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Phys Med Rehabil Clin N Am. Author manuscript; available in PMC 2023 May 01.
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Published in final edited form as:

Phys Med Rehabil Clin N Am. 2022 May ; 33(2): 307–333. doi:10.1016/[Link].2022.01.011.

Trigger Point Injections

Malathy Appasamy, MBBSa, Christopher Lam, MDb, John Alm, DOc, Andrea L. Chadwick,
MD, MSc, FASAd,*
aDepartment of Physical Medicine & Rehabilitation, Main Line Health System, 600 Evergreen
Drive, 2nd Floor, Glen Mills, PA 19342, USA
bDepartment of Anesthesiology, University of Kansas School of Medicine, 3901 Rainbow
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Boulevard, Kansas City, KS 66160, USA

cDepartmentof Physical Medicine & Rehabilitation, University of Kansas School of Medicine,
3901 Rainbow Boulevard, Kansas City, KS 66160, USA
dDepartment of Anesthesiology, University of Kansas School of Medicine, 3901 Rainbow
Boulevard, MailStop 1034, Kansas City, KS 66160, USA

Keywords
Myofascial pain; Piriformis syndrome; Trigger point injection; Botulinum toxin; Corticosteroid;
Local anesthetic
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INTRODUCTION
Myofascial pain is a common cause of acute and chronic pain. The term “myofascial pain”
encompasses many different painful conditions and can exist independently of other pain
generators, known as primary myofascial pain. Common primary myofascial pain diagnoses
include piriformis syndrome, iliopsoas-related pain, and pain related to compression
of the brachial plexus by the scalene muscles (neurogenic thoracic outlet syndrome).
Frequently, myofascial pain coexists with or is secondary to other acute and chronic painful
musculoskeletal conditions including (1) head and neck disorders (temporomandibular
disorders, cervical degenerative disc disease, cervical facet arthropathy, neck pain after
whiplash injury, cervicobrachial syndrome, and cervicogenic or chronic tension-type
headache); (2) thoracolumbar back disorders (degenerative disc disease, kyphosis, scoliosis,
and lumbar facet arthropathy); (3) pelvic pain; and (4) upper and lower extremity pain
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disorders. Myofascial pain is most effectively treated with a multimodal treatment plan
including injection therapy (known as trigger point injections [TPIs]), physical therapy,
postural or ergonomic correction, and treatment of underlying musculoskeletal pain
generators.

The objectives of this review are to describe the known pathophysiology of myofascial pain
and trigger points (TrPs), discuss the clinical presentation of myofascial pain and piriformis

*
Corresponding author: anicol@[Link].
 Appasamy et al. Page 2

syndrome, an extremely common primary myofascial pain disorder, describe best practices
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for TPI and piriformis muscle injection therapy, and outline the current data for TPI therapy
with local anesthetic and/or steroids and botulinum toxin.

NATURE OF THE PROBLEM: THE PATHOPHYSIOLOGY OF MYOFASCIAL

PAIN AND TrPs
Although much remains to be discovered about the pathophysiology of myofascial pain,
several mechanistic theories have been advanced in recent years. Certainly, as with most
chronic pain conditions, the biopsychosocial model of pain pathophysiology applies.1
Underlying biomechanical and postural factors may interact with neurologic factors,
psychological elements including depression and anxiety, and hormonal and nutritional
imbalances. These factors, in total or in part, may lead to peripheral sensitization, autonomic
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dysregulation, and central sensitization, which then amplifies the pain experienced by
patients with myofascial pain. Vasoactive mediators, pronociceptive neurotransmitters,
and inflammatory mediators including bradykinin, norepinephrine, serotonin, calcitonin
gene–related peptide, substance P, tumor necrosis factor α, and interleukin-1β have all
been identified in the hypersensitive loci of TrPs.2–4 These substances are pronociceptive
and sensitize peripheral nociceptors. In a sensitized state, nociceptors spontaneously
discharge with a lower threshold to painful stimulation and also exhibit discharge to
nonpainful stimuli.5 Over time, this heightened abnormal peripheral sensory input creates
a state of central neuronal sensitization.6 The hypothalamus-pituitary-adrenocortical and
sympathetic-adrenal-medullary system responses to experimentally induced stress in patients
with myofascial pain has shown that plasma concentrations of cortisol, epinephrine, and
norepinephrine were found to be significantly increased in myofascial pain patients than in
healthy controls.7
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CLINICAL PRESENTATION AND DIAGNOSIS

Myofascial Pain
A careful history and physical examination remain the keystone of diagnosis. As discussed
previously, TrPs are localized painful areas of skeletal muscle containing taut bands that can
be exquisitely sensitive to digital pressure (Fig. 1). TrPs may be active or latent. Active TrPs
are present in patients with painful regional conditions. Latent TrPs are asymptomatic but
may be revealed by deep palpation on physical examination. Latent TrPs are very common
and have been identified in the shoulder girdle muscles of 45% to 55% of healthy young
adults.8 TrPs are different from tender points, which are defined as a localized area of
tenderness in a muscle, muscletendon junction, fat pad, or bursal region.9 Myofascial pain
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may occur after an injury, with chronic strain from repetitive microtrauma, or without any
clear precipitating event. Aberrant body mechanics or postural abnormality may initiate or
further maintain the problem. The quality of pain tends to be a deep “aching” of variable
intensity and the pain is generally confined to a specific anatomic region. Characteristic
referred pain patterns are associated with specific muscles, although these referral patterns
are often unreliable.10 Commonly involved TrP musculature include the trapezius, splenii,
cervical and lumbar paraspinal, piriformis, and quadratus lumborum.

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Simons and colleagues have developed a set of diagnostic criteria that are often referenced
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when describing the features of TrPs including presence of taut band, tenderness from taut
band, reproducibility of pain, local twitch response, restricted range of motion, autonomic
symptoms, and referred pain.11 Furthermore, palpation of an active TrP can cause referred
pain through activation of the central nervous system along the distribution of the nerve
innervating the muscle that is activated.12

It is essential to have hands-on training in the physical examination of myofascial pain and
TrPs.13 Musculoskeletal examination should be performed with the objective of identifying
possible orthopedic or neurologic pathologies that could have a role in generating secondary
myofascial pain and dysfunction. A distinct pattern of TrP findings may reveal itself
in myofascial pain syndrome after a given insult.14 These painful TrPs limit full range
of passive motion in the afflicted muscle group. Although these findings have been
suggested as diagnostic criteria,15–17 investigators have found it problematic to demonstrate
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consistent agreement in the presence or absence of TrPs among examiners in blinded

studies with control groups.18–20 Discrepancies in diagnosis may be attributed in part to
a lack of a standardized examination technique as well as variability in the interpretation
of examination findings. Furthermore, variations in muscle anatomy, physical conditioning,
and deconditioning can pose obstacles to proper diagnosis as well. The most reproducible
diagnostic findings on physical examination include identification of a TrP in an affected
muscle, referral of pain to a zone of reference, and reproduction of the patient’s regular pain
on physical examination.21

Differential diagnosis of myofascial pain should include (1) musculoskeletal and

neuropathic disorders such as arthritis, degenerative disk disease, radiculopathy, bursitis,
and tendonitis; (2) autoimmune or infectious etiologies; (3) metabolic and endocrine
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dysfunction; (4) psychiatric disorders including depression and anxiety; and (5) fibromyalgia
or diffuse amplified musculoskeletal pain.

