigger points. Commonly called muscle knots, these tight and sometimes painful spots often can be treated on your own. But when that fails, they might need further attention from a healthcare professional. Such treatment might include trigger point injections directly into the affected muscle. Another treatment is dry needling (similar to acupuncture), in which a healthcare specialist uses shallowly inserted thin needles without injection. The effectiveness of trigger point injections and dry needling for pain management varies.

At-home treatments for trigger points include massage, manually or with a massage ball, and foam-rolling exercises. To learn more about treatments your healthcare provider can offer, read on.

Trigger Point Injections

Trigger point injections (TPIs) involve substances injected directly into the trigger point that can reduce pain or discomfort caused by irritated and stiff muscle fiber1,2. TPI needles (or what’s in them) disrupt the trigger point(s) so the muscle fiber can relax and lengthen3. TPIs apply a small amount of pressure to the irritated muscle fibers. They can contain fluids such as sterile water, an anesthetic, lidocaine mixed with a steroid, or botulinum toxin (such as BOTOX®). TPIs aim to reduce inflammation and relax trigger points, which lessen pain2. TPIs relieve some types of musculoskeletal pain, as well as chronic headache and migraines associated with trigger points. The effectiveness of TPIs for other types of pain (including other types of headaches/migraines) is still unfolding. Individual small studies have shown promise for the use of TPIs with, for example, neck and shoulder pain4, sciatica pain1, myofascial5,6.

The most commonly known and widely studied TPI is BOTOX®, which was FDA-approved in 2010 as a treatment for chronic migraine pain. Studies into the use of BOTOX® to treat other types of headaches, such as tension headaches, so far have had mixed findings7,8.

In addition, the effectiveness of BOTOX® injections has been explored in (mostly small) trial studies for reducing pain of upper back myofascial (connective tissue) pain syndrome9,10, cervical headaches11, and pelvic pain in women12, but other findings so far are mixed13. To date none of these treatments are FDA approved and all need further study. The effectiveness of TPIs varies with the solution used in the injection. Trials and studies are ongoing, but much is still unknown5,14-16.  

Dry Needling

Another approach is referred to as “dry needling.” It involves inserting needles (such as acupuncture or hypodermic needles) into a trigger point without injecting a medication or other liquid. The thin needles apply pressure to the underlying muscle or tissue17. Dry needling might reduce upper back pain compared to another technique of applying pressure18. However, there is not yet enough reliable research on the use of dry needling for trigger point pain management.

Concerns

More research is needed to reach a full understanding of the risks and benefits of TPI and dry needling. However, these treatments usually have very few side effects, are relatively inexpensive, and typically provide short-term pain relief.

The most common side effects of TPI and dry needling are soreness, tenderness, bruising, and redness at the treatment site. Other side effects are specifically associated with BOTOX®. However, certain types of TPIs might cause tissue or organ damage if not done correctly. These treatments are not recommended if you have a bleeding disorder or an infection or recently ingested aspirin. Also, if you have an allergy to anesthesia, muscle trauma, or extreme fear of needles, TPI isn’t likely the best course of treatment for you19.

TPIs and needling might lead to injury if not performed correctly, so it's important to seek a healthcare professional who is properly trained to administer these treatments2.

Debrief

Muscle knots and trigger points are common experiences for many service members. TPIs and needling can sometimes reduce pain for short periods of time, but it isn’t clear how effective they are, especially in the long run2,3. Trigger point treatments should always be performed by specially trained healthcare providers.

The following resources offer more information about trigger point injections for pain management:

 

Note: This article is an educational overview that describes the use of trigger point release as a strategy for pain management; it is not a comprehensive review of the current state of the research.

This article was created in collaboration with the Defense & Veterans Center for Integrative Pain Management.

References

  1. Saeidian SR, Pipelzadeh MR, Rasras S, Zeinali M. Effect of trigger point injection on lumbosacral radiculopathy source. Anesth Pain Med. 2014;4(4):e15500.
  2. Scott NA, Guo B, Barton PM, Gerwin RD. Trigger point injections for chronic non-malignant musculoskeletal pain: a systematic review. Pain Med. 2009;10(1):54-69.
  3. Wong CS, Wong SH. A new look at trigger point injections. Anesthesiol Res Pract. 2012;2012:492452.
  4. Byrn C, Olsson I, Falkheden L, Lindh M, et al. Subcutaneous sterile water injections for chronic neck and shoulder pain following whiplash injuries. Lancet. 1993;341(8843):449-52.
  5. Graboski CL, Gray DS, Burnham RS. Botulinum toxin A versus bupivacaine trigger point injections for the treatment of myofascial pain syndrome: a randomised double blind crossover study. Pain. 2005;118(1-2):170-5.
  6. Kamanli A, Kaya A, Ardicoglu O, Ozgocmen S, et al. Comparison of lidocaine injection, botulinum toxin injection, and dry needling to trigger points in myofascial pain syndrome. Rheumatol Int. 2005;25(8):604-11.
  7. Harden RN, Cottrill J, Gagnon CM, Smitherman TA, et al. Botulinum toxin a in the treatment of chronic tension-type headache with cervical myofascial trigger points: a randomized, double-blind, placebo-controlled pilot study. Headache. 2009;49(5):732-43.
  8. Jackson JL, Kuriyama A, Hayashino Y. Botulinum toxin A for prophylactic treatment of migraine and tension headaches in adults: a meta-analysis. JAMA. 2012;307(16):1736-45.
  9.  Cheshire WP, Abashian SW, Mann JD. Botulinum toxin in the treatment of myofascial pain syndrome. Pain. 1994;59(1):65-9.
  10. Gobel H, Heinze A, Reichel G, Hefter H, et al. Efficacy and safety of a single botulinum type A toxin complex treatment (Dysport) for the relief of upper back myofascial pain syndrome: results from a randomized double-blind placebo-controlled multicentre study. Pain. 2006;125(1-2):82-8.
  11. Freund BJ, Schwartz M. Treatment of chronic cervical-associated headache with botulinum toxin A: a pilot study. Headache. 2000;40(3):231-6.
  12. Nesbitt-Hawes EM, Won H, Jarvis SK, Lyons SD, et al. Improvement in pelvic pain with botulinum toxin type A - Single vs. repeat injections. Toxicon. 2013;63:83-7.
  13. Ferrante FM, Bearn L, Rothrock R, King L. Evidence against trigger point injection technique for the treatment of cervicothoracic myofascial pain with botulinum toxin type A. Anesthesiology. 2005;103(2):377-83.
  14. Langevin P, Lowcock J, Weber J, Nolan M, et al. Botulinum toxin intramuscular injections for neck pain: a systematic review and metaanalysis. J Rheumatol. 2011;38(2):203-14.
  15. Wheeler AH, Goolkasian P, Gretz SS. Botulinum toxin A for the treatment of chronic neck pain. Pain. 2001;94(3):255-60.
  16. Zhou JY, Wang D. An update on botulinum toxin A injections of trigger points for myofascial pain. Curr Pain Headache Rep. 2014;18(1):386.
  17. Dunning J, Butts R, Mourad F, Young I, et al. Dry needling: a literature review with implications for clinical practice guidelines. Phys Ther Rev. 2014;19(4):252-65.
  18. Ziaeifar M, Arab AM, Karimi N, Nourbakhsh MR. The effect of dry needling on pain, pressure pain threshold and disability in patients with a myofascial trigger point in the upper trapezius muscle. J Bodyw Mov Ther. 2014;18(2):298-305.
  19. Alvarez DJ, Rockwell PG. Trigger points: diagnosis and management. Am Fam Physician. 2002;65(4):653-60.