What are the treatment options for a patient presenting with trigger points?

Treatment of Trigger Points

Manual trigger point therapy should be the first-line treatment for patients presenting with trigger points, followed by supervised stretching exercises and physical therapy modalities. 1

First-Line Conservative Treatments

The most effective initial approach combines manual techniques with physical interventions:

• Manual trigger point therapy provides the largest reduction in pain severity, approximating twice the minimally important difference compared to placebo, with moderate certainty evidence 1
• Therapist-assisted mobilization should be offered when appropriately trained clinicians are available, particularly for patients with pelvic floor or musculoskeletal trigger point tenderness 1
• Supervised stretching and exercise programs are strongly recommended, combining jaw exercise, stretching, and manual trigger point therapy for optimal outcomes 1
• Spray-and-stretch technique represents an effective non-invasive option that can be used as initial or adjunctive therapy 2, 3, 4

Important Caveat on Exercise

Avoid pelvic floor strengthening exercises (e.g., Kegel exercises) when trigger points involve the pelvic floor musculature, as these can worsen symptoms 1

Second-Line Treatment Options

When first-line therapies provide insufficient relief after 4-6 weeks:

• Massage therapy using soft tissue manipulation through various specific methods, with pressure and intensity varying based on patient tolerance 1
• Transcutaneous electrical nerve stimulation (TENS) may provide symptomatic relief by modifying pain perception, though evidence is limited 1
• Progressive relaxation techniques involving deliberate tensing and relaxation of muscles to facilitate recognition and release of muscle tension 1

Invasive Interventions: Use With Caution

Trigger point injections should be reserved only for patients whose myofascial pain has been refractory to conservative measures for at least 3 months. 5

Evidence Limitations for Injections

The evidence for trigger point injections is problematic:

• No single pharmacologic agent (local anesthetics, corticosteroids, or botulinum toxin) has proven superior to another or to placebo in high-quality studies 5
• Dry needling appears comparable to drug injection, suggesting the mechanical disruption rather than the injectate may be therapeutic 1
• Studies show only 7.7% of patients selected for facet joint injection based on clinical criteria achieved complete symptom relief, compared to 5% whose symptoms worsened 1
• Injections carry risks of moderate harm including local infection and should not be first-line therapy 1

When Injections May Be Considered

If conservative therapy fails after 3+ months:

• Trigger point injections with local anesthetic (e.g., lidocaine or bupivacaine) may be attempted 1, 2, 3
• The addition of corticosteroids to local anesthetic showed some benefit in one trial, with significant decreases in pain scores compared to saline 1
• Dry needling (without injectate) may be equally effective as drug injection 1

Adjunctive Therapies

These should accompany primary treatments:

• Cognitive behavioral therapy (CBT) with or without biofeedback provides important pain relief, approximating 1.5 times the minimally important difference 1
• Patient education about trigger points, self-care strategies, and home exercise programs 1
• Anxiety management strategies including breathing techniques, grounding strategies, and mindfulness, as anxiety often perpetuates trigger point pain 1, 6

Critical Perpetuating Factors to Address

Treatment will fail unless perpetuating factors are identified and corrected: 6

• Poor posture and body mechanics
• Psychological stress or depression
• Poor sleep quality
• Nutritional deficiencies
• Hypersensitivity to touch, light, sound, or movement 1

Treatment Algorithm

1. Weeks 0-4: Manual trigger point therapy + supervised stretching + patient education 1
2. Weeks 4-8: Add massage therapy, TENS, or progressive relaxation if inadequate response 1
3. Weeks 8-12: Add CBT if pain persists; address perpetuating factors aggressively 1, 6
4. After 3+ months: Consider trigger point injections only if all conservative measures have failed 5

Common Pitfalls

• Do not use trigger point injections as first-line therapy – the evidence does not support this approach and exposes patients to unnecessary procedural risks 5
• Do not prescribe strengthening exercises for muscles harboring trigger points until the trigger points are inactivated, as this can worsen symptoms 1
• Do not focus solely on the trigger point without addressing perpetuating factors like posture, stress, and sleep, or treatment will likely fail 6
• Do not assume all tender points are trigger points – proper diagnosis requires palpation with 2-4 kg/cm² pressure for 10-20 seconds to elicit the characteristic referred pain pattern 6