Imaging studies have only recently demonstrated anatomic changes associated with TrPs.
Ultrasound (US) examination in combination with Doppler blood flow has been reported to
allow visualization of TrPs, and US imaging can help direct muscle injection techniques.
Recently developed techniques using magnetic resonance and US elastography purport to
reveal changes in intramuscular signal consistent with TrPs, but the use of this technology in
clinical practice has not yet been validated.22,23

Piriformis Syndrome
Piriformis syndrome consists of pain in the buttock with or without radiation in the
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distribution of the ipsilateral sciatic nerve. It is considered the principal pain generator
in approximately 8% of patients presenting with the buttock as the origin of pain. The
syndrome can be a consequence of an abnormal relationship between the sciatic nerve
and the piriformis muscle that results in irritation of the sciatic nerve. A hypertrophic
muscle, infection, or invasion of the muscle by tumor can cause pressure or irritation on the
nerve.24,25 In 78% to 84% of the population, the sciatic nerve passes in front of the muscle.
In 12% to 21% of individuals, the divided nerve passes through or posterior to the piriformis
and is exposed to muscle contractions, which trigger sciatic symptoms.24

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There is no consensus set of diagnostic criteria and is often diagnosed from a history
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indicative of this condition with confirmatory physical examination with an often normal
electrodiagnostic testing and imaging.26 The syndrome should be considered in patients
who have buttock pain, tenderness to palpation over the piriformis muscle, and possible
symptoms of sciatic nerve pain. In addition, positive response to provocative maneuvers may
indicate the diagnosis, including the following: specific confirmatory physical examination
testing for piriformis syndrome includes the active piriformis test, the Beatty test, the FAIR
test, and the Pace test.26

PATIENT SELECTION
Trigger Point Injection
TPI is a widely used invasive therapy wherein a needle is guided directly into a TrP
that has been previously identified on physical examination. TPI is best used as part of
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a comprehensive multimodal treatment plan. This strategy can be particularly beneficial

when TPI is initially used to reduce pain in patients otherwise intolerant of physical therapy
or stretching, allowing the physical modalities to be more effective.27 TPIs should be
considered in patients once a thorough evaluation is completed to rule out other causes of
back pain including muscle strain, axial back pain, structural causes of pain, discogenic back
pain, vertebrogenic back pain, spinal stenosis, vertebral body disease (including fracture),
and radicular back pain.

Piriformis Muscle Injection

As discussed previously, piriformis syndrome is a condition associated with low back pain
where the traversing sciatic nerve is compressed by the sciatic nerve. Once diagnosed,
patients can be treated with conservative management first, including pharmacologic therapy
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and physical therapy. If pain persists after conservative management, it is reasonable to trial
a piriformis muscle injection.

Risks and Contraindications

The following conditions are contraindications to TPI and piriformis muscle injection:
(1) infection, systemic or localized (absolute); (2) coagulopathy (relative); (3) distorted
or complicated anatomy (relative); and (4) patient refusal (absolute).28 According to the
anticoagulation guidelines from the American Society of Regional Anesthesia and Pain
Medicine, TPIs classify as a low-risk procedure.28

TPIs are commonly performed as an outpatient procedure. Although serious complications

are rare, there have been case reports of complications particularly in the cervical and
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thoracic region.

The most commonly reported serious complication is pneumothorax.29–31 A case series of

38 patients developed pneumothorax after acupuncture or acupoint insertion with one death
from pneumothorax in the series.32 Specific attention to TrP technique and use of ultrasound
guidance can help avoid this complication in the cervical and thoracic injections.33,34
Management of iatrogenic pneumothorax depends on size of the pneumothorax and

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symptoms and can range from observation, oxygen supplementation and close monitoring to
ultrasound or CT-guided aspiration and tube thoracotomy.35,36
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Rare possibility of intrathecal injection has been reported in a 28-year-old woman

after superficial trapezius TPI.37 This patient developed respiratory depression and
pneumocephalus requiring emergency tracheal intubation and ventilatory support and fully
recovered over the course of 24 hours. There has been another case report of cervical
epidural abscess that has been reported.38

Skeletal muscle myotoxicity has been demonstrated in experimental studies with the use
of local anesthetic agents as they cause reversible myonecrosis. Histologic changes include
hypercontracted myofibrils followed by lytic degeneration of striated muscle sarcoplasmic
reticulum and myocyte edema and necrosis over 1 to 2 days. Muscle regeneration
occurs within the next 3 to 4 weeks as myoblasts, basal laminae, and connective tissue
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elements remain intact. This effect has been seen in only a few case reports of myotoxic
complications after local anesthetic administrations causing clinically relevant myopathy
and myonecrosis after TPIs.39 In experimental studies, procaine produces the least and
bupivacaine causes the most severe muscle injury.

There has been one case report of severe hypokalemic paralysis after left iliopsoas muscle
injection with ultrasound guidance that highlights the importance that high index of
suspicion is warranted for prompt diagnosis and management.40 It was postulated in this
case that the cause of the hypokalemia was due to transcellular shifting due to epinephrine
component of the TPI injectate.

Other complications that can occur include vasovagal syncope, allergic reaction,
skin infection, and hematoma formation.41 Proper preparation, taking adequate sterile
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precautions, and close monitoring of the patient during and after the procedure can minimize
long-term effects.

