Trigger point injections help with pain management.

A trigger point is a hyperirritable knot in a tight band of skeletal muscle. They develop because of chronic inflammation in a muscle, often due to repeated microtrauma and stress to muscle fibers. This results in pain, spasm, and loss of range of motion, especially in muscles that help maintain body posture. These include the neck, shoulders, back, and the muscles that form the floor of the pelvis.

Trigger points may be associated with chronic myofascial pain syndromes and fibromyalgia, and may have associated temporal headaches and temporomandibular joint (TMJ) pain.

Palpating, or pressing, on the knotted muscle of the trigger point causes pain at that area, as well as referred or radiating pain (also called reflective pain). This is pain that is felt by the patient away from the trigger point in other parts of the body.

Stimulating the trigger point can also cause a twitch response, where muscle fibers and skin can be felt or seen to briefly contract. This is often diagnostic of a trigger point.

Before making the diagnosis of a trigger point, the healthcare provider will want to look for other potential causes of the patient’s pain, including radicular pain from a pinched nerve in the neck or low back, or degenerative joint disease, especially in the spine.

A trigger point injection is a procedure where a needle is inserted through the skin into the palpated painful muscle, the trigger point. Medication may be injected to help relax the area and ease the pain.

Dry needling is the term used when the needle is inserted without medication injected.

Trigger point injection is not a first line treatment for the condition causing the pain. Initial treatment options depend upon the patient’s condition and where the trigger point is located. Common initial treatments include ice/heat therapy, massage therapy, physical therapy, myofascial release, and over the counter pain medication like acetaminophen or ibuprofen.

Depending on the location and the history of the pain, additional tests such as X-rays might be performed before the diagnosis of trigger point is made.

What drugs are used for trigger point injections?

Medications that are most often injected into a trigger point include:

• A local anesthetic like lidocaine (short acting) or bupivacaine (longer acting) to decrease the pain directly.
• A corticosteroid like methylprednisolone or triamcinolone may be added to help decrease inflammation in the area.
• Botulism toxin may be used, but it is only approved in the United States for a few pain conditions:
  • Cervical dystonia (also known as spasmodic torticollis). This occurs when neck muscles contract involuntarily, causing the head to turn to one side.
  • Chronic migraine headaches
  • Upper limb spasticity. This condition usually occurs after a stroke or other neurologic injury, causing the arms to be flexed and stiff, and associated with involuntary muscle twitching.

Do trigger point injections actually work?

Trigger point injections do work for pain relief for chronic conditions, and may provide relief almost immediately in some patients. The injection can also help increase range of motion of different areas of the body including the neck, shoulder, or low back; this also helps ease the patient’s pain.

Trigger point injections are done by the many types of physicians who care for patients with chronic pain conditions. These include rheumatologists, neurologists, physical medicine and rehabilitation specialists, and pain management specialists including anesthesiologists. Some primary care physicians like family physicians and internists also inject trigger points.

For women with trigger points associated with pelvic floor pain, gynecologists specializing in female pelvic medicine and reconstructive surgery may be involved.

Physical therapists are able to offer dry needling where no medication is injected.

Trigger point injections are usually done in the office. The patient does not need to prepare prior to the injection.

Once the healthcare provider palpates and finds the trigger point and marks its location on the skin, the skin is cleaned and made sterile. A thin needle is inserted through the skin into the knotted muscle and medication(s) are injected. The needle is withdrawn and the procedure is done.

After the injection, the provider may choose to actively stretch the muscle through its full range of motion. This may increase the benefit of the injection.

The provider may also consider examining the patient again to see whether another trigger point may be felt. A decision would be made whether another trigger point injection is possible.

The most time-consuming part of the injection is locating the trigger point.

Trigger point injections may be helpful in many chronic muscle conditions. Examples include:

• Myofascial pain syndrome: a chronic long term pain syndrome that affects muscles and their covering (the fascia)
• Fibromyalgia: a chronic condition of tenderness, stiffness, and pain in the muscles, tendons, and connective tissues in many parts of the body
• Complex regional pain syndrome: a chronic pain condition that often follows an injury, usually affecting an arm or leg. It was previously known as reflex sympathetic dystrophy
• Tension headaches: headaches caused by spasm of the muscles of the scalp and the neck
• Temporomandibular joint (TMJ) syndrome: pain associated with the joint that attaches the jaw to the skull. It can cause pain and spasm of the muscles that are involved with chewing (masseter muscle, temporalis muscle)
• Chronic muscle pain of the neck, upper back, and low back: This is not pain due to a radiculopathy, which is pain from a nerve that leaves the spinal cord (a “pinched nerve” in the neck or an inflamed nerve in the low back like sciatica)
• Pelvic girdle muscle pain: This involves pain in the muscles that line and support the pelvis.

Do trigger point injections break up knots?

The purpose of the trigger point injection is to relax the muscle to allow the knot to resolve. This also helps to relieve the pain.

Ideally, trigger points resolve after one injection. However, if the pain does not resolve, the trigger point can be injected again within 3-4 days.

Depending upon the patient and their situation, a trigger point injection may offer relief for months or years. In some patients, repeated injections may be needed every few weeks or months.

How long should trigger point injections last?

After the injection, some of the pain may resolve immediately, especially if the muscles in the area are taken through their range of motion and stretched. Much of the pain should be resolved within 1-3 days.

If successful, pain relief may last a month or more after the injection. However, some trigger points may need more than one injection. Often, the second injection occurs after 3-4 days to give time to see whether the initial injection was successful.

Who should not get trigger point injections?

Injections are not appropriate in patients who are on blood thinners (anticoagulated) or have a bleeding disorder, have skin infections at the injection site, or where the trigger point cannot be safely accessed by the needle.

Trigger point injections are also contraindicated in patients with an acute muscle injury and in those patients who have an extreme fear of needles.

Patients who have an acute illness should wait until they have recovered prior to getting a trigger point injection.

Trigger point injections should be used cautiously in patients with severe fibromyalgia, a history of keloid scar formation, and in pregnant patients.

What are the dos and don'ts after trigger point injections?

There may be some expected soreness in the region of the injection. The patient should actively use and move the muscle that is injected, but should avoid strenuous activity for a few days. The area should be kept clean.

Any other restrictions will depend upon the situation and should be discussed with the healthcare provider.

There are usually few side effects of a trigger point injection, with the most common being residual muscle soreness at the site of the injection that may last a few days.

As with any injection, there is a risk of bleeding and a risk of infection.

How painful is a trigger point injection?

There is discomfort with a trigger point injection.

• It will be uncomfortable when the provider palpates and tries to localize the trigger point.
• There may be some burning when the needle is inserted through the skin especially while a medication is injected.
• Because the needle is being placed where there is already pain, the pain may worsen as the tip of the needle approaches the trigger point. The good news is that this means the needle has been appropriately placed to deliver the medications.

After the injection is complete, there may be some residual muscle soreness and skin tenderness.