Peripheral Nerve Blocks: A Color Atlas, 3rd Edition

68. Trigger Point Injection

Nashaat N. Rizk

Albert J. Carvelli

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 In addition, the needle should not be withdrawn from the skin while dry needling, but should be pulled back superficially and then re-advanced in a slightly different angle.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).



1.   Trigger points in the trapezius muscle group are more superficial than the practitioner may think.

2.   Be aware of the potential for pneumothorax on injection of upper- and mid-back trigger points.

Suggested Readings

Cousins MJ, Bridenbaugh PO, eds. Neural blockade in clinical anesthesia and management of pain, 3rd ed. Philadelphia: Lippincott-Raven, 1998.

Loeser JD, ed. Bonica's management of pain, 3rd ed. Philadelphia: Lippincott Williams & Wilkins, 2001.

Raj PP, ed. Practical management of pain, 3rd ed. Philadelphia: Mosby, 2000.