TECHNIQUE FOR TPI (EXCLUDING PIRIFORMIS MUSCLE)

Technique for TPI
Preparation—TPIs should be performed by skilled professionals with adequate
anticipation and preparation for complications such as vasovagal reaction and allergic
reaction. After reviewing the contraindications as described earlier and after discussing
the risks of the procedure including, but not limited to increased pain, infection, bleeding,
allergic reaction, soft tissue injury, pneumothorax, cutaneous atrophy, bleaching of the skin
(if steroid is administered), written informed consent is obtained.
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Technique—The targeted areas are then identified and marked by the presence of discrete
TrPs with localized tenderness, hypertonicity, and taut bands. Using the nondominant hand,
the skin and underlying tissue is pinched between the index finger and thumb, and the needle
attached to the syringe with the injectate is inserted using the dominant hand at a 30° angle
until the taut band is reached. The needle is then advanced and retracted to various sites
within the muscle until relaxation is achieved. At each site, after aspiration is performed to

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ensure negative return of blood or fluid, 0.2 to 0.5 mL of solution is injected. The needle is
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then withdrawn after all the injectate is administered in a fanlike distribution in the muscle
and a sterile band-aid is applied.

EVIDENCE FOR THE USE OF IMAGE GUIDANCE FOR TPI (EXCLUDING

PIRIFORMIS MUSCLE)
Traditionally, TPIs have been performed using blind technique without image guidance
by palpating the TrPs and inserting the needle with or without injecting a solution.
However, palpation of TrPs can be technically difficult in obese patients that can result in
ineffective injection if placed in the soft tissues and can cause complications if inadvertently
placed in other tissues. Several diagnostic methods including electromyography, magnetic
resonance elastography, and ultrasonography have been studied to determine the location
and characteristics of myofascial TrPs.22,42,43 All these methods were shown to have
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limitations in proper identification. However, subsequent studies have supported the use of
ultrasound, which is considered to be safe, portable, and inexpensive imaging modality for
identification and evaluation of the effectiveness of therapeutic interventions in myofascial
TrPs.23,44

The technique for using ultrasound guidance for TPIs was first described by Botwin and
colleagues.33 The authors described the muscle to have hyperechoic marbled appearance
while adipose tissue had mixed echogenicity, using a 13–6 MHz 38 mm broadband linear
array transducer. They demonstrated clear visualization of the injectate using a 25g 1.5-inch
needle under direct ultrasound guidance that was further confirmed with color mode. A
subsequent study also demonstrated ultrasound can differentiate myofascial tissue with and
without active TrPs.23 Several studies have shown that ultrasound-guided injections are
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extremely effective modality in various musculoskeletal locations and maximize injection

accuracy and minimize potential complications.45–48 Ultrasound may be considered by
practitioners for guiding musculoskeletal injections to avoid complications from blind
injections.

However, there are very limited number of studies on the effectiveness of ultrasound-guided
injections for myofascial pain syndrome. Ultrasound-guided interfascial block with lidocaine
between the rhomboids major and trapezius showed statistically significant improvement
in pain and quality of life similar to pulsed radiofrequency treatment.49 Ultrasound-guided
deep injection using 12 to 18-MHz US transducer of the rhomboid major muscle was
more effective than superficial injection of trapezius muscle for parameters of pain,
disability, and quality of life in 61 patients with myofascial pain syndrome in a prospective
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randomized double-blinded study at 2 and 4 weeks post-treatment.50 The author’s findings

corroborated with other studies that deep injections were superior to superficial injections
and they concluded that ultrasound guidance can help to minimize the complications of
blind injections such as pneumothorax, air embolism, inadvertent intrathecal injection,
peripheral nerve injuries, and muscle injuries that are all rare reported complications, which
is discussed in detail in the following section.31

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Shear wave elastography using ultrasound has emerged as a quantitative method of

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measuring the mechanical properties of the soft tissue including skeletal muscle through
external induction of the shear wave or with the use of the radiation force of the
ultrasound.51–53 A recent pilot feasibility study on 41 patients compared ultrasound-guided
myofascial injections and blind injections with the use of shear wave elastography and
showed statistically significant improvement in the pain (VAS) scores, neck disability
scores (NDI), and shoulder pain disability score (SPADI) at baseline and at 4 weeks with
significantly higher efficacy in the ultrasound group.48

Limitations of these studies comparing ultrasound-guided myofascial injections with

blind injections are small sample size and lack of placebo intervention and short
follow-up period.50 Other efforts to characterize neuromuscular activation using surface
electromyography signals using machine learning have been studied but have not been
evaluated in clinical outcome studies.54,55
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TECHNIQUE FOR PIRIFORMIS MUSCLE INJECTION AND EVIDENCE FOR

THE USE OF IMAGE GUIDANCE
The use of imaging devices in the performance of piriformis injection procedures can help
increase accuracy and reduce complications. It is important to select the appropriate image
guidance to increase the success rate of procedures. Fluoroscopy and ultrasound are the most
commonly used imaging techniques to perform piriformis injections. Ultrasound has been
shown to provide higher accuracy in needle placement. In a study by Finnoff and colleagues,
ultrasound-guided piriformis injections were found to be significantly more accurate than
fluoroscopically guided contrast-controlled injections.56 The authors concluded that despite
the use of bony landmarks and contrast, most of the fluoroscopically attempted piriformis
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injections were placed superficially within the gluteus maximus.

The use of electromyography for localization of the piriformis muscle or other TrPs has been
reported with mixed results. In a 2016 study, it was reported that there was no correlation
between the location of a TrP and the position of peak EMG amplitude.57 Fluoroscopic
guidance relies on identification of bony target points that guide the practitioner to the
piriformis muscle, whereas sonography can directly identify the piriformis muscles and
provide a real-time image of surrounding soft tissues (nerves, muscles, vessels, etc.), an
image of needle tip advancement relevant to surrounding structures, and visualization of
injectate spread.58 In addition, neither the patients nor clinicians are exposed to radiation
during an ultrasound-guided procedure and therefore present as a much safer option long-
term with the absence of cumulative doses of radiation associated with repeat procedures.59
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For the fluoroscopically guided injection with EMG guidance, the patient is placed prone
on a fluoroscopy table, and the inferior margin of the sacroiliac joint is imaged and marked.
The needle insertion site is 1 to 2 cm caudal and 1 to 2 cm lateral to the inferior margin
of the sacroiliac joint. After sterile preparation and infiltration of local anesthetic, a 7-to
10-cm insulated needle is inserted and advanced with the nerve stimulator turned on (1 mA,
2 Hz, 0.1 msec) until an evoked motor response of the sciatic nerve is achieved (dorsiflexion,
plantar flexion, eversion, inversion) at 0.4 to 0.6 mA. The needle is then withdrawn until the

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sciatic stimulation disappears to avoid intraneural injection and 1 to 2 mL of contrast agent

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is injected. The contrast agent should outline the piriformis muscle belly with no sign of
spillage (Fig. 2). After the characteristic spread of dye is achieved, a local anesthetic solution
with steroid is administered.

