What is the recommended management of chronic myofascial pain syndrome?

Treatment of Chronic Myofascial Pain

Manual physical therapy techniques targeting trigger points should be your first-line treatment, combined with supervised exercise programs and NSAIDs for symptomatic relief. 1

First-Line Physical Therapy Interventions

Start with manual physical therapy as the cornerstone of treatment:

• Manual trigger point therapy to resolve muscular trigger points 1
• Techniques to lengthen muscle contractures 1
• Release of painful scars and connective tissue restrictions 1
• Therapist-assisted mobilization 2
• Supervised postural exercise programs 2
• Supervised jaw exercise and stretching (can be combined with manual trigger point therapy) 2

Add low-resistance exercise to improve joint stability by increasing muscle tone 1. Physical therapy for myofascial release is often necessary before patients can fully participate in exercise programs 1.

Pharmacologic Management

For symptomatic relief, use NSAIDs as your primary pharmacologic option:

• Diclofenac patches (180 mg once or twice daily) or diclofenac gel applied three times daily 1
• Topical NSAIDs provide localized relief without systemic side effects 3

For persistent pain that fails to respond to NSAIDs and physical therapy:

• Tricyclic antidepressants: nortriptyline 10-25 mg nightly, titrated to 50-150 mg 1
• SNRIs: duloxetine 30-60 mg daily, titrated to 60-120 mg 1
• Anticonvulsants: gabapentin starting 100-300 mg nightly, titrated up to 900-3600 mg daily in divided doses, or pregabalin starting 50 mg three times daily, titrated to 100 mg three times daily 1

Topical Therapies

Use topical agents for localized pain relief:

• 5% lidocaine patches applied daily to painful sites 1
• Capsaicin cream 2
• Heat and cold packs 2

Critical Contraindications

Avoid these interventions that lack evidence or cause harm:

• Strong opioids should NOT be used for myofascial pain management 1
• Corticosteroids have no role in isolated myofascial pain syndrome unless concomitant joint pathology exists 1
• Paracetamol should not be used as monotherapy because it provides insufficient analgesia 1
• Glucosamine and chondroitin provide no benefit 1
• Botulinum toxin is NOT recommended for routine use in myofascial pain (only for piriformis syndrome when other therapies fail) 1, 4

Adjunctive Behavioral Interventions

Incorporate cognitive-behavioral therapy for patients with chronic pain, particularly when psychosocial factors contribute to pain chronicity 2, 1. Add relaxation techniques and breathing exercises as supportive adjuncts 1.

Interventional Procedures (Reserved for Refractory Cases)

Consider trigger point injections only after 3+ months of failed conservative treatment:

• Use as part of a comprehensive multimodal program, not standalone therapy 3
• Limit to 4 sets maximum to assess therapeutic response 3
• TENS may be incorporated into multimodal treatment but never as standalone therapy 1

Treatment Algorithm

1. Initiate manual physical therapy + supervised exercise + topical NSAIDs simultaneously 1
2. If inadequate response after 4-6 weeks, add systemic pharmacotherapy (start with tricyclic antidepressants or SNRIs) 1
3. If pain persists despite 8-12 weeks of combined therapy, add anticonvulsants 1
4. Reserve trigger point injections for patients failing 3+ months of comprehensive conservative management 3
5. Throughout treatment, address underlying pathologies including spinal conditions, postural abnormalities, and behavioral issues 5

Common Pitfalls to Avoid

Do not prescribe opioids - they lack benefit and carry significant harm in myofascial pain 2, 1. Do not use botulinum toxin routinely - randomized controlled trials show equivocal results except for piriformis syndrome 4. Do not rely on monotherapy - myofascial pain requires multimodal treatment combining physical therapy, pharmacologic agents, and behavioral interventions 1, 5.