Trigger Point Injections: A Solution for Myofascial Pain

Explore trigger point injections as a treatment for myofascial pain. Learn how they can provide effective relief.

Abstract

In this educational post, I will take you on a journey into the world of integrative musculoskeletal care, focusing on a powerful and effective technique for managing chronic pain: trigger point injections. We will explore the physiological underpinnings of muscle spasms, adhesions, and the resulting pain patterns that affect so many individuals. I will share insights from my clinical practice at Injury Medical Clinic PA in El Paso, Texas, where we blend cutting-edge techniques with a deep understanding of human anatomy and physiology. This post will detail the “how” and “why” behind trigger point injections, comparing different approaches like dry needling versus injections with therapeutic agents such as lidocaine and Sarapin. We will discuss the science behind these treatments, including the mechanisms of action, appropriate dosages, needle depths, and patient safety considerations.

Furthermore, I will explain our unique multidisciplinary model, where my expertise in chiropractic and functional medicine is complemented by the medical oversight of our Medical Director, Dr. Maria Guadalupe Cardenas, an esteemed internist. Together, we provide a comprehensive treatment paradigm that addresses the root cause of pain, from structural misalignments corrected by chiropractic adjustments to the muscular dysfunction treated with targeted injections. Join me as we unravel the complexities of chronic muscle pain and discover how this integrated approach can offer profound and lasting relief.

A Collaborative Vision for Comprehensive Patient Care

Before we delve into the specifics of trigger point therapy, I believe it’s essential to provide context on our practice’s philosophy. At Injury Medical Clinic PA, also known as Mission Plaza Injury Medical Clinic, our mission has always been to offer patients a truly holistic and integrated path to wellness. My journey as a Doctor of Chiropractic (DC) and a board-certified Family Nurse Practitioner (APRN, FNP-BC) has been driven by the understanding that the human body is an interconnected system. A problem in one area, such as the musculoskeletal system, can have far-reaching effects on overall health.

This understanding is the foundation of our multidisciplinary setup. I am honored to work alongside Dr. Maria Guadalupe Cardenas, MD, a highly respected physician board-certified in Internal Medicine with over four decades of clinical experience. Dr. Cardenas serves as our Medical Director and Collaborative Physician, providing invaluable medical oversight and a depth of knowledge that enriches our patient care protocols. Her NPI is #1164426749, and she is licensed in Texas under #J2933. This collaborative structure is common and highly effective in modern integrative and injury care settings. It allows us to seamlessly merge the principles of chiropractic care—focusing on spinal alignment and nervous system function—with the diagnostic and prescriptive authority of conventional medicine.

Our team integrates:

• Chiropractic Care (Dr. Jimenez): Focused on spinal adjustments, biomechanical correction, and restoring proper nervous system communication.
• Medical Oversight (Dr. Cardenas): Ensuring all procedures meet the highest medical standards, managing complex patient cases, and providing a conventional medical perspective.
• Functional Medicine: Investigating the root causes of disease by looking at lifestyle, genetics, and environmental factors.
• Personal Injury Care & Rehabilitation: Providing comprehensive programs for recovery from accidents and injuries.
• Advanced Therapies: Including the trigger point injections we will discuss in detail today.

This synergistic approach ensures that our patients receive a well-rounded and personalized treatment plan that addresses their health from every angle.

Understanding Muscle Spasms and Trigger Points

To appreciate the effectiveness of trigger point injections, we first need to understand the problem they are designed to solve. When a muscle is injured, overused, or subjected to chronic stress—be it physical or emotional—it can enter a state of sustained contraction known as a muscle spasm. This is a protective mechanism, but when it becomes chronic, it creates a vicious cycle of pain and dysfunction.