For the ultrasonography-guided procedure, the piriformis is identified in long axis with the
transducer in the oblique axial plane on the body just inferior to the sacroiliac joint and
greater sciatic notch (Fig. 3). It is important to maintain visualization of the piriformis
musculature, lateral edge of the sacrum, and sciatic nerve to avoid needle contact with the
nerve itself.60 Although the muscle is being visualized in the long axis, the nerve will be in
the short axis and is typically seen deep to the piriformis when in the prone position. During
this preprocedure scan, Doppler imaging should be used to locate vessels that will need to
be avoided.61 While maintaining visualization of the needle, the needle can then be inserted
in plane with the transducer until it enters the piriformis muscle tissue at the targeted site.
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The needle trajectory can be adjusted as the needle is inserted to reach the desired location
and to avoid the sciatic nerve. When the needle is in the correct position at the muscle,
the medication can be injected and visualized entering the tissue.62 Local anesthetic is
visualized as anechoic, whereas corticosteroid may be hyperechoic with particulate steroids
or anechoic in nonparticulate steroids.

Injectate Therapeutic Options

Saline, corticosteroids, a variety of local anesthetics including lidocaine and bupivacaine,
botulinum toxin serotype A (BoNT-A), and dry needling have all been used and studied.
Stimulation of the local twitch response in direct needling of the TrP is valuable in achieving
immediate effect.63 There is good evidence to suggest that there is no advantage of one
injection therapy over another, or of any drug injectate over dry needling.64 In a systemic
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review of 23 randomized controlled trials (RCTs), Cummings and White concluded that
any effect derived from TPI is likely derived from the needle itself, rather than any specific
substance injected, as there was no difference in therapeutic benefit of “wet” needling versus
“dry” needling.64 Their review also suggested that pain reduction with saline TPI is equal to
pain reduction with local anesthetic TPI, both being significant.

Although adding corticosteroid preparation to local anesthetic is a common practice, it has

not been reliably shown to reduce pain more than TPI with local anesthetic alone.64,65
Botulinum toxin type A (BoNT-A) produces sustained and prolonged relaxation of muscles
by inhibiting release of Ach at the motor endplate and is itself an analgesic inhibiting central
sensitization.66 Commercially prepared BoNT-A is expensive and should be used with care
by a well-trained physician. Despite the widespread practice of TPI for myofascial pain,
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there is no consensus regarding the number of injection points, frequency of administration,

and volume or type of injectate. Controlled studies are needed to evaluate the comparative
efficacy of TPIs and their potential benefits in long-term pain reduction, if any.

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OUTCOMES DATA AND DISCUSSION FOR TPIs WITH LOCAL ANESTHETIC

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± STEROID
Over the years, few well-designed RCTs regarding TPIs have been performed with even
fewer published in the last decade. Available literature investigated the efficacy of the
injection for myofascial pain with diverse medications (Table 1). Initial studies evaluated the
efficacy of TPI with various types of local anesthetics, concentrations of local anesthetics,
and a variety of steroids.65,67–70 The majority of these studies evaluated the injection
techniques on the cervical neck, shoulder, masseter, abdominal/pelvic, and trapezius
muscles. Regardless of medication used, the key component involved placing the needle
into a taut band, which resulted in improved pain compared with baseline. Recent studies
largely in the emergency medicine literature within the last 5 years have reaffirmed findings
from earlier studies. In a study where patients presented to the emergency department with
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lumbar myofascial pain, patients were randomized to either intravenous (IV) nonsteroidal
anti-inflammatory drugs (NSAIDs; 50 mg dexketoprofen) or TPI with 1.0% lidocaine.
Of 54 patients enrolled in this RCT, TPIs were found to have superior analgesic effect
compared with IV NSAIDs at all studied time points up to 60 minutes after intervention.71
Though superior to pharmacologic, the type of injectate did not seem to make a substantial
difference in most studies. Roldan and colleagues compared patients treated with either TPIs
containing normal saline or lidocaine 1% with 40 mg triamcinolone who presented to the
emergency department for management of lumbar myofascial pain. They found that there
was no statistically significant difference between the two groups immediately after injection
or at 2 weeks follow-up.72

Aside from comparing efficacy of the injection for myofascial pain relief, studies have been
performed evaluating if the concentrations of local anesthetic used affected the presence
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of pain on injection or its efficacy of relief.69,73 Iwama and colleagues compared 0.25%
lidocaine to 1.0% lidocaine TPI in patients with bilateral shoulder myofascial pain. It was
found that injection pain was statistically significantly less with injection of 0.25% lidocaine
compared with 1.0% with overall improved pain relief at 7 and 14 days postinjection.69
A follow-up study performed by Iwama and colleagues compared water diluted 0.25%
lidocaine TPI to water diluted 0.20% lidocaine TPI in patients with shoulder and cervical
myofascial pain found that both patient cohorts reported statically significant pain relief for
the same duration of time.73 The same study evaluated diluted mepivacaine and bupivacaine
along with diluted lidocaine to evaluate its effect on injection pain. The study found that
diluted mepivacaine resulted in the least amount of pain with injection.

Other studies have also studied this phenomenon, finding that pain on injection varies
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among local anesthetics. Krishnan and colleagues studied intramuscular injection pain in
healthy volunteers comparing the amount of injection pain when bupivacaine, ropivacaine,
bupivacaine with steroids, and ropivacaine with steroids were used. In the study, bupivacaine
injections were noted to be more painful than ropivacaine in intensity that was deemed not
associated with the differences in the local anesthetic pH.74 Needle size affecting the pain
upon injection was investigated by Yoon and colleagues comparing 21-gauge to 23-gauge
needles for TPIs in 77 patients with trapezius myofascial pain found no statistical difference

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in pain scores at the time of injection or visual analog scores at follow-up.75 Injection
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pain aside, only one study in 1981 found indicate benefit of local anesthetic compared
with normal saline for TPI 7 days after injection in a cohort of only 15 patients.68 Ga and
colleagues also found this similar trend when acupuncture was compared to TPI with 0.5%
lidocaine in patients with myofascial pain. When both modalities were used resulting in
a twitch response, there was no statistically significant difference in the amount of pain
improvement in patients, up to 1 month out.76 This was further validated by Mitideri and
colleagues when Ashi acupuncture was compared to local anesthetic TPI in patients with
pelvic pain from abdominal myofascial pain. When the taut band was intervened upon, they
found equal efficacy in pain relief between both intervention groups.77

