Myofascial Trigger Points: Why They Are Missed and How Injections and Dry Needling Work
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By Dr. Jeffrey Peng, MD · Published March 6, 2026 · 12 min read
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Myofascial pain syndrome and trigger points are among the most common — and most commonly missed — causes of chronic musculoskeletal pain. In my sports medicine practice, I regularly evaluate patients who have seen multiple providers, undergone extensive imaging, completed months of physical therapy, and sometimes even had surgery — all without relief — because the underlying myofascial trigger points were never identified or properly treated.
The challenge is that myofascial trigger points are rarely taught in medical school or residency training. Most physicians and therapists receive little to no formal education on how to diagnose or manage them. Because trigger point pain is typically felt at a site distant from the actual trigger point — a phenomenon called referred pain — clinicians who are not specifically looking for trigger points will often miss them entirely.
In this article, I review the pathophysiology of myofascial trigger points, share a real patient case that illustrates how devastating a missed diagnosis can be, and walk through the current evidence on treatment options including trigger point injections, dry needling, exercise, and shockwave therapy.
What Are Myofascial Trigger Points?
A myofascial trigger point is a hyperirritable spot within a taut band of skeletal muscle that produces pain when compressed, stretched, or overloaded. These points can generate both local tenderness and characteristic referred pain patterns — meaning the pain is felt in a location different from where the trigger point actually resides. Trigger points can also cause restricted range of motion, muscle stiffness, and autonomic dysfunction (Malanga & Cruz Colon, 2010).
Myofascial pain syndrome affects a staggering number of people. Research suggests that myofascial trigger points are present in up to 95% of individuals with chronic pain disorders. The condition can present as painful restricted range of motion, stiffness, referred pain patterns, and even autonomic symptoms. The underlying cause is often related to muscular imbalances from overuse, poor posture, repetitive strain, or trauma.
Why Are Trigger Points So Often Missed?
The most important reason trigger points go undiagnosed is simple: most clinicians were never trained to look for them. Few medical schools or physical therapy programs teach myofascial trigger points as a core part of their curriculum. As a result, practitioners who encounter patients with trigger point pain often attribute the symptoms to other diagnoses — tendinopathy, bursitis, radiculopathy, or even psychological factors — because those are the conditions they were trained to recognize.
The referred pain pattern makes diagnosis even more challenging. A trigger point in the gluteus medius muscle, for example, can produce pain that radiates down the leg, mimicking sciatica. Trigger points in the vastus medialis can cause anterior knee pain that looks identical to patellofemoral syndrome. Without specifically palpating for trigger points and their associated taut bands and local twitch responses, the true source of pain remains hidden.
A Case Study: 2.5 Years of Undiagnosed Myofascial Pain
To illustrate how devastating a missed trigger point diagnosis can be, consider a case from my practice: a 16-year-old competitive hockey player with aspirations of making the USA national team who developed left hip and buttock pain in December 2019.
Over the next two years, this patient saw an orthopedist, a pediatric orthopedist, a pediatric rheumatologist, a pain management specialist, and her primary care physician — repeatedly. She underwent four MRI scans (hip, pelvis, femur, and lumbar spine), plain radiographs, an MR arthrogram with a diagnostic intra-articular injection, blood work for autoimmune and inflammatory conditions, and a biomechanical motion analysis. She tried physical therapy multiple times, attempted multiple NSAIDs (ibuprofen, meloxicam, indomethacin, piroxicam, and celecoxib), was offered amitriptyline, and underwent several sessions of shockwave therapy — which actually made her symptoms worse.
Despite all of this, her pain continued to escalate. By the time she came to see me in January 2022, she could not sit for more than 15 minutes. She carried a letter from her primary care physician requesting that she be allowed to stand during class. Her pain was rated 7 to 9 out of 10 on most days.
On examination, her hip joint was entirely normal — full range of motion, negative impingement tests, negative labral tests, no SI joint tenderness. Diagnostic ultrasound of the proximal hamstring tendon appeared normal. However, there was focal tenderness at the ischial tuberosity and, critically, diffuse tenderness to palpation within the bilateral gluteus medius, gluteus minimus, and piriformis muscles — consistent with active myofascial trigger points.