Inside that chronically contracted muscle, several things happen at a microscopic level:

1. Reduced Blood Flow (Ischemia): The tightened muscle fibers constrict the tiny blood vessels (capillaries) that run through them. This starves the muscle tissue of oxygen and essential nutrients.
2. Metabolic Waste Buildup: Without adequate blood flow to flush them out, metabolic byproducts like lactic acid accumulate in the tissue. This creates a toxic, acidic environment that further irritates the muscle and its nerve endings.
3. The Energy Crisis: A muscle requires energy (ATP) not only to contract but also to relax. The persistent contraction depletes energy reserves, and the lack of oxygen prevents the muscle from producing more. The muscle becomes “stuck” in a contracted state because it lacks the energy to release.
4. Formation of Scar Tissue (Adhesions): The body’s response to this chronic injury and inflammation is to lay down fibrous scar tissue, or adhesions, within the muscle. These adhesions are like internal glue, sticking muscle fibers together that should be gliding freely. This creates a palpable, ropey band of tissue with a highly sensitive nodule at its center—what we call a trigger point.

This trigger point is not just a local problem. It can refer pain to other parts of the body in predictable patterns. For example, a trigger point in the upper trapezius muscle in your shoulder can cause a tension-type headache that wraps around your ear to your temple. This is why a patient might complain of pain in one area, while the actual source of the problem is located elsewhere.

The Evolution of Treatment: From Dry Needling to Advanced Injections

In my years of practice, I’ve seen treatment modalities evolve significantly. Initially, a common and effective technique was dry needling. This involves inserting a thin, solid filiform needle (the same kind used in acupuncture) directly into the trigger point without injecting any substance.

The Mechanics of Dry Needling

The therapeutic effect of dry needling comes from several physiological responses:

• Mechanical Disruption: The simple act of inserting and manipulating the needle breaks up the microscopic scar tissue and adhesions within the muscle. Imagine untangling a knotted rope by physically poking and separating the fibers.
• Local Twitch Response: When the needle accurately hits the center of a trigger point, it often elicits an involuntary “twitch” or contraction of the muscle band. This response is a spinal cord reflex that is believed to reset the chemistry in the area, helping to break the pain-spasm cycle.
• Neurophysiological Effects: The needle stimulates nerve receptors in the muscle (A-delta fibers), which send signals up the spinal cord to the brain. This can activate the body’s own pain-relieving mechanisms, such as the release of endorphins and enkephalins, and modulate how the brain perceives pain signals from the trigger point.

Many practitioners, including acupuncturists and physical therapists, still use dry needling with great success. It’s a valuable tool, especially for patients who may have allergies to injectable substances. However, we’ve found that we can achieve a more profound and faster result by introducing therapeutic agents directly into the dysfunctional tissue.

Enhancing Efficacy with Trigger Point Injections

This brings us to our current methodology: trigger point injections. Instead of just mechanically disrupting the tissue, we are now also delivering medication directly to the site of the problem. This allows us to address the biochemical and inflammatory components of the trigger point more directly.

In my practice, I have found a particularly effective combination: Lidocaine and Sarapin.

• Lidocaine: This is a well-known local anesthetic. When injected into the trigger point, it blocks the sodium channels in the nerve endings. Nerves rely on the flow of sodium ions to transmit pain signals. By blocking these channels, lidocaine effectively “numbs” the area, providing immediate and significant pain relief. This breaks the immediate pain-spasm-pain cycle. It allows the patient to experience relief, which in turn helps the central nervous system to “calm down” and stop perpetuating the chronic pain signals.
• Sarapin (Ceraferm): This is where our approach diverges from many conventional pain management practices that might use corticosteroids. Sarapin is a biological medicine, a sterile aqueous solution derived from the pitcher plant (Sarracenia purpurea). It acts as a powerful, all-natural anti-inflammatory. Its mechanism is fascinating; it is believed to work by selectively inhibiting nerve conduction in C-type sensory nerve fibers, the small, unmyelinated fibers responsible for transmitting dull, aching, chronic pain signals. It does not affect motor nerves, so it doesn’t cause muscle weakness, nor does it affect the larger nerves responsible for sensation and touch.

I prefer Sarapin over corticosteroids for trigger point injections for several critical reasons. While steroids are potent anti-inflammatories, they can have significant side effects, especially with repeated use. These can include tissue atrophy (thinning of the muscle and skin), weakening of tendons, and systemic effects like elevated blood sugar and suppression of the adrenal system. Sarapin, being a biological agent, works with the body’s physiology and does not carry these risks. It provides potent anti-inflammatory effects right where they are needed without the collateral damage associated with steroids.