OUTCOMES DATA AND DISCUSSION FOR TPIs WITH BOTULINUM TOXIN

Similar to the studies evaluating local anesthetic and steroids for TPI, there is a paucity
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of well-designed RCTs evaluating the efficacy of botulinum toxin in the management

of myofascial pain (Table 2). One of the earlier studies was performed by Wheeler and
colleagues and was a double-blind RCT where 33 participants were randomized to receive
either 50 or 100 units of BoNT-A or normal saline injection into symptomatic TrPs of
the cervicothoracic area. Their findings showed significant improvement in pain scores,
neck disability, and an increase in pressure pain threshold testing by algometer; however,
there was no significant difference between BoNT-A groups and saline control groups.78
Another study by Qerama and colleagues was a double-blind RCT in patients with chronic
myofascial pain comparing TPI performed with 50 U BoNT-A to normal saline. This study
found that there was no statistically significant difference in pain outcomes between the 2
groups at 28 days after injection.79 Kwanchuay and colleagues compared the efficacy of
BoNT-A TPI in patients for upper trapezius myofascial pain to normal saline TPI. Their
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study found no difference in efficacy in VAS reduction; however, BoNT-A did increase the
pressure pain threshold at 6 weeks after the injection in a statistically significant manner.80
Dessie and colleagues also compared BoNT-A TPI to normal saline TPI in patients with
pelvic myofascial pain syndrome where no statistically significant difference was found
between the 2 groups at 4 and 12 weeks postprocedure.81

Other studies have found that BoNT-A may provide durable relief compared with other
medications upon injection. In a double-blind RCT by Gobel and colleagues, patients with
myofascial pain were randomized to receive either BoNT-A injections (10 sites, 40 U each)
to saline TPI. The study found that BoNT-A did result in statistically significant pain control
at 5 weeks with fewer days of pain between 5 and 12 weeks.82 Kamanil and colleagues
compared lidocaine TPI, BoNT-A TPI, and dry needling in patients with myofascial pain.
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At 1 month follow-up, patients receiving a TPI had statistically improved VAS compared
with dry needling. However, all 3 modalities resulted in decreased VAS after treatment.
Furthermore, in the study, it was argued by the authors that lidocaine TPI was less disruptive
than dry needling and more cost-effective than BoNT-A TPI though BoNT-A may be useful
for patients with MPS resistant to conventional treatment.83

Ferrante and colleagues found no statistically significant improvement compared to placebo

with BoNT-A injection when injected directly into painful TrPs for cervicothoracic MP.84

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They concluded that although it is intuitive for the clinician to consider therapeutic injection
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of BoNT-A as a treatment for MP (given its a priori similarity to TPI), peculiarities

inherent to the use of toxin in lieu of dry needling or local anesthetic must be accounted
for (ie, toxin spread through fascial planes), including the effects of dosing of toxin,
volume of injectate, muscles chosen to inject, postural relations and abnormalities, and
injection technique. Harden and colleagues were able to identify a short-term (12-week)
reduction in MP of chronic tension-type headache with BoNT-A injection as compared
with placebo.85 Graboski and colleagues found no significant difference in BoNT-A versus
0.5% bupivacaine injected into TPs of patients with MPS, though both were effective in
reducing pain below the baseline level.86 Venancio and colleagues studied 45 MP patients
who were assigned randomly to 1 of the following 3 groups: dry needling, 0.25% lidocaine
TPI, and BoNT–A TPI, and assessed over a 12-week period.87 Although all 3 groups
showed favorable response to treatment, the BoNT-A group demonstrated less use of rescue
medication, and less postinjection local sensitivity.87 In another study, Nicol and colleagues
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reported that BoNT-A injected directly into painful muscle groups using a “follow the pain”
and pattern injection technique in lieu of TrPs led to reduced average numerical pain scores,
reduced number of headaches per week, and improvement in general activity and sleep
quality of life measures.88 Similar positive findings were seen in the studies by Benecke
and colleagues89 and Miller and colleagues90 wherein patients with cervical myofascial pain
received BoNT-A using a fixed-location injection technique.

OUTCOMES DATA AND DISCUSSION FOR PIRIFORMIS INJECTION WITH

LOCAL ANESTHETICS ± STEROID
In patients who fail to respond to conservative treatment of piriformis syndrome that
includes activity modification, rest, mobilizing soft tissue restrictions, medical management,
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physical therapy, and alternative therapies such as acupuncture or dry needling, invasive
options have been suggested.91,92 Injection interventions for piriformis TrPs with local
anesthetics with or without steroids have been studied (Table 3). Early studies involving
the analysis of 279 patients found that about 79% of the patients had at least 50%
improvement when steroid (triamcinolone) injections to the piriformis were added to the
physical therapy protocol suggesting the added benefit of injection treatment.93 In a later
study, 239 patients were injected with local anesthetic of bupivacaine and betamethasone
demonstrated significant reduction of pain in 45% of patients for 2 to 4 months and 15%
having 8 months or longer with significant improvement of pain.94

A subsequent study involving 162 patients, using MRI guidance and injection of local
anesthetic provided complete relief without recurrence in 15% of patients and short-term
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relief up to 4 months with recurrence in 69% of patients.94 Sixteen percent had no relief
with injection. Another small study of 13 patients and 10 control subjects showed the
potential benefit of CT-guided piriformis injection with local anesthetic and steroid with
statistically significant improvement in VAS score at 5 to 7 days, 2,3,6, and 12 months.95 A
small case series showed 9 of 10 patients who received CT-guided piriformis injection had
full and sustained recovery after piriformis injection.96 In a study by Jeong and colleagues,
63 patients underwent ultrasound-guided piriformis injection of 40 mg triamcinolone, in

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 Appasamy et al. Page 12

which 40.5% of enrolled participants showed significant improvement with injection and
18.9% had partial improvement.97
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As part of neural therapy to reduce pain and improve function, 51 patients with piriformis
syndrome received 6 sessions of lidocaine injections that involved piriformis muscle
injections, T11-S2 segmental injections and sacral canal injections along with stretching
exercises.98 Both the control group and the treatment group received stretching exercises
as part of treatment and the study showed statistically significant improvement in pain and
functional level in both groups with changes from baseline noticeably larger in the neural
therapy group. This study showed that adding lidocaine injections can play a conjunctive
role with other treatment options.