After a diagnostic ropivacaine injection confirmed the ischial tuberosity as a significant pain generator (her pain dropped from 8 to 0 within hours), she received a PRP injection at the hamstring origin followed by three sessions of trigger point injection therapy over two weeks. Each session produced significant local twitch responses and progressive improvement.
By her follow-up in May 2022, her symptoms had resolved dramatically. She was exercising and playing hockey without pain, drove to Disneyland without discomfort, was completely off all NSAIDs, sleeping better, and no longer needed pain psychology or pain management follow-up — after 2.5 years of suffering.
How Are Trigger Points Diagnosed?
Diagnosis of myofascial trigger points is primarily clinical — there is no imaging study or lab test that can identify them. The key diagnostic features include: a palpable taut band within the affected muscle, a hyperirritable spot within that taut band that reproduces the patient’s pain complaint (especially the referred pain pattern), and a local twitch response when the trigger point is snapped or needled. A thorough physical examination with careful muscle palpation is essential.
The clinician must consider the possibility of trigger points and specifically search for them. Because trigger point pain is so commonly felt at a site away from the trigger point itself, the responsible trigger point can easily be overlooked if the clinician only examines the area where the patient reports pain.
How Do Trigger Point Injections Work?
Trigger point injections involve inserting a needle directly into the myofascial trigger point, often with a small amount of local anesthetic such as lidocaine or bupivacaine. The goal is to elicit a local twitch response (LTR) — an involuntary contraction of the taut band — which is the hallmark of successful treatment. A landmark clinical trial by Hong (1994) demonstrated that eliciting local twitch responses during injection is essential to achieving an immediately desirable therapeutic effect (Hong, 1994).
That same study found that injection with 0.5% lidocaine is recommended over dry needling because it significantly reduces the intensity and duration of post-injection soreness. All patients who received dry needling experienced post-procedure soreness, compared with only 42% of those who received lidocaine injection. A comprehensive review of treatment options for myofascial trigger points confirmed that the best available evidence supports trigger point injection and dry needling as the most effective interventions (Malanga & Cruz Colon, 2010). Importantly, corticosteroids should not be injected into trigger points, and repeated injections without a comprehensive rehabilitation program should be avoided.
Dry Needling vs. Trigger Point Injections: What Does the Evidence Say?
Dry needling — inserting a thin filiform needle into the trigger point without injecting any substance — has become an increasingly popular treatment. A systematic review of high-quality randomized controlled trials found that dry needling produces measurable benefits for trigger points across multiple body regions, including improvements in pain, range of motion, and functional outcomes (Boyles et al., 2015). Another systematic review confirmed that dry needling is effective in the short term for pain relief and improved range of motion compared with sham or placebo, though more high-quality trials with standardized procedures are still needed (Espejo-Antúnez et al., 2017).
When comparing the two approaches head-to-head, the evidence slightly favors wet needling (trigger point injection with anesthetic). A meta-analysis of neck and shoulder trigger points found that dry needling is effective in the short and medium term, but wet needling with lidocaine was superior for medium-term pain relief (Liu et al., 2015). A more recent systematic review and meta-analysis focusing on cervical trigger points found low-level evidence suggesting that trigger point injection produces greater short-term pain reduction compared with dry needling, though no significant differences were found for disability, pressure pain thresholds, or cervical mobility (Navarro-Santana et al., 2022).
A systematic review comparing dry needling with manual therapy techniques such as ischemic compression and massage found that both approaches improve pain and function in the short to medium term, with neither demonstrating clear superiority over the other (Lew et al., 2020). This suggests that for patients who prefer non-needling approaches, manual therapy remains a viable alternative.
Can Exercise Help Myofascial Pain?
Exercise is an important component of any comprehensive trigger point treatment program. A systematic review found that exercise produces small-to-moderate improvements in pain intensity at short-term follow-up, and that a combination of stretching and strengthening exercises achieves greater effects than either alone (Mata Diz et al., 2017). In my practice, I emphasize that trigger point injections or dry needling should not be used as standalone treatments. They work best as part of a comprehensive rehabilitation program that includes targeted stretching, strengthening, and correction of underlying muscular imbalances.
What About Shockwave Therapy for Trigger Points?
