Myofascial Pain: Trigger Points and Treatments That Work

Name: Myofascial pain and trigger points: the muscle knot that massage won't fix
Creator: Dr. Mauricio Casarsa
Published: 2026-05-18

Medical second opinion

Before making an important decision about your treatment, a second opinion from a Pain Medicine specialist can open up minimally invasive alternatives.

Myofascial syndrome is probably one of the most underdiagnosed conditions I see in my practice. Patients arrive with normal MRIs, orthopedic surgeons who found "nothing structural," and yet a pain that is very real, very localized, and very reproducible when you press certain points in the muscle. Those points — the trigger points — set off pain in the area and often refer it to distant sites, mimicking other conditions. That is why many patients wander from doctor to doctor for months before someone tells them: this is muscular, and it has a concrete treatment.

What myofascial pain is

Myofascial pain syndrome is a very common and often underdiagnosed condition. It is characterized by pain arising from the muscles and their fascia (the connective sheath that surrounds them), with trigger points that reproduce the patient's pain when pressed.

It is not the same as an ordinary "muscle knot." An occasional knot goes away with rest and heat. Myofascial pain is persistent and recurrent, and it often lasts for months or years because the mechanisms that perpetuate it are never addressed.

The most common locations are the upper trapezius, levator scapulae, rhomboids, suboccipital muscles, scalenes, quadratus lumborum, gluteus medius, piriformis, and calf muscles. It is very common in people with sedentary jobs, prolonged postures in front of a computer, sustained stress, and in patients with other painful conditions (chronic low back pain, fibromyalgia, headaches).

One important nuance: myofascial pain is not diagnosed with an MRI or an ultrasound. It is diagnosed with a careful physical exam — palpating, reproducing the patient's pain, and mapping the taut muscle bands. Imaging is there to rule out other things, not to confirm this one. That is exactly why it is so often missed: if the physician does not include a myofascial exam in the evaluation, this pain shows up on no test and gets labeled "nonspecific." To me, palpation is part of the diagnosis, not a formality.

Trigger points: the heart of the problem

Myofascial trigger points are hyperirritable nodules within a taut muscle band. When pressed, they produce local pain and referred pain at a distance, in a pattern characteristic of each muscle.

Some examples of referral patterns:

Upper trapezius trigger points: refer pain to the temple and the area behind the ear. They are a common cause of tension-type headaches.
Levator scapulae trigger points: cause posterior neck pain and difficulty rotating the neck.
Quadratus lumborum trigger points: refer pain to the iliac crest and the buttock, mimicking low back or sacroiliac pain.
Gluteus medius trigger points: mimic lateral hip pain or sciatica.
Piriformis trigger points: can compress the sciatic nerve and cause pain radiating down the leg.

Recognizing these patterns is key to avoiding misdiagnosis. Pain that looks like "sciatica" may actually be myofascial pain from the piriformis or the gluteal muscles. "Hip" pain may be myofascial pain from the quadratus lumborum.

Why it always comes back to the same spot

Myofascial pain has one defining feature: if you only treat the symptom (the massage, the cream, local heat), it eases temporarily and then comes back. The reason is that there are almost always perpetuating factors keeping the trigger points active:

Prolonged postures: working long hours at a computer without breaks, driving long distances, sleeping in positions that hold muscle tension.
Biomechanical asymmetries: one leg shorter than the other, a tilted pelvis, bite problems that affect the neck muscles.
Sustained stress: emotional tension translates into muscle tension, especially in the neck, shoulders, and jaw.
Muscle disuse: untrained muscles become more susceptible to knots and trigger points.
Comorbidities: fibromyalgia, depression, nutritional deficiencies (low vitamin D, low iron) can keep trigger points active.

Without addressing these factors, any treatment is palliative. That is why managing myofascial pain requires combining several interventions, not just one.

Treatments that actually work

The ideal plan is stepwise and multimodal:

Trigger point injections: the trigger point is targeted directly with a needle, either with diluted local anesthetic or with the dry needling technique. It is one of the most effective treatments when there are identifiable active trigger points. It usually brings rapid relief and can be repeated.
Specific myofascial physical therapy: myofascial release techniques, sustained stretching, progressive strengthening. Generic physical therapy is not enough; it has to be focused on the myofascial component.
Botulinum toxin: in selected refractory cases, especially in specific patterns (refractory chronic tension-type headache, cervical dystonia, very localized myofascial pain). The evidence is mixed, but in properly selected patients it can deliver very good results.
Postural and ergonomic management: reviewing your chair, monitor height, break frequency, and workstation ergonomics. Without this, treatment is like bailing out water while the tap is still running.
Medication: in chronic cases, it is not NSAIDs that help most, but muscle relaxants for short periods, and sometimes gabapentinoids or low-dose antidepressants when there is associated central sensitization.
Treating comorbidities: correcting vitamin deficiencies, treating anxiety or depression, addressing sleep dysfunction when present.