Steroid injections with local anesthetic have been studied in a recent cohort of 32 patients
receiving injection therapy in the piriformis muscle using ultrasound guidance and showed
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statistically significant improvement in pain scale from baseline and at 1 month as well as
1 week to 1 month.99 In another study of 49 patients with deep gluteal syndrome of which
piriformis syndrome is one of the subtypes, ultrasound-guided injection of a mixture of
20 mLs of normal saline, 4 mLs of 2% lidocaine, and 1 mL of corticosteroid (40 mg of
methyl-prednisone acetate) in the perisciatic region between the gluteus maximus and pelvic
trochanteric muscles provided some level of pain relief in 73.7% with reduction in pain
score from 8.3 preinjection to 2.8 postinjection. Recurrence of pain was reported in 50% of
the patients and the effect lasted for 5.3 weeks.100

Although these previous studies have shown that piriformis injection with image guidance
with local anesthetic and steroid had improvement in pain level at varying degrees, the effect
of local anesthetic alone versus local anesthetic with a steroid was studied in a randomized
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controlled double-blinded study of 50 patients. This study failed to show a statistically

significant difference in the pain level in 2 groups with and without steroid.101 After a
test injection and diagnosis of piriformis syndrome, one group (n = 22) received 5 mL
of 2% lidocaine and other group (n = 25) received 4 mLs of 2% lidocaine and 1 mL of
betamethasone. Both groups had a significant reduction in pain compared with baseline,
there was no difference between the groups at rest, in motion, 1 month, or 3 months,
suggesting that the addition of steroids may not have an added benefit over local anesthetic
injections.

Another study has studied the effect of hydrodissection before injection of corticosteroid
in piriformis syndrome and showed promising results. In this study, hydrodissection was
performed by injecting fluid in the perineural tissue using ultrasound guidance to help
reduce the adhesions and broaden the tissue space to deliver local anesthetic and steroid.
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Of the 38 patients studied, 17 received betamethasone and 21 received triamcinolone.

Thirty-two patients (84%) received immediate pain relief with a reduction in pain score
from 4.7/10 to 0.5/10. Of the 19 patients followed up at 33.6 days, 9 patients (47%) reported
continuous pain relief.102 Further large-scale studies are needed to compare the effect of
hydrodissection before injection treatment.91

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 Appasamy et al. Page 13

OUTCOMES DATA AND DISCUSSION FOR PIRIFORMIS INJECTION WITH

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BoNT
Piriformis muscle injection with BoNT-A is an increasingly common injection when the
duration of effect from local anesthetic/corticosteroid injections is insufficient. A typical
dose would be 100 units in a 2-mL volume.103 Owing to its paralytic effect on the
muscle, it causes atrophy and fatty degeneration of the muscle over time as evidenced by
MRI.104 This reduction in muscular volume would decrease pressure on the sciatic nerve
and is the mechanism of analgesia93,105–112 but is a more profoundly effective treatment
when combined with physical therapy.93,107,110 Several uncontrolled studies have evaluated
the use of BoNT-A, often in combination with physical therapy, and reported high rates
of success that lasted for months (Table 4).103,106–111 A controlled study demonstrated
superiority of BoNT-A over placebo injection for 10 weeks.109 Other controlled studies have
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reported that the efficacy of botulinum toxin is superior to that of local anesthetic/steroid or
normal saline injections for the treatment of piriformis syndrome.110,113

SUMMARY
Myofascial pain and myofascial pain syndromes are among some of the most common
acute and chronic pain conditions. The pathophysiology of myofascial pain includes
biomechanical and postural factors that likely interact with neurologic factors, psychological
elements including depression and anxiety, and hormonal and nutritional imbalances. These
factors (in total or in part) may create peripheral sensitization, autonomic dysregulation, and
ultimately, central spinal cord sensitization, which can amplify the symptoms experienced
by patients with myofascial pain. Many interventional procedures can be performed in both
an acute and chronic pain setting to address myofascial pain syndromes. Injections can be
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achieved with or without imaging guidance such as fluoroscopy and ultrasound; however,
the use of imaging in years past has been recommended to improve safety and accuracy
of needle placement. Injections can be performed using no injectate (dry needling), or can
involve the administration of local anesthetics, botulinum toxin, or corticosteroids, with the
evidence suggesting that most injectates have minimal or no superiority over one another.
A proper history and physical examination of the patient and imaging studies may prove to
be helpful in identifying the correct myofascial pain syndrome and aiding in developing an
appropriate treatment strategy for these very common conditions.

DISCLOSURE
Dr Chadwick receives research funding from the National Institutes of Health, National Institute of General
Medical Sciences, grant # K23GM123320. Dr Chadwick has served as a consultant for Swing Therapeutics.
Author Manuscript

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KEY POINTS
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• Trigger points are localized painful areas of skeletal muscle containing taut
bands that can be exquisitely sensitive to digital pressure.

• Conservative treatment of myofascial pain is recommended; however, if this

fails to relieve pain, then trigger point injections can be considered.

• Trigger point injections should be part of a multidisciplinary treatment

program that includes physical therapy.

• Trigger point injections are commonly done with local anesthetic with or
without corticosteroid, botulinum toxin, or without injectate (dry needling).

• The growing accessibility of imaging, including ultrasound and fluoroscopy,

has improved available options for safe injection technique to myofascial
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trigger points.
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 Appasamy et al. Page 21

CLINICS CARE POINTS

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• A trigger point is the hallmark of myofascial pain syndromes, which may be

treated with physical therapy and trigger point injections.

• Common injectates used for trigger point injections include local anesthetics,
corticosteroids, and botulinum toxins.

• The growing accessibility of ultrasound has improved available options for

imaging guidance for trigger point injections and piriformis muscle injection.

• Ultrasound guidance may be used to improve safety and in the case

of piriformis syndrome has been shown to improve accuracy of needle
placement in the piriformis muscle.

• Outcomes data for trigger point injections have shown analgesic benefit
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with the use of local anesthetics, corticosteroids, and botulinum toxins for
myofascial pain syndromes, with no evidence of superiority of any injectate.

• Outcomes data for piriformis muscle injections have shown that local
anesthetic, steroid, and botulinum toxins are efficacious in reducing pain
and improving symptoms. Botulinum toxins may provide superior analgesia
and may be considered when local anesthetics/steroids are helpful but not
providing long-term relief.
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 Appasamy et al. Page 22
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Fig. 1.
Schematic of the anatomy of a taut band and trigger point.
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 Appasamy et al. Page 23
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Fig. 2.
Fluoroscopic-guided piriformis muscle injection.
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 Appasamy et al. Page 24
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Fig. 3.
(A) Longitudinal US view of the piriformis during needle placement using a medial-to-
lateral approach parallel to the long axis of the transducer. The proximal end of the needle
has been digitally enhanced to highlight the needle trajectory. (B) Postinjection tenogram at
the level of the greater sciatic foramen. Anechoic injectate (FLUID) within the piriformis
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tendon sheath lies superficial and deep to the hyperechoic tendon. RT PIR LG, right side,
piriformis, longitudinal view; TIP, needle tip. (Reproduced with permission from Archives
of Physical Medicine and Rehabilitation, Authors Jay Smith, Mark-Friedrich Hurdle,
Adam J. Locketz, Steven J. Wisniewski. December 2006. Copyright © 2006 American
Congress of Rehabilitation Medicine and the American Academy of Physical Medicine
and Rehabilitation. Published by Elsevier Inc. All rights reserved. (PERMISSIONS HAVE
BEEN OBTAINED BY ALC).)
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Table 1

Outcomes data for trigger point injections with local anesthestic/steroid

Study
Study Author Study Type Size Metrics Study Question Outcomes
Appasamy et al.

