Can You Treat Myofascial Trigger Points with Botulinum Toxin?

Myofascial pain syndrome (MPS) is a common chronic pain condition. You can traditionally manage it with physical therapy, massage, ice packs, and non-steroidal anti-inflammatory drugs (NSAIDs). But can botulinum toxin injections also help? Turns out it can—it has been shown effective by large-scale clinical trials in reducing the pain associated with MPS. 

Let’s look at the therapeutic potential of BOTOX® for treating myofascial trigger points and the technical and safety considerations for its use.

Key Takeaways 

• Myofascial trigger points are commonly found in the neck, shoulders, trapezius muscle, and pelvic floor muscles.
• Research suggests botulinum toxin can help with specific MPS regions, such as piriformis syndrome.
• Botulinum toxin can also help with MPS refractory to classic treatments.
• Relief from botulinum injections lasts for about 3-4 months.
• Botulinum toxin is not FDA-approved for use in MPS. However, it is FDA-approved for pain relief in similar neurological conditions. 
• Reported side effects of botulinum toxin MPS treatment include transient muscle pain and weakness, itching, flu-like symptoms, and headache. 

Myofascial Pain Syndrome and Its Causes

MPS is characterized by tender points within muscles called myofascial trigger points. These trigger points cause pain locally or in seemingly unrelated areas (referred pain).

Common trigger point locations include:

• Neck: Myofascial trigger points in the neck restrict movement and contribute to headaches or pain in the head and shoulders.
• Shoulder: Myofascial trigger points in the shoulder muscles, such as the deltoids or rotator cuff muscles, cause shoulder pain, limited range of motion, and difficulty performing overhead activities.
• Trapezius: The trapezius muscle is prone to developing trigger points due to poor posture, stress, or overuse. Myofascial trigger points in the trapezius muscle lead to pain and tension in the neck, shoulders, and upper back.
• Pelvic floor: Myofascial trigger points in the pelvic floor muscles cause pelvic pain, discomfort, and dysfunction. They also cause urinary urgency, frequency, or pain during intercourse.

The exact myofascial trigger points causes remain unclear. However, several factors, such as repetitive muscle usage, microscopic tears, lactate build-up in the muscles, and abnormal nerve signaling contribute to trigger point formation. 

Can Botulinum Toxin Be Used for MPS Trigger Points?

Yes, botulinum can be used for trigger points. Botulinum toxin type A brands are commonly known for their cosmetic applications, but clinical studies have also shown their efficacy in treating MPS.

For example, German researchers investigated the effectiveness of DYSPORT®, a type of botulinum toxin, in relieving muscle pain in the upper back of patients with MPS.

They conducted a 12-week study involving patients with moderate-to-severe pain affecting cervical and/or shoulder muscles, with ten trigger points and a disease duration of 6-24 months.

Patients were randomly assigned to receive DYSPORT® injections or a saline placebo. Each patient received injections into their ten most tender trigger points, with 40 units of DYSPORT® per site. The primary outcome measured was the proportion of patients reporting mild or no pain at week five.

Results showed that at week five, 51% of patients in the DYSPORT® group reported mild or no pain, compared to 26% in the placebo group. This difference was statistically significant.

What’s more, DYSPORT® led to a significantly greater reduction in pain intensity between weeks 5-8 compared to placebo. Patients who received DYSPORT® also experienced significantly fewer days per week with pain between weeks 5 and 12. The treatment was well-tolerated, with most side effects resolving within 8 weeks.

But at the same time, we have some studies that don’t support the efficacy of botulinum toxin for treating MPS. 

For example, a review published in the Cochrane Database of Systematic Reviews looked at 233 participants from four studies on botulinum toxin and MPS. Researchers concluded that “there is inconclusive evidence to support the use of botulinum toxin in the treatment of MPS based on data from the four studies”.

Similarly, a content analysis published by Spanish researchers concluded that the mixed results about whether botulinum toxin A is effective for MPS linked to neck and back pain mean we can’t confidently say if this treatment should be used or not. However, it did point out that botulinum toxin may be helpful for specific MPS regions—such as piriformis syndrome—or MPS cases refractory to first-line treatments.

The bottom line is that BOTOX® injections for trigger points may help, but they may not work for all patients. This is why it’s best to use them with other treatments, such as physical therapy, ice packs, and NSAIDs.

How Does Botulinum Toxin Treat Myofascial Pain Syndrome?

Botulinum toxin type A disrupts the communication between nerves and muscles by blocking the release of acetylcholine (ACh). Blockage of ACh release at the neuromuscular junction weakens the muscle and reduces its ability to contract. 

This interrupts the pain cycle and reduces the production of pro-inflammatory substances. BOTOX® also reduces pain perception by modulating the activity of pain-sensitive nerves, providing relief for three to four months. How often to get BOTOX® depends on individual patient characteristics. 

Is It Safe to Use Botulinum Toxin for Myofascial Pain Syndrome?

BOTOX® for myofascial trigger points is not approved by the US Food and Drug Administration (FDA). It, however, is approved for pain reduction in neurological disorders like cervical dystonia and strabismus. Talking about side effects, the consensus seems to be that botulinum toxin may cause mild side effects if used properly and more severe complications if administered using a poor technique.

For example, in a 2020 systematic review on the use of botulinum toxin for upper back MPS, the most common side effects were transient muscle pain and weakness that resolved spontaneously. Researchers did not report significant side effects, such as arrhythmia, autonomic dysreflexia, and skin rash.

At the same time, botulinum toxin injection has been associated with itching, headache, dry mouth, and flu-like symptoms in some studies. Researchers attribute these effects to improper muscle targeting, which leads to the escape of the toxin into surrounding anatomical structures.

Administration of Botulinum for Myofascial Trigger Points

The injection technique for botulinum toxin is as follows: 

1. Locate myofascial trigger points through palpation or by observing referred pain patterns.
2. Using a skin marker, mark the points where the injections will be administered. These points are usually within or around the palpable taut bands associated with the trigger points.
3. Reconstitute the BOTOX® as per manufacturer instructions. Use a sterile syringe and a fine gauge needle for drawing up the BOTOX® solution.
4. Insert the needle into the marked trigger point area at a 90-degree angle to the skin. Inject BOTOX® solution into each trigger point. Slowly inject the solution while withdrawing the needle to distribute it evenly within the muscle. Keep in mind that low doses (5-10 IU) may not be effective.
5. Repeat the injection process for each identified trigger point. Some studies have also found that multiple injections in the same region may lead to better pain control than a single injection.
6. Apply gentle pressure to the injection sites to minimize bruising or bleeding. Advise the patient to avoid strenuous activity for the next 24 hours and to refrain from rubbing or massaging the treated area.

Patients may experience temporary bruising, swelling, or discomfort at the injection site, so it’s important to discuss these side effects before the procedure.

Which Muscles Should Be Avoided During Botulinum Toxin Treatment for Myofascial Trigger Points?

Here are four areas that are best avoided when using BOTOX® for trigger points:

• Respiratory muscles: Stay clear of muscles involved in breathing, such as the diaphragm and intercostal muscles. Injecting botulinum toxin into these muscles can lead to breathing difficulties or respiratory compromise.
• Muscles near vital structures: Avoid injecting near major blood vessels or nerves to prevent vascular compromise or nerve damage.
• Muscles responsible for swallowing and speaking: Injecting botulinum toxin into muscles involved in these functions may produce dysphagia, dysphonia, or difficulties in facial expression.
• Large muscle groups: Avoid injecting botulinum toxin into large muscle groups that may affect significant function or mobility. