REVIEW

CURRENT
OPINION Myofascial pain syndrome and trigger points:
evaluation and treatment in patients with
musculoskeletal pain
Marco Barbero a,b, Alessandro Schneebeli a, Eva Koetsier b,c,
and Paolo Maino b,c

Purpose of review
Myofascial pain syndrome is a chronic pain condition characterized by the presence of myofascial trigger
point, a hyperirritable painful spot involving a limited number of muscle fibers. The literature suggest that
myofascial trigger points should be considered peripheral pain generators and this critical review will
summarize recent findings concerning the clinical evaluation and the treatment of myofascial trigger points.
Recent findings
The clinical features of myofascial trigger points and their contribution to the patient pain and disability
have been detailed in several recent studies, which support the clinical relevance of the condition. Recent
studies reported that manual palpation to identify MTrPs has good reliability, although some limitations are
intrinsic to the diagnostic criteria. During the last decade, a plethora of treatments have been proposed
and positive effects on pain and function demonstrated.
Summary
The myofascial trigger point phenomenon has good face validity and is clinically relevant. Clinicians are
encouraged to consider the contribution of myofascial trigger points to the patient’s pain and disability
through a careful medical history and a specific manual examination. Patients with myofascial trigger
points will benefit from a multimodal treatment plan including dry needling and manual therapy techniques.
Internal and external validity of research within the field must be improved.
Keywords
evaluation, myofascial pain syndrome, myofascial trigger point, treatment

INTRODUCTION CLINICAL FEATURES AND EVALUATION

Musculoskeletal pain is an extremely common com-
plaint across ages, races, and cultures but it remains
difficult to understand, explain, and treat. The
Global Burden of Diseases, Injuries, and Risk Factors
Study 2017 confirmed that osteoarthritis, low back
pain, neck pain, and other musculoskeletal disor-
ders contribute significantly to global years lived
with disability [1] and they account for 40–50%
of the economic burden for work-related disorders
in the European Community [2]. Although not life-
threatening, these disorders have a significant effect
on quality of life and psychosocial status [3]. When
providing care to patients, myofascial pain syn-
drome (MPS) should be considered as a potential
cause of musculoskeletal pain. It requires a proper
evaluation and a specific treatment approach.
The present critical review will summarize recent
findings concerning the clinical evaluation and
treatment efficacy of myofascial trigger points.
The original and the most commonly accepted defi-
nition of MPS was formulated by Simons and Travell
in the first volume of The Trigger Point Manual edited
in 1983 [4]. The authors defined the MPS as a
regional pain characterized by the presence of one
a
Rehabilitation Research Laboratory 2rLab, Department of Business
Economics, Health and Social Care, University of Applied Sciences
and Arts of Southern Switzerland, Landquart, Manno, bPain Management
Center, Neurocenter of Southern Switzerland and cDivision of Anaes-
thesiology, Department of Acute Medicine, Regional Hospital of Lugano,
Lugano, Switzerland
Correspondence to Prof. Marco Barbero, PT PhD – Head of Laboratory,
Head of Laboratory of Rehabilitation Research Laboratory 2rLab, Depart-
ment of Business Economics, Health and Social Care, University of
Applied Sciences and Arts of Southern Switzerland, Stabile Piazzetta, Via
Violino 11, CH-6928 Manno, Switzerland. Tel: +41 (0)58 666 64 35;
e-mail: marco.barbero@supsi.ch; website: http://www.supsi.ch/rrlab
Curr Opin Support Palliat Care 2019, 13:270–276
DOI:10.1097/SPC.0000000000000445

www.supportiveandpalliativecare.com Volume 13  Number 3  September 2019

Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.