Hong CZ et al,63 1994 RCT 58 PS, Cervical Comparing 0.5% lidocaine TPI to dry needling in upper Lidocaine TPI resulted in more immediate soreness than dry
ROM trapezius muscle MPS. needling. However, dry needling resulted in greater intensity
and longer duration of soreness after procedure than lidocaine
TPI

Tschopp KP et al,67 1996 RCT 107 PS Comparing 0.25% bupivacaine to 1.0% lidocaine to No difference in relief between groups so long as needle hits
saline TPI for MPS. muscle belly.

Hameroff SR et al,68 1981 Crossover 15 PS Comparing bupivacaine to etidocaine to saline for TPI Local preferred to saline alone.
double-blind evaluating relief 7 days after injection for MPS.
RCT

Iwama H et al,69 2007 RCT 20 PS Comparing 0.25% to 1.0% lidocaine for TPI for MPS. 0.25% lidocaine had less injection pain and better efficacy
(14 d relief compared to 7 d)

Zaral idou AT et al,70 2009 RCT 68 PS Comparing ropivacaine to levobupivacaine for TPI for No significant differences were found between groups at 2
MPS. wk out.

Garvey TA et al,65 1989 Double-blind 63 NRS Comparing local anesthetic TPI, local anesthetic No difference between types of procedural techniques was
RCT with steroid TPI, acupuncture, and cool spray with noted. Did not matter if medication was injected for
acupuncture for MPS. procedure, both resulted in pain relief.

Kocak AO et al,71 2019 RCT 54 VAS Comparing NSAID and TPI for low back MPS. TPI was superior to NSAIDs when assessed with pain relief
within the first hour of intervention.

Roldan CJ et al,72 2020 RCT 48 NRS Comparing local anesthetic and steroid TPI to saline Resulted in similar change in pain relief in both groups.
TPI in ED patients.

Iwama H et al,73 2001 RCT 21 PS Testing injection pain with dilute local anesthetic in Less pain with dilute local injections. Duration relief in MPS
volunteers as well as using dilute local anesthetic doses patients not affected by using dilute local at low enough
in patients with MPS. doses.

Krishnan SK et al,74 2000 RCT 30 VAS Comparing injection pain of bupivacaine, ropivacaine, Ropivacaine was less painful (alone) compared to
bupivacaine with steroids, ropivacaine with steroids, bupivacaine or either local anesthetic in combination with
and just needle insertion. steroids.

Yoon SH et al,75 2007 RCT 77 VAS, NDI, Comparing needle sizes on injection pain. No difference was noted between sizes of needles used.

Phys Med Rehabil Clin N Am. Author manuscript; available in PMC 2023 May 01.
SF-36

Ga H et al,76 2009 RCT 39 VAS, FACES, Comparing TPI with 0.5% lidocaine with acupuncture No difference between groups.
PPI, GDS-SF for MPS.

Mitidieri AMS et al,77 2020 RCT 35 VAS, NCS, Comparing acupuncture to TPI (local anesthetic) for No difference between outcomes when analyzed at 1 wk, 1
MPQ pelvic pain from abdominal MPS. mo, 3 mo, and 6 mo out except for MPQ differences at 1 wk.

Abbreviations: FACES, Wong-Baker FACES Paine Scale; GDS-SF, Geriatric Depression Scale-Short Form; MPQ, McGill Pain Questionnaire; MPS, myofascial pain syndrome; NCS, Numeric Categorical
Scale; NDI, Neck Disability Index; NPAD, Neck Pain and Disability Scale; NPQ, Neck Pain Questionnaire; NRS, numeric rating score; NSAID, nonsteroid anti-inflammatory drugs; PFDI-20, Pelvic Floor
Distress Inventory - 20; PPI, Pressure Pain Intensity Scores; PS, pain score (internal system); RCT, randomized controlled trial; ROM, range of motion; SF-36, Medical Outcomes Study 36 Item Short Form
Health Survey; TPI, trigger point injection; VAS, visual analog score.
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Table 2

Outcomes data for trigger point injections with botulinum toxin

Study
Study Author Study Type Size Metrics Study Question Outcomes
Appasamy et al.

Wheeler AH et al,78 1998 Double-blind 33 NPAD, PS Comparing 50 U BoNT-A, 100 U BoNT-A, and All 3 groups improved pain. No statistically significant benefit
RCT normal saline TPI for MPS. between injection types.

Qerama E et al,79 2006 Double-blind 30 NRS, PPDT, Comparing BoNT-A TPI to saline TPI for MPS. No difference in pain relief between groups at 28 d, but BoNT-
RCT PPTT A caused decreased EMG activity.

Kwanchuay P et al80 2015 Double-blind 33 VAS, PPT Comparing BoNT-A to saline TPI for MPS. No difference between groups 6 wk out though BoNT-A TPI
RCT resulted statistically significant increase in pain threshold 6
wk out.

Dessie SG et al,81 2019 Double-blind 59 VAS, PFDI-20 Comparing saline or BoNT-A TPI for abdominal No statistically significant difference between groups at 4 and
RCT MPS in pelvic pain for MPS. 12 wk after injection.

Gobel H et al,82 2006 Double-blind 145 PS Comparing BoNT-A to saline TPI for MPS. BoNT-A provided better relief between weeks 5 and 8.
RCT

Kamanli A et al,83 2005 Single-blind 29 PPT, PS, VAS, Comparing BoNT-A TPI to dry needling to TPI in general found to have better benefit than dry needling.
RCT NHP bupivacaine TPI for MPS. Authors noted bupivacaine was best for TPI as it was fast
acting meanwhile BoNT-A TPI should be used in medically
refractory cases.

Ferrante FM et al,84 2005 Double-blind 132 VAS, PPT Comparing saline to 10, 25, or 50 U BoNT-A in up No significant differences occurred between placebo and
RCT to 5 active TrPs for cervicothoracic MPS BoNT-A groups among all outcomes.

