Myofascial pain syndrome is a chronic regional pain condition defined by trigger points. These are touchy, irritable spots inside tight bands of muscle. They cause pain right where they sit and also pain felt somewhere else.1 That second part is what makes it confusing. A trigger point in one muscle can send pain to a different place entirely. So the spot that hurts is often not the spot making the pain.
Why is myofascial pain syndrome so often missed?
Myofascial pain syndrome is often missed because its symptoms overlap with other pain disorders. These include fibromyalgia, neuropathic (nerve) pain and joint disorders.1 How it starts, how to diagnose it and how to classify it are all still being studied. That is part of why standard treatment plans have been slow to develop.1
Things that start it and keep it going include muscle overuse, poor posture, whole-body conditions, and mental and behavioral factors.1 That mix matters. It is not purely mechanical. Treating it as purely mechanical is one reason it keeps coming back.
What is the best treatment for trigger points?
A 2025 narrative review ranked the treatment research by strength of evidence. That ranking beats most treatment lists, because it says plainly what is weak.
Sufficient evidence
Local anesthetic injections have sufficient evidence to support their use in myofascial pain syndrome.1 That is the strongest statement in the review. It is the basis for trigger point injections.
Some evidence
Some evidence suggests dry needling, acupuncture, magnetic stimulation, ultrasound therapy, laser therapy, extracorporeal shock wave therapy and manual therapy may work. This holds mainly when they are compared with sham or placebo.1 Related options here include shockwave therapy and cold laser therapy.
Insufficient or inconclusive evidence
Non-steroidal anti-inflammatory drugs, diclofenac, botulinum toxin and transcutaneous electrical nerve stimulation show insufficient evidence. For muscle relaxants, antidepressants, gabapentin, opioids, topical lidocaine, capsaicin, EMLA cream and kinesio taping, the results are still inconclusive.1
Look hard at that list, because it holds most of what people are usually given first. Maybe you have cycled through anti-inflammatories, a muscle relaxant and a cream with no benefit. That fits the evidence. It is not a sign that your pain is unusual.
Which works better, dry needling or manual therapy?
A systematic review and meta-analysis pooled six randomized controlled trials with 241 participants. It compared dry needling against trigger point manual therapy for neck and upper back myofascial pain. Differences between the two were non-significant on pain (standardized mean difference 0.41, 95% CI −0.18 to 0.99), pressure pain threshold (0.64, 95% CI −0.19 to 1.47) and the Neck Disability Index (−0.66, 95% CI −1.33 to 0.02).2
The authors concluded that both improve pain and function in the short to medium term. Neither was better than the other.2 In practice, you can choose based on what you tolerate and can get to. Neither one can claim to be better.
Where this fits in a wider plan
Mental and behavioral factors help keep the pain going. So treating them is part of the plan, not an afterthought — counseling for chronic pain is offered in-house here. When symptoms overlap with widespread sensitivity, telling the two apart matters; see fibromyalgia and why normal tests are expected. The full set of options is on the pain treatments page.
Frequently asked questions
What exactly is a trigger point?
A touchy, irritable spot inside a tight band of muscle. It causes pain right there and also pain felt somewhere else. That spread is why the painful area and the source often differ. See trigger point injections.
Why did anti-inflammatories and muscle relaxants not help?
Because the evidence for them in this condition is weak. NSAIDs, diclofenac, botulinum toxin and TENS have insufficient evidence. Muscle relaxants, antidepressants, gabapentin and opioids remain inconclusive. Local anesthetic injection is the option with sufficient evidence behind it — see the range of pain treatments.
Is dry needling better than hands-on manual therapy?
On pooled evidence from six randomized trials, no. Both improved pain and function in the short to medium term. There was no significant difference between them. Options are described on the trigger point injections page.
Could this be fibromyalgia instead?
They can be hard to tell apart. Overlap with fibromyalgia is one of the main reasons myofascial pain gets missed. The difference is discussed in fibromyalgia and why normal tests are expected.
Why does it keep coming back?
Muscle overuse, poor posture, whole-body conditions, and mental and behavioral factors all keep it going. So treating the muscle alone often is not enough. See counseling for chronic pain.
Do trigger point injections work?
Local anesthetic injection is the treatment with sufficient evidence behind it for myofascial pain syndrome. That is the strongest rating in a 2025 review that ranked every option by strength of evidence. It is the basis for trigger point injections at this practice. Overuse, posture and behavior keep trigger points coming back. So the injection works best inside a wider plan.
Does Botox help trigger points?
Not on current evidence. Botulinum toxin sits in the insufficient-evidence group for myofascial pain syndrome. So do anti-inflammatories, diclofenac and TENS. If those have already failed you, that fits the evidence. It does not mean your pain is unusual. Local anesthetic injection is the option with sufficient evidence. Dry needling and manual therapy have some evidence behind them.
To have muscular pain evaluated, request an appointment, call (314) 481-5000, or text (314) 886-5902.
Sources
- Steen JP, Jaiswal KS, Kumbhare D. Myofascial Pain Syndrome: An Update on Clinical Characteristics, Etiopathogenesis, Diagnosis, and Treatment. Muscle & Nerve. 2025;71(5):889–910. doi:10.1002/mus.28377. Retrieved via PubMed. DOI
- Lew J, Kim J, Nair P. Comparison of dry needling and trigger point manual therapy in patients with neck and upper back myofascial pain syndrome: a systematic review and meta-analysis. The Journal of Manual & Manipulative Therapy. 2020;29(3):136–146. doi:10.1080/10669817.2020.1822618. Retrieved via PubMed. DOI
Dr. Gurpreet Singh Padda, MD, MBA, MHP