KEY POINTS
 Myofascial trigger point could be considered a
peripheral nociceptive input associated with different
disorders, it has good face validity and its diagnosis
can be proposed for clinical practice.
 Clinicians are encouraged to screen for the presence of
myofascial trigger points in patients complaining of
musculoskeletal pain using the proposed diagnostic
criteria. Nevertheless, it should be highlighted that the
reliability of the diagnostic criteria depends on the
muscle under examination.
 The contribution of myofascial trigger points to the
patient’s pain and disability should be established on a
case-by-case basis and a treatment plan proposed in
light of the clinical data.
 A multimodal treatment plan, including dry needling
and manual therapy techniques targeting myofascial
trigger points, can be recommended as a first-line
treatment to reduce pain and disability in the
short term.
 The research agenda within the myofascial trigger
point field should include high-quality studies with
robust internal and external validity.
or more myofascial trigger points (MTrPs). They
recommend that it should be considered a specific
diagnosis and clinicians should avoid using this
term to refer to soft tissue pain in general. A MTrP
is a distinctive clinical characteristic of this painful
disorder and it is defined as a hyperirritable palpable
nodule contained in the skeletal muscle fibers. The
palpable nodule, also named taut band, is described
as a limited number of fibers with an increased
stiffness. MTrP can produce local and referred pain,
either on manual compression or spontaneously
[5,6]. From a clinical perspective, it is important
to note that referred pain is usually reported as deep
dull sensation that expands into an area that can be
difficult to define although a center can be localized
[7]. Additionally, if stimulated with dry needling or
snapping palpation MTrPs may exhibit a muscle
fasciculation called local twitch response [8,9].
Two different clinical stages have been attrib-
uted to MTrPs. There is a latent stage, in which the
MTrP does not cause spontaneous pain, and local or
referred pain occurs by definition only with the
&&
application of vigorous digital pressure [10 ]. The
pain mechanism underlying latent MTrP is associ-
ated with mechanical hyperesthesia, pressure pain
hyperalgesia, and vibration hypoesthesia. Interest-
ingly, the referred pain area shows pinprick and
vibration hypoesthesia [11]. From a clinical perspec-
tive, MTrPs in the latent stage may potentially alter
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Myofascial pain syndrome and trigger points Barbero et al.
the muscle activation patterns or cause muscle
weakness in pain-free people [12–14]. Restriction
of the range of motion in the ankle has also been
demonstrated in healthy recreational runners, with
latent MTrPs in the gastrocnemius soleus muscles
[15]. Moreover, an association with psychological
disorders like depression and anxiety has been
observed [16,17]. Although higher quality evidence
is needed to support the clinical relevance of latent
MTrPs, the authors suggest that they should be
screened and treated in patients with painful con-
ditions [18–20].
Conversely, an active MTrP is responsible for the
presenting complaints of patients. With an active
MTrP, manual palpation reproduces the patient’s
pain symptoms and, in some cases, also autonomic
phenomena like skin redness (vasomotor response),
sweating (sudomotor response), goose pimpling
(pilomotor response), and dizziness [4]. The extent
of the referred pain elicited by active MTrPs is larger
than in latent MTrPs [21]. Recent clinical investiga-
tions also confirmed how local and referred pain
from active MTrPs reproduce at least partially
the pain pattern of individuals with spinal condi-
tions, and contribute significantly to their symp-
toms [22–25]. Otherwise, the current findings about
the relationship between active MTrPs and self-
reported disability are contradictory. A moderate
positive relationship was reported in people with
acute whiplash-associated disorders, plantar heel
pain, and shoulder pain [22,26–28]. This was not
the case in two studies involving patients with
mechanical neck pain and nonspecific low back
pain [24,25]. It is speculated that muscles harboring
an active MTrP may exhibit a limited extensibility
and that consequently the joints involved can
exhibit an objective functional limitation. This
was demonstrated for cervical active mobility in
patients with acute whiplash-associated disorders
[22]. Anecdotal evidence on the relationship
between MTrPs and range of motion of the gleno-
humeral joint was also collected in two case studies
of patients with shoulder conditions [29,30].
Accurate medical history and a thorough physi-
cal examination are essential for a correct MPS diag-
nosis, starting with an anamnestic interview
focusing on pain symptomatology. The key ele-
ments regarding pain are: quality, intensity, timing,
location and extent. Patients with MPS usually
describe their pain using the following terms: dull,
deep, expanding, or aching. A visual analogue scale
(VAS) should be provided to patients to measure
pain intensity, at a daily or weekly frequency, and
any correlation with the activities of daily life must
be recorded. Additionally, patients can use body
charts to draw both the location and extent of their
www.supportiveandpalliativecare.com 271
Musculoskeletal problems
pain. A comparison with the MTrP maps will be
helpful to hypothesize about which muscles have