Harden RN et al,85 Double-blind 23 PPT, Cervical Comparing BoNT-A 25 U per trigger point (max 4 Participants in the BoNT-A group reported greater reductions
RCT ROM, MPQ, TrPs) to saline TPI for cervical MPS and chronic in headache frequency compared with placebo.
BDI, HSES, tension type headache
STAI, PDI, VAS

Graboski et al,86 Double-blind 18 VAS Comparing BoNT-A 25 U per TrP to 0.5% Both treatments were effective in reducing pain significantly
RCT bupivacaine for MPS but no difference between BoNT-A and bupivacaine groups.

Venancio et al87 2009 Double-blind 45 VAS Comparing dry needling, 0.25% lidocaine, and All groups showed favorable reductions in pain; however, the
RCT BoNT-A for MPS BoNT-A group demonstrated less use of rescue medication,
and less postinjection local sensitivity

Nicol et al,88 2005 Double-blind 114 NRS, SF-36, Comparing BoNT-A to saline TPI for cervical and BoNT-A provided improved pain scores, headaches, and

Phys Med Rehabil Clin N Am. Author manuscript; available in PMC 2023 May 01.
RCT BPI, NDI shoulder girdle MPS physical function parameters compared to saline TPI

Benecke et al,89 2011 Double-blind 154 NRS Comparing BoNT-A to saline TPI for cervical and BoNT-A provided improved pain relief compared to saline at
RCT shoulder MPS 8 wk after TPI

Miller et al,90 2009 Double-blind 47 VAS, MOPQ Comparing BoNT-A to saline TPI for cervical and BoNT-A TPI led to improved pain intensity scores compared
RCT shoulder MPS to saline TPI

BDI, Beck Depression Inventory; BoNT-A, botulinum toxin type A; HSES, Headache Specific Self-Efficacy Scale; MOPQ, Modified Oswestry Pain Questionnaire; MPQ, McGill Pain Questionnaire; MPS,
myofascial pain syndrome; NDI, Neck Disability Index; NHP, Nottingham Health Profile; NRS, numeric rating score; PDI, Pain Disability Index; PPDT, pressure pain detection thresholds; PPT, pressure
pain threshold; PPTT, pressure pain tolerance thresholds; PS, pain score (internal system); RCT, randomized controlled trial; ROM, range of motion; SF-36, Medical Outcomes Study 36 Item Short Form
Health Survey; STAI, State-Trait Anxiety Inventory; TPI, trigger point injection; VAS, visual analog score.
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Table 3

Outcomes data for piriformis injection with local anesthestic ± steroid

Image guidance/
Author/Year Sample Size Methods Additional Treatment Injectate Used Main findings/Outcome Follow-up
Appasamy et al.

Fishman LM et al,93 2002 279 Before-after trial of No image guidance/ Lidocaine and triamcinolone 79% had >50% relief at 10 mo 48 mo
cohort of consecutive received PT/serially
patients identified by reported pain and disability
operational definition assessments

Filler AG et al94 2005 162 239 consecutive MRI Marcaine 15% complete relief, 16% no relief, recurrence 4 mo
patients failed in 69% at 4 mo
treatment of sciatica

Masala S et al,95 2012 23 (cases-13/ Case-control study CT Methyl prednisone and Improvement in VAS at 5–7 d, 2,3,6, and 12 mo 12 mo
control-10) lidocaine

Ozisik PA et al,96 2014 10 Case series CT Depomedrol and Marcaine 9/10 patients had full recovery, no pain or VAS 2y
score of 1–3

Nazlikul H et al,98 2018 102 Prospective No image guidance/ 6 sessions of lidocaine Improvement in VAS and ODI, more None
randomized control stretching exercises (n 5 injections with T11-S2 improvement in the neural therapy group
study 51), injections in neural segmental injections and
therapy group (n 5 51) sacral canal injections

Terlemez et al,99 2019 30 Prospective cohort Ultrasound Lidocaine and betamethasone Improvement in pain score from baseline at 1 1 mo
wk and 1 mo

Rosales J et al,100 2015 49 Prospective Ultrasound Lidocaine + saline + methyl- 73.7% had some relief VAS-pre-8.3/post-2.8, 6 wk
prednisone acetate relief lasted 5.3 wk

Misirlioglu et al,101 2015 50 Prospective double- Ultrasound Lidocaine only vs lidocaine Pain reduction (NRS and LAS scale) from 3 mo
blinded, RCT and betamethasone baseline but no difference between LA vs
steroid group at 1 and 3 mo

Burke CJ et al,102 2019 38 Consecutive patients Ultrasound/hydrodissection LA and steroid 84% immediate relief (pre-4.7/post-0.5), 47% 1 mo
(17-betamethasone, 21- continued relief at 33.6 d
triamcinolone)

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Table 4

Outcomes data for piriformis injection with botulinum toxin

Study (Year) Intervention Results

Porta,103 2000 BoNT-A (dose not reported), 0.5% bupivacaine, BoNT-A and steroid group had no significant differences in pain reduction at 1 mo; however, at 2 mo
Appasamy et al.

methylprednisolone postinjection, there was a significant reduction in the BoNT-A group compared with the steroid group

Lang,106 2004 5000 u BoNT-B Significant reduction in hip and buttock pain at 4, 12, and 16 wk

Fishman et al,107 2004 12,500 u BoNT-B Combined with PT, 88.9% of patients injected had 50% improvement on the VAS

Yoon et al,108 2007 150 u BoNT-A vs 5 mg dexamethasone/1% lidocaine Pain significantly lower in Dysport group at 4, 8, and 12 wk vs baseline P < .0001

Childers et al,109 2002 100 u BoNT-A Significant improvement in pain, spasm, distress, and interference with activities

Fishman et al,110 2002 200 u BoNT-A vs 1.5 mL 2% lidocaine/20 mg 50% improvement at last 2 visits following 20 mg TL vs placebo injection: P = .001; BoNT-A vs TL: P =
triamcinolone, vs placebo .044; BoNT-A vs placebo: P = .001

Fishman et al,111 2017 300 u BoNT-A vs saline VAS score decreased significantly at 2,4,6,8,10, and 12 wk compared with placebo

Rodriguez-Pinero et al,112 2018 100 U BoNT-A VAS scores and quality of life scores statistically significantly reduced at 1 and 6 mo after injection

Yan,113 2021 100 u BoNT-A/1% lidocaine/0.5% bupivacaine vs 1% Median pain-free days were 30 d for the BoNT-A group and 1 d for the non–BoNT-A group
lidocaine/0.5% bupivacaine/4 mg dexamethasone

Dr Chadwick has served as a consultant for Swing Therapeutics and receives research funding from the National Institutes of Health, National Institute of General Medical Sciences, Grant #
K23GM123320.

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