New patients often ask “Is this acupuncture?”

The answer is no, trigger point injections originated in western medicine. A medical doctor who practiced in the United States, named Dr. Janet Travell, invented the technique in the 1940’s. Trigger point injections are a powerful way of releasing muscles that are too tight.

Since that time, trigger point injections have branched in many directions. There are now a wide variety of injection techniques and there is much debate on which is the best. There are even doctors who are unaware of trigger point injections, or believe that trigger point injections do not work.

The variables of trigger point injection techniques:

• Location of injection
• Depth of injection
• Whether twitch response is obtained
• Volume of medication injected
• Ingredients of medication injected

With all the variables above, it is not surprising that different doctors get different results.

Trigger Point Injections are Difficult to Study

As a physician, I practice evidence-based medicine whenever possible. This means prescribing treatments that have been rigorously tested by scientific research. Unfortunately, not all diseases and treatments can be accurately studied. Myofascial pain and trigger point injections fall in the category of being difficult to study.

Reasons why trigger point injections are difficult to study:

• Pain is heterogeneous:

In order to study the benefits of trigger point injections, we must first find people who truly have muscle pain and only muscle pain. In the real world, this is not such an easy task. Currently, there is no imaging that can reliably show the types of muscle problems that respond to trigger point injections.

I have successfully treated 8 different patients by targeting 8 different anatomical structures (including some that were not muscles) using 8 different injection techniques, yet all of them had the same symptom of pain along one side of the neck. In a research study, all 8 patients would have been given the same type of injection. The results of the study would show that trigger point injections are not effective because only 1 in 8 patients received benefit from it!

It is crucial that the right tool is used for a job. It takes years of experience to be able to diagnose which type of injection should be used for which type of pain.

• Trigger point injections is a manual skill:

Every doctor does trigger point injections a little differently. Even when trained by the same teacher using the same protocol, the way each doctor’s technique ends up being different than that of their original teacher. This means the outcomes from each doctor’s injections are different. This can make results variable in a research study.

• Funding sources for studies are more limited:

The medications used in trigger point injections are cheap and are not under patent. There are no pharmaceutical companies to provide funding with hopes of selling more of the medications.

The Art of Trigger Point Injections

Having treated thousands of patients using trigger point injections, it is my medical opinion that trigger point injections are an excellent way of treating tight and painful muscles when applied in the right way, for the right patient. When we do not get long-term improvements within the first 6 to 8 sessions of trigger point injections, it means the pain is being generated by something other than a muscle (I will cover this in a future post).

I consider trigger point injections an art because there are many ways to apply them.

• Inject where it hurts:

This is the most simple scenario. In some cases, the pain generator is as simple as one single muscle that has become overly tight. In these cases, trigger point injections will fix the problem within 1 to 5 sessions.

Sometimes, these muscles do not relax for many years until it gets an injection. A patient of mine had pain for 6 years before it was fixed by 4 sessions of trigger point injections.

• Inject based on pain radiation patterns:

A trigger point is defined as a taut band of muscle, which when pressed, causes pain or other types of sensation such as numbness, to travel to other parts of the body. Dr. Travell and Simons have done much work to map out these referral patterns. Knowing these referral patterns helps a doctor determine where to inject.

For example, if someone has a headache around their temple, trigger point injections for the upper trapezius muscle, which is a muscle at the slope of the neck/shoulder, can often reduce the headache. However for some people, a headache around the temple is caused by tightness of the jaw muscles. It takes a lot of experience and sometimes trial and error to figure out which muscle is responsible.

• Inject based on muscle function, muscle imbalances, and compensation patterns:

This is the most advanced way to apply trigger point injections. This approach is based on the fact that sometimes, where you feel the pain is not where the pain is coming from. A deep understanding of muscle function, posture, and alignment is required to apply this approach successfully. Sometimes, muscles that do not hurt need to be injected.

A detailed physical examination helps to figure out which muscles are being overused and which are underused. Trigger point injections are then done for the overused muscles. Exercises are prescribed for the underused muscles. This restores optimal muscle balance to achieve long-term improvements.

For example, if you sit at a computer for work, you tend to develop a posture where the head is forward. In this situation, pain is often felt along the slope of the shoulder, but injecting where it hurts gives only short-term pain reduction, even if you’ve had 15-20 treatments! The painful muscle is actually the victim of other muscle imbalances. The pain will not improve until the underlying muscle imbalance is corrected.

This type of issue usually requires at least 3 to 4 months of treatment to feel a significant improvement. It also requires dedication from the patient to do exercises.

• The location of trigger points are different for each person:

We all have different body proportions and different movement patterns. A skilled hand is needed to feel these trigger points, find the twitches with the needle, and get results.

Trigger Point Injections at White Oak Pain Clinic

For people who have muscle pain that has not responded to other treatments, it is always worthwhile to try trigger point injections with a different doctor. A different technique or approach might work better for you.

At White Oak Pain Clinic, our doctors have a wide skill-set to help our patients with different types of soft tissue pain. We have the experience to know when to persist with one type of injection and when it’s time to try something new.

Author: Dr. Xiao Yuan MD CCFP D-CAPM