a MTrP. Nevertheless, as suggested by Simons in the
second edition of The Trigger Point Manual [31], MTrP
referred pain maps should be considered nonspecific
and constitute only a cue for clinicians. Moreover, it
should be noted how referred pain from a joint and
nearby muscles share a similar topographic distribu-
tion. Physical examination, which is essentially a
manual palpation procedure, is then performed to
confirm the presence of the MTrP diagnostic criteria.
In 2018, an international Delphi panel revised the
MTrP diagnostic approach introduced by Simons
and Travell [4] and proposed the presence of at least
two of the following criteria: a taut band, a hyper-
sensitive spot, and referred pain. The reproduction
of the patient’s painful symptoms has been con-
firmed as the diagnostic criterion that differentiates
&&
between latent and active MTrP [10 ]. The diagnos-
tic criteria must be verified with an accurate manual
palpation performed by drawing the fingertips of
the examining hand forward and back, perpendicu-
lar to the muscle fibers. Alternatively, some muscles
can be palpated between fingers and thumb using a
pincer grip. Once the taut band has been identified
within the muscle, the hypersensitive spot should
be located by gentle compression of contiguous
spots along the taut band. Beside palpation, clini-
cians must ask the following questions: ‘Which of
the following spots is the most painful?’, ‘Is this pain
part of your usual complaints?’, ‘Does the pain refer
anywhere from the spot that I am compressing?’. By
definition, an affirmative reply to the first question
will confirm the hypersensitive spot criteria. An affir-
mative reply to the second question will confirm the
pain recognition criteria; and finally, the third ques-
tion will confirm the presence of referred pain.
Several clinical studies on the reproducibility of
the diagnostic criteria for MTrP were conducted and
published in peer-reviewed journals between 1992
and 2007 [32–38]. There were many differences
between the studies, including different popula-
tions, examiners, settings, muscles, and variations
in the diagnostic protocol. Notably, two systematic
reviews have been conducted with the aim of deter-
mining the reliability of physical examination to
identify a MTrP [39,40]. All the selected studies
investigated the reproducibility of manual palpa-
tion to identify MTrPs using an appropriate repeated
measures design, although several methodological
biases were identified. Both the authors agreed that
the reliability of the MTrP diagnostic criteria was
inconsistent ranging from excellent to poor. The
hypersensitive spot was the only criterion that
achieved an acceptable reliability in a few specific
muscles. More recently, Mayoral selected ten
272 www.supportiveandpalliativecare.com
Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.
muscles of the upper quarter to determine the
reliability and the validity of diagnostic criteria
for MPS. The trained examiners showed a perfect
agreement in diagnosing the presence of the MPS.
The interexaminer reliability for identifying muscles
harboring MTrP were also very good. Furthermore,
the results supported a good agreement between
examiners for taut band, spot tenderness, and
&&
referred pain [41 ]. An acceptable intraexaminer
and interexaminer reliability was also reported by
another recent study on identification of MTrP in
&&
shoulder muscles [42 ]. Additionally, in optimal
clinical conditions (i.e. an experienced examiner
and a superficial muscle), the reliability of manual
palpation in locating the MTrP spot tenderness in
the upper trapezius was confirmed [43].
A few important considerations can be drawn
from the available literature on MPS and MTrPs. In
the last decade, MTrPs have received greater atten-
tion and almost 200 clinical studies have been com-
pleted [44]. A survey by American pain specialists
has revealed a general agreement that MPS is a
legitimate medical diagnosis [45], and since 2005,
the International Association for the Study of Pain
has included MPS in the Core Curriculum for the
Professional Education in Pain [46]. Interestingly,
investigations have shown a wide-ranging preva-
lence of MTrP associated with various painful con-
ditions including endometriosis, interstitial cystitis,
&
and breast cancer [47 ,48,49], suggesting that MTrP
is a common ‘pain generator’ that could be an
epiphenomenon or relevant comorbidity in a wide
range of painful conditions. Practitioners recognize
that MTrPs have good face validity and understand
their clinical relevance, but there are still controver-
sies about the MPS diagnosis in the scientific com-
munity [50]. It should be acknowledged that the
construct validity of MPS is threatened by an evident
discrepancy between the construct as labeled and
the construct as implemented in both research and
clinical practice. The reliability of the diagnosis
depends on the subjective clinical procedures exe-
cuted during manual palpation. Furthermore, it is
clear that the reliability of each MTrP criterion
depends on the muscle under examination. In
deep-lying muscles, any manual examination aimed
to identify a localized muscle tone alteration (i.e.
taut band) and subsequently to locate the hypersen-
sitive spot is challenging, and the results are there-
fore arguable.
TREATMENTS OF PEOPLE WITH
MYOFASCIAL TRIGGER POINTS
The effective treatment of a musculoskeletal disor-
der requires an accurate assessment of both the
Volume 13  Number 3  September 2019

