What are the treatment options for myofascial pain syndrome?

Treatment of Myofascial Pain Syndrome

Manual physical therapy techniques targeting trigger points should be initiated as first-line treatment for myofascial pain syndrome, as they provide the largest reduction in pain severity with minimal risk of harm. 1, 2

First-Line Non-Pharmacological Interventions

Manual Physical Therapy (Primary Treatment)

• Manual trigger point therapy and myofascial release are the cornerstone of initial management 1, 2
• Treatment protocols should consist of 10 sessions of 60 minutes over 12 weeks, which results in 59% of patients reporting moderate or marked improvement 2
• Specific techniques include: maneuvers that resolve muscular trigger points, techniques that lengthen muscle contractures, and release of painful scars and connective tissue restrictions 1
• Ischemic compression therapy has demonstrated efficacy in clinical trials 3

Additional Physical Modalities

• Spray and stretch technique is effective for acute trigger point management 3
• Transcutaneous electrical nerve stimulation (TENS) provides symptomatic relief 3
• Low-resistance exercise programs should be incorporated to improve joint stability by increasing muscle tone 1
• Heat and cold packs can be used as adjunctive measures 1

Pharmacological Management

Topical Agents (Preferred for Safety Profile)

• Lidocaine patches are the preferred topical treatment for localized myofascial pain 1, 2
• Diclofenac patches have demonstrated significant benefit in clinical trials 1, 3
• Capsaicin cream may provide additional relief 1

Oral Medications

• NSAIDs should be offered for symptomatic relief as first-line oral therapy 1, 4
• Tricyclic antidepressants (such as amitriptyline) may be beneficial for persistent pain 1
• SNRIs (serotonin-norepinephrine reuptake inhibitors) can be considered as an alternative to tricyclics 1
• Anticonvulsants (gabapentin, pregabalin) should be reserved for persistent pain that has not responded to other measures 1
• Muscle relaxants (such as thiocolchicoside) have shown efficacy in clinical trials 3

Medications NOT Recommended

• Strong opioids are not recommended for myofascial pain syndrome 5
• Corticosteroids are not recommended 5

Interventional Procedures (Reserved for Refractory Cases)

Trigger Point Injections

• Should ONLY be considered after 3+ months of conservative treatment failure 2, 4
• Must be used as part of multimodal treatment, not as monotherapy 2, 4
• Patients must continue concurrent physical therapy during and after injections 2, 4
• Limit to 4 sets of injections maximum to assess therapeutic response 4

Nerve Blocks

• Peripheral somatic nerve blocks should NOT be used for long-term treatment of myofascial pain 2, 4
• Supraorbital, supratrochlear, and occipital nerve blocks have insufficient evidence for myofascial pain syndrome 4

Behavioral and Psychosocial Interventions

• Cognitive behavioral therapy may benefit some patients with myofascial pain 5, 1
• Relaxation techniques and breathing exercises can be useful adjuncts 1
• Patient education regarding posture, ergonomics, and stress management is essential 1
• Underlying psychological factors such as stress, poor coping strategies, and depression must be addressed as they contribute to chronicity 2

Treatment Algorithm

Step 1 (Weeks 0-12):

• Initiate manual physical therapy (10 sessions over 12 weeks) 2
• Add topical lidocaine or diclofenac patches 1, 2
• Trial NSAIDs if needed for additional pain control 1, 4
• Incorporate heat/cold therapy and home exercise program 1

Step 2 (If inadequate response after 12 weeks):

• Add tricyclic antidepressant or SNRI 1
• Consider muscle relaxants for documented muscle spasm 4
• Intensify physical therapy with additional modalities (TENS, spray and stretch) 3
• Initiate cognitive behavioral therapy if behavioral factors present 1

Step 3 (If inadequate response after 3+ months):

• Consider anticonvulsants (gabapentin, pregabalin) for persistent pain 1
• Evaluate for trigger point injections as part of continued multimodal therapy 2, 4
• Maximum 4 sets of injections with mandatory concurrent physical therapy 4

Critical Pitfalls to Avoid

• Do not use trigger point injections as monotherapy - they must be combined with ongoing physical therapy 2, 4
• Do not proceed to injections without documented failure of conservative measures including NSAIDs, muscle relaxants, topical treatments, and at least 3 months of physical therapy 4
• Do not use nerve blocks for chronic myofascial pain - evidence is insufficient and they are not recommended for long-term management 2, 4
• Do not prescribe strong opioids - they are explicitly not recommended for this condition 5
• Do not neglect underlying pathologies - spinal conditions, postural abnormalities, and behavioral issues must be addressed for successful treatment 3