Myofascial pain syndrome is a chronic regional pain condition defined by trigger points — hyperirritable spots within taut bands of muscle fibers that produce both localized and referred pain.1 The referred part is what makes it confusing: a trigger point in one muscle can send pain somewhere else entirely, so the place that hurts is often not the place generating the pain.
Why it gets missed
Myofascial pain syndrome frequently goes unrecognized because its symptoms overlap with other pain disorders, including fibromyalgia, neuropathic pain and joint disorders.1 Its pathogenesis, diagnostic criteria and classification are all still under investigation, which is part of why standardized treatment protocols have been slow to develop.1
Factors contributing to onset and persistence include muscle overuse, postural imbalance, systemic conditions, and psychological and behavioral influences.1 That mix is worth noting — it is not purely mechanical, and treating it as purely mechanical is one reason it recurs.
What the evidence supports, in order
A 2025 narrative review sorted the treatment literature by strength of evidence, and the resulting hierarchy is more useful than most treatment lists because it is explicit about 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, and 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 be effective, particularly when 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. The effectiveness of muscle relaxants, antidepressants, gabapentin, opioids, topical lidocaine, capsaicin, EMLA cream and kinesio taping remains inconclusive.1
That list deserves attention, because it contains most of what people are typically given first. If you have cycled through anti-inflammatories, a muscle relaxant and a topical without benefit, that is consistent with the evidence rather than a sign that your pain is unusual.
Dry needling compared with manual therapy
A systematic review and meta-analysis of six randomized controlled trials with 241 participants 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 both improve pain and function in the short to medium term, with neither superior to the other.2 Practically, that means the choice can be made on tolerability and access rather than on a claim that one is better.
Where this fits in a wider plan
Because psychological and behavioral factors contribute to persistence, addressing them is part of treatment rather than an afterthought — counseling for chronic pain is delivered in-house here. Where symptoms overlap with widespread sensitivity, distinguishing the two 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 hyperirritable spot within a taut band of muscle fibers that causes both local pain and pain referred elsewhere. The referral pattern 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, while 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 with no significant difference between them. Options are described on the trigger point injections page.
Could this be fibromyalgia instead?
It can be hard to separate them, and symptom overlap with fibromyalgia is one of the main reasons myofascial pain is underrecognized. The distinction is discussed in fibromyalgia and why normal tests are expected.
Why does it keep coming back?
Muscle overuse, postural imbalance, systemic conditions and psychological and behavioral factors all contribute to persistence, so treating the muscle alone often is not enough. See counseling for chronic pain.
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