My approach to myofascial pain is to combine several tools. Dry needling and trigger point injections bring rapid relief, especially when the muscles are very tight, but on their own they do not solve the underlying problem. I always integrate them with a plan of active physical therapy, strengthening, postural correction, and a review of habits: screen, sleep, desk, backpack, stress management. When patients understand that the muscle is the main organ driving their condition, they engage much more in the treatment and the results hold up far better over time.

Preventing relapses

Once the perpetuating factors have been identified and the active trigger points resolved, the goal is to keep the condition from coming back. That requires sustained changes:

Active breaks during the workday: every 45-60 minutes, stand up, move around, stretch the areas that tend to tighten up.
Regular physical activity: a trained muscle is less prone to developing trigger points. Walking, swimming, general strengthening.
Stress management: when there is a significant emotional component, addressing it (psychotherapy, relaxation techniques, mindfulness) makes a real difference in the outcome.
Restorative sleep: prioritize sleep hygiene, because muscle needs that time to recover.

Patients who understand their perpetuating factors and manage them actively have a much better long-term prognosis than those who only seek one-off treatments for the symptoms.

What defines long-term success in myofascial pain is that the patient stops needing me every four weeks. If we get them to understand their triggers, to have an exercise plan of their own, and to recognize the early warning signs, relapses become far less frequent and much shorter. When they come back for a follow-up and tell me they have not had a bad flare in months, I know the treatment worked — not just in the office, but above all in their daily life. That is the real goal: giving them back control of their body, not tying them to an injection every few months.

Do your muscle knots always come back to the same spot?

If massage and creams ease the pain for a while but it keeps coming back, there are probably active trigger points and perpetuating factors going untreated. A targeted evaluation can change the approach.

💬 My muscle knots won't go away

Myofascial pain — frequently asked questions

What is the difference between an ordinary muscle knot and myofascial pain?

An ordinary muscle knot resolves within a few days with rest, heat and simple measures. Myofascial pain is persistent or recurrent, involves identifiable trigger points that reproduce the pain when pressed, and usually comes with perpetuating factors (postural, ergonomic, biomechanical, emotional) that keep it active.

Does botulinum toxin work for myofascial pain?

In properly selected patients, yes. Botulinum toxin is used for refractory chronic tension-type headache, cervical dystonia, and very localized, persistent myofascial pain. It is not a first-line treatment; it is considered when conventional treatments fail to control the condition.

Is dry needling the same as acupuncture?

They share the tool (fine needles), but the rationale and technique are different. Dry needling is based on the pathophysiology of the myofascial trigger point and specifically seeks the local twitch response of the affected muscle. Acupuncture has a different conceptual basis (energy meridians) and is used with other goals.

Can I keep exercising if I have myofascial pain?

Yes, but adjusting the intensity and type of exercise. Complete rest deconditions the muscles and makes things worse in the medium term. Well-dosed activity, combined with myofascial release and postural work, usually speeds up recovery.

References and recommended reading

Simons DG, Travell JG, Simons LS. Travell & Simons' Myofascial Pain and Dysfunction: The Trigger Point Manual. 3rd ed. Wolters Kluwer.
Borg-Stein J, Iaccarino MA. Myofascial pain syndrome treatments. Phys Med Rehabil Clin N Am. 2014;25(2):357-374.
Dommerholt J, Mayoral del Moral O, et al. Trigger point dry needling. J Man Manip Ther. 2006;14(4):E70-E87.
Soares A, Andriolo RB, et al. Botulinum toxin for myofascial pain syndromes in adults. Cochrane Database Syst Rev. 2014;7:CD007533.

Dr. Mauricio Casarsa

Anesthesiologist, specialist in Pain Medicine and Interventional Pain Management. Postgraduate training at UBA (Fundación Dolor) and UNLP (CAIDBA). Staff physician at Hospital Alemán, Buenos Aires.

MN 137756 · San Isidro · Villa Urquiza