Stimulated by Steen et al 2025.[1]
MPS – myofascial pain syndrome(s)
PM&R – physical medicine and rehabilitation
MSK – musculoskeletal
LS – lumbosacral
IF – impact factor
TPI – trigger point injection
LA – local anaesthetic
DN – dry needling
SR – systematic review
RCT – randomised controlled trial
LTR – local twitch response
IMS – intramuscular stimulation– key to acronyms
Review papers on MPS are published from time to time in a variety of different journals. I have even coauthored one myself.[2] This one comes from an academic PM&R group in Toronto. It is an invited review, and I suspect that it has been requested by the editors of the journal Muscle Nerve (IF 3.4) following feedback from their set of papers on MSK mimics of LS radiculopathy last year.
This is a comprehensive review paper covering 22 journal pages and including 242 references – more than both the papers on MSK mimics of LS radiculopathy combined.
After a short introduction and discussion of prevalence, the review starts with a neat discussion of risk factors. This section is divided into 4 subsections:
- Physical and Mechanical Factors
- Systemic and Metabolic Conditions
- Psychological and Emotional Factors
- Lifestyle and Behavioural Factors
Next the authors cover the hypothetical pathogenic mechanisms:
- Cinderella hypothesis
- Neuromuscular junction dysfunction
- Integrated trigger point hypothesis
- Central sensitisation
- Neurogenic inflammation
- Densification of fascia (this one is new and comes from the Steccos)
Of course, it is likely that several, if not all, of these mechanisms are at play in the development and maintenance of MPS. Perhaps the only thing missing is consideration of sympathetic reflexes mediating the development of MPS secondary to visceral pain conditions. This was first mentioned to me by Maria Adele Giamberardino, who has performed some extraordinary clinical experimental work in viscero-somatic and viscero-visceral hyperalgesia.[3,4]
Next, we come on to a discussion of diagnosis and the differentiation of MPS from fibromyalgia, neuropathic pain, and joint disorders. There is a useful table of diagnostic aids and the advantages and disadvantages of each. This section is summarised and closed with a diagnostic flowchart before moving on to treatment strategies.
The treatment section also seems very comprehensive including a discussion of drugs, injections, dry needling, acupuncture, and a number of non-invasive physical methods.
The authors seem to favour trigger point injection (TPI) with local anaesthetic (LA) and they assert that ‘LA injections have consistently provided significant short-term pain reduction compared to DN in systematic reviews and meta-analyses on neck, head, and shoulder MPS.’
Since my first SR included a lot of papers involving LA injection,[5] I was rather sceptical of this assertion, so I checked their references,[6,7] and the references of their references – at least the ones in the critical forest plots purporting to show LA TPI to be superior to DN.[8–15]
In the majority of RCTs of LA TPI versus DN, the latter was performed with a 22G hypodermic needle and an empty syringe rather than a filiform needle. I first saw this performed by John (Chang Zern) Hong in a demonstration at a BMAS Scientific meeting in the 90’s. His research suggests that LA reduced the post-needling soreness. Typically, he would inject a tiny volume of LA (say 0.2ml) every time he elicited an LTR. Considering how destructive the needling appeared, I would be tempted to use LA as well for this particular technique.
So, only 1 paper of the 6 pooled RCTs in both SRs quoted actually used filiform needles for DN rather than hypodermics.[10] In this paper there was no difference between interventions. In this paper the needling designated as DN in the SRs was in fact IMS, which involved trigger point DN plus needling to multifidus at the relevant segments (C3 to C5 in this case), so it was very similar to local plus dorsal segmental acupuncture.
Somewhat ironically, acupuncture is delt with separately and gets a rather upbeat review with 5 positive SRs referenced.
What is the bottom line? Well, as suggested by Karel Lewit in the 70’s…[16]
In reviewing techniques for therapeutic local anaesthesia of pain spots, it appeared that the common denominator was puncture by the needle and not the anaesthetic employed.
