What is the best approach to manage myofascial trigger points in patients presenting with pain, stiffness, and limited range of motion?

Management of Myofascial Trigger Points

Manual physical therapy techniques targeting trigger points should be the first-line treatment for patients with myofascial trigger points, as this approach provides the largest reduction in pain severity with minimal risk of harm. 1, 2, 3

Initial Treatment Approach

Manual Physical Therapy (First-Line)

• Manual trigger point therapy and myofascial release techniques should be initiated immediately as they provide approximately twice the minimally important difference in pain reduction compared to placebo 1
• Treatment protocols should consist of 10 sessions of 60 minutes over 12 weeks, which results in 59% of patients reporting moderate or marked improvement 3
• Specific techniques include maneuvers to resolve muscular trigger points, lengthen muscle contractures, and release painful scars and connective tissue restrictions 4, 2
• Manual palpation to identify trigger points has good reliability and should guide treatment 5

Supervised Exercise Programs

• Supervised jaw exercise and stretching (with or without manual trigger point therapy) provides important pain relief approximating 1.5 times the minimally important difference 1
• Supervised postural exercise should be incorporated as it provides moderate to high certainty evidence for pain reduction 1
• Low-resistance exercise improves joint stability by increasing muscle tone 2

Patient Education and Self-Management

• Education about the nature of myofascial pain and realistic treatment expectations is essential 4
• Avoid Kegel exercises or any exercises that increase muscle tension in already hypertonic muscles, as these worsen symptoms 4
• Application of heat or cold over affected areas provides symptomatic relief 4, 2
• Relaxation techniques targeting affected muscles should be taught 4

Pharmacological Management

First-Line Medications

• NSAIDs are recommended for initial pain management 4, 2, 3
• Topical treatments (lidocaine patches, diclofenac patches, capsaicin) are preferred for safety and may provide symptomatic relief 2, 3
• Muscle relaxants reduce muscle tension and should be considered early 4

Second-Line Medications for Persistent Pain

• Tricyclic antidepressants (TCAs) for pain modulation and sleep improvement 4, 2
• Serotonin-norepinephrine reuptake inhibitors (SNRIs) for chronic pain modulation 4, 2
• Anticonvulsants (gabapentin, pregabalin) for neuropathic pain components 4, 2

Critical Medication Warnings

• Strong opioids should NOT be used for myofascial pain management 2
• Corticosteroids have no role in isolated myofascial pain syndrome unless concomitant joint pathology exists 2
• If opioids become necessary, use the lowest effective dose and reevaluate regularly 4

Adjunctive Therapies

Cognitive and Behavioral Interventions

• Cognitive behavioral therapy (CBT) augmented with relaxation therapy or biofeedback provides the largest reduction in pain severity, approximating twice the minimally important difference 1
• Breathing exercises and other behavioral therapies are useful 2
• Psychosocial support should be provided 2

Alternative Modalities

• Acupuncture may be considered, though evidence supporting its efficacy is limited 4, 6
• Transcutaneous electrical nerve stimulation (TENS) may be considered for persistent pain, though evidence is inconclusive 4

Interventional Procedures (Reserved for Refractory Cases)

Trigger Point Injections

• Should only be considered as part of multimodal treatment after conservative measures have failed 3
• Patients must continue concurrent physical therapy when receiving injections 3
• Injections with local anesthetics or dry needling can effectively eliminate pain immediately 7, 8
• Trigger point injection has been shown to be one of the most effective modalities to inactivate trigger points and provide prompt relief 8

Advanced Interventions

• Dorsal column stimulation for chronic pain unresponsive to other treatments 4
• Peripheral somatic nerve blocks should NOT be used for long-term treatment 2, 3

Treatment Monitoring and Outcomes

Assessment Principles

• Functionality may be a better endpoint for measuring outcomes rather than numerical pain ratings 4
• Regular reassessment of treatment efficacy is essential, discontinuing ineffective interventions 4
• Trigger points tend to be smaller, stiffer, and deeper in muscle tissue for patients with pain compared to those without pain 9
• More than one trigger point within a single area increases the stiffness of neighboring trigger points 9

Common Pitfalls to Avoid

• Do not use splinting as it may prevent restoration of normal movement and can increase attention to the area, exacerbating symptoms 1
• Avoid immobilization leading to muscle deconditioning and learnt non-use 1
• Do not be overly restrictive with exercise prescription, as this is equally problematic as being too aggressive 1