The Art and Science of the Injection Technique

Performing trigger point injections is as much an art as it is a science. It requires a deep, three-dimensional understanding of anatomy, a well-honed sense of palpation to locate these elusive nodules, and a precise technique to deliver the medicine effectively and safely.

The “Star Pattern” Technique

One of the techniques we employ is often referred to as a “star pattern” or fanning technique. This is an evolution of the pistoning method used in dry needling. Here is how it works:

1. Initial Insertion: After identifying the trigger point through careful palpation, the needle is inserted through the skin and into the heart of the taut muscle band.
2. Fanning Out: Instead of just moving the needle in and out in one spot, we withdraw it to just beneath the skin without fully removing it. Then, we redirect it at a slightly different angle and advance it again into the trigger point complex. We repeat this process multiple times, moving in a radial or “star” pattern around the central point.
3. Injecting the Solution: As we perform this fanning motion, we are slowly and simultaneously injecting our one-to-one mixture of lidocaine and Sarapin.

The purpose of this technique is multifaceted:

• Maximizing Mechanical Breakup: The multi-directional movement of the needle is far more effective at mechanically breaking up the fibrous adhesions and scar tissue than a single in-and-out motion.
• Wider Distribution of Medication: This technique ensures that the therapeutic solution is distributed throughout a larger volume of the dysfunctional tissue, not just in a single pocket. This allows the anesthetic and anti-inflammatory to reach more of the affected muscle fibers and nerve endings.
• Eliciting Multiple Twitch Responses: By probing different areas within the trigger point complex, we are more likely to elicit the therapeutic local twitch responses that help to reset the muscle’s neurological feedback loop.

Patient Comfort and Strategy

From a clinical perspective, managing the patient’s experience is paramount to a successful treatment. These injections can be uncomfortable, especially when the needle hits an active trigger point. The sensation is often described as a deep ache or a brief, sharp “zing” that may replicate their familiar pain pattern.

I’ve learned over many years that the order in which I address the trigger points matters. I always save the most sensitive, most active trigger point for last. If I were to start with the most painful one, the patient’s apprehension and pain response would be heightened for the remainder of the procedure. They might tense up, making it harder to work on the remaining areas, or even want to stop the treatment altogether. By starting with the less sensitive points, we build trust and allow the patient to acclimate to the sensation. By the time we get to the “worst one,” they are more relaxed and understand what to expect. It’s a small psychological detail, but it makes a world of difference in patient compliance and overall experience.

Dosage and Needle Selection: Tailoring to Anatomy

The human body is not uniform. The muscles and overlying tissues vary greatly in thickness from one region to another, and from one person to another. Therefore, our equipment and dosage must be tailored accordingly.

• Cervical (Neck) and Upper Thoracic (Upper Back) Regions: In these areas, the muscles are generally more superficial, and they lie closer to sensitive structures. For these regions, I typically use:

• • Dosage: Approximately 1 mL of the solution per injection site. The smaller muscle bellies in this area cannot accommodate a larger volume without causing excessive pressure and discomfort.
  • Needle: A 30-gauge, 1-inch needle. The 30-gauge is very fine, which minimizes patient discomfort upon insertion. The 1-inch length is sufficient to reach the target muscles (like the trapezius, levator scapulae, or rhomboids) without risking injury to deeper structures.

• Lower Thoracic and Lumbar (Mid to Lower Back) Regions: The muscles here, such as the quadratus lumborum and the large erector spinae group, are much thicker and more robust.

• • Dosage: These larger muscles can safely and effectively accommodate up to 2 mL of solution per site.
  • Needle: We often use a slightly larger needle, perhaps a 25-gauge, 1.5-inch needle. The 1.5-inch length is necessary to penetrate the thick fascia and muscle belly to reach the deep trigger points common in this area.

Critical Safety Concern: Pneumothorax

A crucial safety consideration, particularly when working in the thoracic region, is the risk of pneumothorax (a punctured lung). This is a question I am often asked by clinicians learning this technique. The lung lies deep to the rib cage and the intercostal muscles.

My clinical rule of thumb is this:

• A 1-inch needle, when used properly over the thoracic musculature (e.g., the rhomboids or mid-trapezius), does not pose a significant risk of pneumothorax, even in a very thin, elderly individual. The needle must pass through the skin, subcutaneous fat, fascia, and the target muscle itself. In most individuals, this combined thickness is greater than one inch.
• When you start using a 5-inch needle, especially in smaller or frail individuals, you must be much more mindful of your anatomy and needle depth. This length is generally reserved for the thick lumbar muscles or for larger individuals where you are confident in the tissue depth.

This is why a profound knowledge of anatomy isn’t just academic—it’s a matter of patient safety. I constantly urge students and colleagues: “Go back and review your anatomy.” It’s a subject many of us struggled with in school, but in a hands-on practice like this, it is the bedrock of safe and effective care. You must be able to mentally visualize the layers of tissue your needle is passing through.

The Role of Chiropractic Care in a Comprehensive Treatment Plan

Now, you might be wondering, “How does this all fit in with chiropractic care?” This is the core of our integrative model. Trigger point injections are a powerful tool for addressing the muscular component of a patient’s pain. Still, they do not, in isolation, correct the underlying structural and biomechanical issues that often cause those muscles to become dysfunctional in the first place.

Imagine a car with a misaligned frame. The tires will wear out unevenly. You can keep replacing the tires (treating the symptom), but until you fix the frame’s alignment (treating the cause), the tires will continue to wear out prematurely.

In the human body:

• The Misaligned Frame: This is equivalent to vertebral subluxations or spinal misalignments. A vertebra that is out of its proper position can irritate the spinal nerves exiting at that level. This nerve irritation can cause the muscles innervated by that nerve to become hypertonic, spastic, and prone to developing trigger points.
• The Unevenly Worn Tires: These are the painful, spastic muscles with trigger points.

Our integrated treatment protocol works on both aspects simultaneously:

1. Chiropractic Adjustments: I use specific, gentle adjustments to correct the vertebral subluxations. This restores proper motion to the spinal joints and, most importantly, removes the interference to the nervous system. This addresses the root cause of why the muscles are being sent signals to chronically tighten.
2. Trigger Point Injections: We use the injections to directly address the downstream consequences—the painful, knotted muscles. The injections provide rapid pain relief, reduce inflammation, and break up the fibrous adhesions that the adjustment alone cannot resolve.

This dual approach creates a positive feedback loop. The trigger point injections make the patient more comfortable and relax the muscles, which in turn makes the chiropractic adjustment more effective and easier to perform. The adjustment, by correcting the underlying neurological issue, helps prevent the trigger points from reforming. This combination is far more powerful than either therapy used in isolation and is fundamental to achieving long-term, sustainable results for our patients.

The Root Causes of Pain- Video

Addressing Common Questions and Considerations

In my educational presentations, several questions frequently arise. Let’s address some of the most common ones here.

“What about patients allergic to ‘caines’?”

Allergies to lidocaine, Marcaine, or other local anesthetics in the “-caine” family are rare but do exist. It’s estimated that true IgE-mediated allergies occur in less than 1% of the population. However, it is a critical part of our patient screening process. For a patient with a confirmed allergy, we have two excellent options:

1. Dry Needling: We can revert to the classic dry needling technique. By using the star pattern with just the needle, we can still achieve the mechanical breakup of adhesions and elicit the therapeutic local twitch response. The results may be less immediate without the anesthetic, but the treatment is still highly effective at breaking the pain-spasm cycle over a series of sessions.
2. Sarapin-Only Injections: Since Sarapin works on sensory nerves without being a “-caine” anesthetic, it can often be used alone. The patient won’t get the immediate numbing effect, but they will still benefit from the powerful anti-inflammatory action and the mechanical effects of the needling.

“What is the difference between this and Prolotherapy or PRP?”

