Trigger Point Injection

Patient Position: Sitting or lying in a comfortable position.

Indications: Myofascial pain syndromes.

Needle Size: 25-gauge, 38-mm needle.

Medication/Volume: 0.25% bupivacaine ± steroid; 20 mg methylprednisolone per 10 mL of local anesthetic.

Anatomic Landmarks:
Trigger points are often located within the mid-depth of the muscle but
can be located deeply or superficially. Pressure with palpation should
reproduce the pain. The area is often felt as a tense band of muscle.

Approach and Technique:
After sterile preparation of the region, gently palpate the taut muscle
band that is painful. Prep the skin with Betadine (Purdue Pharma L.P.,
Stamford, CT). Hold the tissue between the thumb and forefinger of the
nondominant hand. Advance the needle gently in an attempt to elicit and
reproduce the patient’s pain. Ask the patient to indicate when the
painful area feels aggravated by the needle. Avoid deep insertion of
the needle, particularly if treating thoracic or cervical back or the
abdomen. Once the patient’s pain is elicited, hold the hub of the
needle with the nondominant, sterile thumb and forefinger, aspirate,
and inject approximately 2 mL of local anesthetic. “Dry needling” of
the trigger point after injection of the local anesthetic involves
fanning the needle in a 360° fashion in the affected muscle. The
technique includes gentle insertion and withdrawal of the needle into
the trigger point, being careful not to advance the needle deeper than
needed. In addition, the needle should not be withdrawn from the skin
while dry needling, but should be pulled back superficially and then
re-advanced in a slightly different angle. Remove the needle. Apply
manual pressure to and massage the treated areas to promote
distribution of the local anesthetic, increase local blood flow, and
provide hemostasis. Apply Band-Aid (Johnson & Johnson, Somerville,
NJ).