nature and the source of pain. This is also true for
treatments targeting MTrPs, which are considered a
peripheral nociceptive input [51,52]. Moreover, in
the case of chronic myofascial pain, the authors
suggest that any mechanical or muscle overload
should be carefully considered as a potential perpet-
uating factor [53]. Clinicians generally underesti-
mate the importance of these overloads, reducing
the efficacy of their treatment. In some patients, as
confirmed by electromyographic investigations
[54], the perpetuating factors may also include emo-
tional or mental stress, in which case a multidisci-
plinary approach is required [16].
Various methods of MTrP treatment are available
but there are currently no clinical guidelines so clini-
cians are required to balance the evidence, their
clinical experience and the patient’s preferences.
Treatment approaches can be considered as invasive
and noninvasive. Dry needling is an invasive tech-
nique in which a filiform needle is used to penetrate
the skin and stimulate the MTrP [55]. The expected
therapeutic effect is to release the taut band and
reduce the irritability of the spot tenderness [56].
Together with injections (local anesthetics, steroids,
Botulinum toxin A), these are among the most com-
mon treatments for MPS. Noninvasive treatments
include various manual techniques and modalities.
Over recent years, dry needling has gained
popularity among physiotherapists and several sys-
tematic reviews on its efficacy have been completed.
A considerable number of clinical studies on dry
needling targeting MTrPs located in different
anatomical regions and associated with different
musculoskeletal conditions have been conducted,
and they have produced some consistent findings.
Kietrys and collaborator led a systematic literature
search, selecting studies where at least one group of
patients were treated with MTrP dry needling in the
upper-quarter muscles [57]. Twelve studies met the
inclusion criteria although their quality, according to
the MacDermid Quality Checklist, was limited by
some methodological weaknesses that were, in a
few cases, critical. Four meta-analysis, with different
time to outcomes, were completed. In three random-
ized clinical trials, the authors awarded a grade A
recommendation for dry needling for immediate
pain relief, when compared to placebo. The effect
size ranged from 1.2 to 4.9 points for the VAS score.
Additionally, the results of two trials provided evi-
dence that dry needling can reduce pain at four weeks
in patients with upper quadrant myofascial pain,
although it should be noted that the overall effect
was limited by a large confidence interval.
In 2015 another systematic review, this time
without meta-analysis, found strong evidence on
pain reduction after dry needling for MTrP in the
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Myofascial pain syndrome and trigger points Barbero et al.
upper trapezius muscle [58]. Eight clinical studies,
with levels of evidence ranging from B to A2, were
examined and consistently reported a reduction in
pain intensity associated with dry needling.
In the same year, a systematic review focusing
on dry needling of MTrPs associated with neck and
shoulder pain selected 20 randomized trials involv-
ing more than 800 patients [59]. Notably, all the
trials except one showed moderate to high quality
on the PEDro score. Nevertheless, most of them did
not respect the principles of concealed allocation
and blinding of the therapist. The meta-analysis
supported a significant pain reduction only at short
and medium term for dry needling when compared
with control, whereas the effect size was large to
medium only at short term (SMD ¼ 1.91 : 95% CI,
3.10 to –0.73).
The efficacy of MTrP dry needling provided by a
physiotherapist in a variety of musculoskeletal dis-
orders has been examined in a systematic review [60].
Eight meta-analyses were performed using 13 clinical
studies with a PEDro median score of 7. The authors
concluded, according to the GRADE approach, that
very low to moderate quality evidence supports the
effectiveness of dry needling performed by physio-
therapists for both pain and pain pressure threshold
at immediate to 12 weeks. Once again, it should be
acknowledged that the reported effect sizes for both
the outcomes were debatable in terms of clinical
relevance. With respect to functional outcomes over
the same time period, dry needling was not superior
to other treatments.
&&
Recently, Liu et al. [61 ] completed a new meta-
analysis to evaluate the effectiveness of MTrP dry
needling in people with low back pain. The primary
focus was on pain and disability immediately after
treatment and at follow-ups (maximum three
months). Eleven randomized clinical studies,
mostly conducted in Asia and treating more than
800 patients, were included by two independent
reviewers. The conclusions, based on moderate
quality evidence, recommended dry needling over
other interventions for an immediate reduction in
low back pain. However, the quality of the evidence
was downgraded by the lack of appropriate random-
ization and allocation concealment.
In 2019, an original systematic review of dry
needling in patients with orofacial pain, a condition
where MTrPs are frequently observed, was presented
&
[62 ]. Seven studies were included in the qualitative
analysis and only four were used for the meta-
analysis. A high risk of bias, mainly related to the
blinding of outcome evaluation, was detected. Over-
all, the results did not support the efficacy of dry
needling when compared to other treatments.
One meta-analysis including two studies showed a
www.supportiveandpalliativecare.com 273
Musculoskeletal problems
significant effect on pain for dry needling if com-
pared to other interventions, but the obtained mean
