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Am Fam Physician. 2023;107(2):159-164

This clinical content conforms to AAFP criteria for CME.

Author disclosure: No relevant financial relationships.

Trigger points producing myofascial pain syndromes are common in primary care. Located within skeletal muscle, trigger points are taut, band-like nodules capable of producing pain and disability. Some evidence from clinical trials supports massage, physical therapy, and osteopathic manual medicine as first-line less invasive treatment strategies. Trigger points are often treated with injections; although randomized trials have found statistically significant results with trigger point injections, conclusions are limited by low numbers of study participants, difficulty in blinding, the potential for a placebo effect, and lack of posttreatment follow-up. No single pharmacologic agent used in trigger point injections has been proven superior to another, nor has any single agent been proven superior to placebo. Trigger point injections, therefore, should be reserved for patients whose myofascial pain has been refractory to other measures, and family physicians should first employ less invasive treatment strategies. Trigger point management is only one part of a comprehensive, multimodal, and team-based approach to patients with myofascial pain.

Myofascial trigger points are hypersensitive nodules that can occur in tight bands of skeletal muscle and may cause motor, sensory, and autonomic pain symptoms; decreased range of motion; and musculoskeletal disability.13

Clinical recommendation Evidence rating Comments
Placebo effect may be the underlying source of pain relief from trigger point injections.911 B A strong placebo-type effect is seen in a systematic review of numerous randomized controlled trials in which a painful intervention (i.e., trigger point injections) is introduced to a painful condition (trigger point), producing results with placebo-type effect
Massage and physical therapy should be considered as first-line less invasive treatments for trigger point pain.9,16 B Systematic review of low-quality evidence shows effective trigger point management with less invasive methods; when added risk of patient harm is introduced, less invasive therapies are considered more reasonable
Routine use of trigger point injections is not supported by clinical trials.9,10,12,13,16 B Trigger point injection trials have methodologic flaws, small numbers of trial participants, difficulty blinding, and lack of long-term follow-up; a systematic review of low-quality randomized controlled trials consistently demonstrates this pattern

A study in a primary care practice found that 30% of patients presenting with musculoskeletal pain also had myofascial pain.4 Located anywhere skeletal muscle is found, trigger points most commonly occur over the muscles of the back.2,5 In studies of patients presenting with myofascial pain, the majority of all trigger points came from the trapezius muscle. Typical locations for trapezius trigger points are pictured in Figure 1.2,6 Gluteus maximus, gluteus medius, and quadratus lumborum muscles also commonly harbor trigger points. Areas of the back that tend to be affected in patients presenting with trigger points are demonstrated in Figure 2.3


In patients with musculoskeletal pain, especially in the neck or back, identifying trigger points should be part of a detailed history and neuromuscular examination. Physical examination is key to determining the location and number of myofascial trigger points. During the palpation portion of the examination, trigger points are elicited when the patient experiences pain while the physician palpates a band-like nodule within the muscle.2

Less Invasive Management of Trigger Points

Nonpharmacologic treatment modalities for trigger points have been studied, but no standardized treatment protocol has been established.2 Trigger point treatments include oral nonsteroidal anti-inflammatory drugs, acetaminophen, and muscle relaxants. Evidence for the use of medications in trigger point management is lacking.7 Other less invasive treatments include massage, osteopathic manual medicine, physical therapy (PT), and the spray and stretch technique. Proposed invasive strategies include acupuncture, dry needling, and trigger point injections using pharmacologic agents.

Although some statistically significant benefits have been noted in some randomized trials of trigger point therapy, the results are at high risk of bias. Studies have typically had small sample sizes, with difficulty blinding patients to the interventions. Studies of injection therapies have differences in injection techniques and variation in needle sizes. The benefits observed using different injection compositions (including normal saline) suggest a strong placebo response to trigger point injection.8 The underlying source of pain relief from trigger point injections may be the placebo effect.911 The absence of posttreatment patient follow-up in randomized controlled trials (RCTs) of trigger point management also hinders drawing conclusions about long-term clinical effects, especially for trigger point injections.2,8,1214


Massage is a modality in which direct pressure is applied in a slow, controlled fashion over the trigger point.1,15 One recent RCT involved 56 patients with tension-type headaches who were randomized to receive 12 massage treatments or sham treatment (detuned ultrasonography) or to be wait-listed over a six-week period.9 Outcomes for the trial included self-reported headache pain and pain-pressure threshold measured with an algometer (a device measuring pressure against musculature). No differences were found between the massage and placebo groups in headache frequency; however, the pain-pressure threshold and self-reported headache pain improved in the massage-treated patients. A similar RCT containing 62 patients with tension-type headache compared massage with sham massage over 12 sessions.10 A statistically significant improvement in pain-pressure threshold was observed over the trapezius and suboccipital muscles in the massage-treated group, representing an increased ability to tolerate pain. Outcome measures commonly used in trigger point management trials are summarized in eTable A.

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