Extracorporeal shockwave therapy (ESWT) has been studied as a treatment for myofascial pain. A systematic review and meta-analysis found that ESWT showed significant improvement in pain reduction compared with sham treatment or ultrasound, but was not superior to conventional therapies such as dry needling, trigger point injection, or laser therapy (Zhang et al., 2020). The authors concluded that ESWT may serve as a useful adjunct to conventional treatments rather than a replacement. In my experience, shockwave therapy can be a helpful addition for certain patients, but it should not be relied upon as the sole treatment for myofascial trigger points.
Can Trigger Points Cause Knee Pain in Osteoarthritis Patients?
One of the most underappreciated aspects of myofascial trigger points is their role in knee pain — particularly in patients with osteoarthritis who are being considered for total knee replacement. A study of 25 patients on a waiting list for total knee arthroplasty found that every single patient had identifiable trigger points in the muscles surrounding the knee, most commonly in the vastus and gastrocnemius muscles. Remarkably, 92% of these patients experienced significant pain relief with trigger point injections at the very first visit (Henry et al., 2012).
This finding suggests that a significant proportion of the pain attributed to knee osteoarthritis may actually be myofascial in origin. For patients facing the prospect of knee replacement surgery, identifying and treating trigger points could potentially reduce pain enough to delay or even prevent the need for surgery. This is an area that deserves further investigation, and it highlights the importance of considering myofascial pain as a contributing factor in any patient with persistent joint pain.
Practical Takeaways
If you are struggling with chronic or persistent muscle pain that has not responded to conventional treatment, consider whether myofascial trigger points might be part of the problem. Ask your healthcare provider whether they are experienced in diagnosing and treating trigger points. Trigger point injection therapy and dry needling are among the most evidence-supported treatments, but they work best when combined with a structured exercise program that includes both stretching and strengthening. If you would like to explore whether trigger point therapy might help your condition, I encourage you to schedule a consultation.
References
1. Hong CZ. Lidocaine injection versus dry needling to myofascial trigger point. The importance of the local twitch response. American Journal of Physical Medicine & Rehabilitation. 1994;73(4):256-263. doi:10.1097/00002060-199407000-00006
2. Boyles R, Fowler R, Ramsey D, Burrows E. Effectiveness of trigger point dry needling for multiple body regions: a systematic review. The Journal of Manual & Manipulative Therapy. 2015;23(5):276-293. doi:10.1179/2042618615Y.0000000014
3. Liu L, Huang QM, Liu QG, et al.. Effectiveness of dry needling for myofascial trigger points associated with neck and shoulder pain: a systematic review and meta-analysis. Archives of Physical Medicine and Rehabilitation. 2015;96(5):944-955. doi:10.1016/j.apmr.2014.12.015
4. 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 Medicine. 2022;23(3):515-525. doi:10.1093/pm/pnab188
5. Espejo-Antúnez L, Tejeda JF, Albornoz-Cabello M, et al.. Dry needling in the management of myofascial trigger points: a systematic review of randomized controlled trials. Complementary Therapies in Medicine. 2017;33:46-57. doi:10.1016/j.ctim.2017.06.003
6. Zhang Q, Fu C, Huang L, et al.. Efficacy of extracorporeal shockwave therapy on pain and function in myofascial pain syndrome of the trapezius: a systematic review and meta-analysis. Archives of Physical Medicine and Rehabilitation. 2020;101(8):1437-1446. doi:10.1016/j.apmr.2020.02.013
7. 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
8. Malanga GA, Cruz Colon EJ. Myofascial low back pain: a review. Physical Medicine and Rehabilitation Clinics of North America. 2010;21(4):711-724. doi:10.1016/j.pmr.2010.07.003
9. Mata Diz JB, de Souza JRLM, Leopoldino AAO, Oliveira VC. Exercise, especially combined stretching and strengthening exercise, reduces myofascial pain: a systematic review. Journal of Physiotherapy. 2017;63(1):17-22. doi:10.1016/j.jphys.2016.11.008
10. Henry R, Cahill CM, Wood G, et al.. Myofascial pain in patients waitlisted for total knee arthroplasty. Pain Research & Management. 2012;17(5):321-327. doi:10.1155/2012/547183
Medical Disclaimer: This content is for educational purposes only and does not substitute for the medical advice of a physician. Always consult your healthcare provider before beginning any new treatment program. The information presented reflects the opinion of Dr. Jeffrey Peng and does not represent the views of his employers or affiliated hospital systems.
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