This is an excellent question that touches on the broader field of regenerative medicine.

• Trigger Point Injections (as described): The goal is primarily neuromodulation and inflammation reduction. We are aiming to “reboot” a dysfunctional muscle and nerve pattern and calm local inflammation.
• Prolotherapy: This is short for “proliferative therapy.” The goal is to stimulate tissue repair, specifically in lax or injured ligaments and tendons. It involves injecting a mild irritant solution (often containing dextrose, a form of sugar) into the attachment points of these structures. This creates a mild, controlled inflammatory response, which in turn signals the body to send growth factors and repair cells to the area, strengthening and tightening the weakened connective tissue. Sometimes ozone is added to enhance this effect.
• Platelet-Rich Plasma (PRP): This is a more advanced form of regenerative therapy. We draw the patient’s own blood, spin it in a centrifuge to separate the components, and extract a concentrated solution of platelets. This platelet-rich plasma is then injected into the injured area. Platelets are the body’s first responders to injury; they are packed with a multitude of powerful growth factors that orchestrate the entire healing cascade. PRP is used to heal torn tendons, damaged ligaments, arthritic joints, and even severe muscle tears.

While you could inject PRP into trigger points, in my clinical opinion, it would be overkill for most cases. The primary issue in a trigger point is neurological and inflammatory, not a significant tissue tear requiring massive regeneration. Using the right tool for the right job is key. Trigger point injections with lidocaine and Sarapin are the precise tool for muscular trigger points, while Prolotherapy and PRP are the tools for ligamentous laxity and significant tissue damage.

Conclusion: A Patient-Centered Path Forward

The journey from chronic pain to lasting wellness is often complex, requiring more than a single-minded approach. At our clinic, under the collaborative guidance of Dr. Maria Guadalupe Cardenas and me, we have built a model that honors the intricate, interconnected nature of the human body. By integrating the structural precision of chiropractic care with the targeted, science-based application of trigger point injections, we can address both the root cause and the painful symptoms of musculoskeletal dysfunction.

Understanding the “why” behind your pain—the cycle of muscle spasm, ischemia, and scar tissue formation—is the first step toward taking control of your health. Therapies like the ones described here are not just about masking pain; they are about resetting physiology, restoring function, and empowering the body to heal itself. With a deep respect for anatomy, a commitment to patient safety, and a collaborative spirit, we can unlock new levels of health and vitality for our patients.

As I reflect on my clinical observations, which I regularly share on platforms like my Sciatica Clinic website and LinkedIn profile, the recurring theme is the power of this integrated approach. The synthesis of chiropractic, functional medicine, and targeted medical procedures provides a comprehensive framework for tackling even the most stubborn chronic pain conditions. It is a privilege to guide patients on this journey, offering them hope and tangible results grounded in modern, evidence-based care.

References

• Dommerholt, J., & Fernández-de-las-Peñas, C. (Eds.). (2018). Trigger point dry needling: An evidence- and clinical-based approach (2nd ed.). Elsevier.
• Manchikanti, L., Singh, V., Falco, F. J., Cash, K. A., & Fellows, B. (2010). Cervical erector spinae plane block: a novel analgesic technique for management of acute and chronic pain. Pain Physician, 13(5), E315-E321. [Note: This reference provides context on injection techniques in the spinal region, though not specific to Sarapin.]
• Shah, J. P., Thaker, N., Heimur, J., Aredo, J. V., Sikdar, S., & Gerber, L. (2015). Myofascial trigger points then and now: A historical and scientific perspective. PM & R: The Journal of Injury, Function, and Rehabilitation, 7(7), 746–761. https://doi.org/10.1016/j.pmrj.2015.01.024
• Simons, D. G., Travell, J. G., & Simons, L. S. (1999). Travell &Simons’’ myofascial pain and dysfunction: The trigger point manual (Vol. 1, 2nd ed.). Williams & Wilkins.
• Wancura-Kampik, I. (2018). Sarapin in Pain Therapy. In Pain Therapy (pp. 531-536). Springer, Cham. https://doi.org/10.1007/978-3-319-58359-1_53

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