difference highlighted an effect size without clinical
meaning.
Many different manual therapy techniques used
to treat and manage MPS have been investigated in
controlled studies: ischemic compression [63,64],
MTrP pressure release [15], myofascial induction
technique [65], passive stretching [66], muscle
energy techniques [67,68], strain counterstrain
[69], and high velocity low amplitude thrust [70].
In addition, many studies have been conducted for
different modalities, such as ultrasound [71,72], low
level laser [72,73], and transcutaneous electrical
nerve stimulation [74].
Fernández-de-Las-Penãs selected seven trials
that included at least one group receiving a manual
therapy treatment for a systematic review [75]. The
selection of studies was limited by the lack of uni-
formity regarding outcome measures and by poor
interval validity. Only two of the selected studies
included a visual analogic scale, PPT, and range
of motion; the remaining studies reported only a
limited number of outcomes or selected nonappro-
priate outcome measures such as tenderness or
posture. Moreover, the PEDro score for internal
validity reached 6 of 10 in only two studies, and
in three studies, was less than 4 of 10. Also, four of
the selected studies included only one treatment
session. The review did not find any evidence in
favor of manual therapy techniques, even when
associated with other treatments such as ultrasound
and massage. The hypothesis that manual therapy
for MTrP has a specific efficacy beyond placebo, was
neither supported nor refuted. Nevertheless, some
trials included in the review confirmed that manual
treatment of MTrPs might reduce the pressure pain
threshold of spot tenderness and the VAS score. This
was later supported by the eight studies included in
the systematic review by Cagnie et al. [58] on the
efficacy of manual ischemic compression.
The efficacy of noninvasive treatments has also
been investigated by Rickards [76]. The author con-
ducted a systematic review including 23 controlled
or quasi-randomized trials. Only studies which
clearly stated the MTrP diagnostic criteria and with
concealed allocation were included in the review.
The selected trials were divided into five categories
and the following treatments were considered: laser
therapies, electrotherapies, ultrasound, magnet
therapies, and manual therapies. A short-term effi-
cacy was confirmed for decreasing MTrP pain inten-
sity with laser therapy and transcutaneous electrical
nerve stimulation. Moderate evidence supporting
the use of ultrasound was available from one high
quality and two lower quality clinical studies,
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Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.
suggesting that ultrasound is not an effective MTrP
treatment. Notably, four high-quality studies on
manual therapy have been identified in which
short-term efficacy was confirmed. Overall, the evi-
dence for effectiveness of the different noninvasive
MTrP treatments was based on a limited number of
studies and in a few cases, significant methodologi-
cal biases were identified.
Finally, a meta-analysis of seven randomized
trials confirmed that manual therapy treatments
for MTrPs may help in reducing frequency, inten-
sity, and duration of tension-type headache and
migraine, with no negative effect reported in the
&&
considered studies [77 ]. The GRADE approach,
however, rated the level of evidence as very low.
Surprisingly, the effectiveness of active exercises
to reduce pain and disability has not been suffi-
ciently investigated. Only one systematic review is
available, including eight clinical studies for a total
of 255 participants [78]. The performed meta-analy-
sis reported a mean difference in pain intensity for
active exercise of –1.2 points (95% CI, –2.3 to –0.1)
when compared to encouragement or no treatment.
Regarding the effect on disability at short-term fol-
low-up, no significant effects of exercise was
observed when compared to other interventions
or minimal interventions. The association of
stretching with strengthening exercises appeared
to provide a stronger effect on pain.
CONCLUSION
The clinical relevance of MTrPs in patients with
musculoskeletal pain should be defined on a case-
by-case basis. The contribution of MTrPs to the
patient’s pain and disability should be established
through history taking and a complete physical
examination. Consequently, the clinicians will
define how and when interventions targeting
MTrPs should be combined with other evidence-
based interventions. According to the available sys-
tematic reviews, dry needling should be considered
the first-choice treatment to reduce MTrP pain in
the short term. Nevertheless, manual therapy tech-
niques may constitute a valid alternative, especially
when patients suffer from needle phobia or present
contraindications for dry needling. It should also be
mentioned that two well designed, randomized
trials compared dry needling therapy to a manual
therapy protocol, and the effects on pain and func-
tion at follow-ups were similar [79,80]. Addition-
ally, preliminary evidence suggests that a
multimodal treatment plan including, for example,
dry needling, passive stretching, active exercise,
and education may improve the outcome in
patients with neck pain and MPS [81,82]. Clinical
Volume 13  Number 3  September 2019

trials with robust internal and external validity are
needed to support clinicians in the treatment of
patients with musculoskeletal pain associated with
MTrP.
Acknowledgements
The authors are indebted to Susannah Shute for her
invaluable editorial and linguistic help in the preparation
of the manuscript.
Financial support and sponsorship
None.
Conflicts of interest
There are no conflicts of interest.
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Volume 13  Number 3  September 2019