Adrian White and I came to the same conclusion 22 years later when reviewing RCTs on the subject in one of the first SRs.[5]
References
1 Steen JP, Jaiswal KS, Kumbhare D. Myofascial Pain Syndrome: An Update on Clinical Characteristics, Etiopathogenesis, Diagnosis, and Treatment. Muscle Nerve. Published Online First: 20 March 2025. doi: 10.1002/mus.28377
2 Cummings M, Baldry P. Regional myofascial pain: diagnosis and management. Best Pract Res Clin Rheumatol. 2007;21:367–87. doi: 10.1016/j.berh.2006.12.006
3 Arendt-Nielsen L, Schipper K, Dimcevski G, et al. Viscero-somatic reflexes in referred pain areas evoked by capsaicin stimulation of the human gut. Eur J Pain Lond Engl. 2008;12:544–51. doi: 10.1016/j.ejpain.2007.08.010
4 Giamberardino MA, Costantini R, Affaitati G, et al. Viscero-visceral hyperalgesia: characterization in different clinical models. Pain. 2010;151:307–22. doi: 10.1016/j.pain.2010.06.023
5 Cummings TM, White AR. Needling therapies in the management of myofascial trigger point pain: A systematic review. Arch Phys Med Rehabil. 2001;82:986–92. doi: 10.1053/apmr.2001.24023
6 Nouged E, Dajani J, Ku B, et al. Local Anesthetic Injections for the Short-Term Treatment of Head and Neck Myofascial Pain Syndrome: A Systematic Review with Meta-Analysis. J Oral Facial Pain Headache. 2019;33:183–98. doi: 10.11607/ofph.2277
7 Navarro-Santana MJ, Sanchez-Infante J, Gómez-Chiguano GF, et al. Dry Needling versus Trigger Point Injection for Neck Pain Symptoms Associated with Myofascial Trigger Points: A Systematic Review and Meta-analysis. Pain Med. Published Online First: 11 June 2021. doi: 10.1093/pm/pnab188
8 Ay S, Evcik D, Tur BS. Comparison of injection methods in myofascial pain syndrome: a randomized controlled trial. Clin Rheumatol. 2010;29:19–23. doi: 10.1007/s10067-009-1307-8
9 Eroğlu PK. A Comparison of the Efficacy of Dry Needling, Lidocaine Injection, and Oral Flurbiprofen Treatments in Patients with Myofascial Pain Syndrome: A Double-Blind (For Injection, Groups Only), Randomized Clinical Trial. Turk J Rheumatol. 2013;28:38–46. doi: 10.5606/tjr.2013.2779
10 Ga H, Koh H, Choi J, et al. Intramuscular and nerve root stimulation vs lidocaine injection to trigger points in myofascial pain syndrome. J Rehabil Med. 2007;39:374–8. doi: 10.2340/16501977-0058
11 Hong C-Z. Lidocaine injection versus dry needling to myofascial trigger point. The importance of the local twitch response. Am J Phys Med Rehabil. 1994;73:256–63. doi: 10.1097/00002060-199407000-00006
12 Ibrahim DA, Abdelrahem HA. Cervical region trigger point Injection with dry needling versus wet needling by lidocaine in geriatric population: a comparative study. Ain-Shams J Anesthesiol. 2019;11:16. doi: 10.1186/s42077-019-0026-x
13 Kamanli A, Kaya A, Ardicoglu O, et al. Comparison of lidocaine injection, botulinum toxin injection, and dry needling to trigger points in myofascial pain syndrome. Rheumatol Int. Published Online First: 2004.
14 McMillan AS, Nolan A, Kelly PJ. The efficacy of dry needling and procaine in the treatment of myofascial pain in the jaw muscles. J Orofac Pain. 1997;11:307–14.
15 Raeissadat SA, Rayegani SM, Sadeghi F, et al. Comparison of ozone and lidocaine injection efficacy vs dry needling in myofascial pain syndrome patients. J Pain Res. 2018;11:1273–9. doi: 10.2147/JPR.S164629
16 Lewit K. The needle effect in the relief of myofascial pain. Pain. 1979;6:83–90. doi: 10.1016/0304-3959(79)90142-8
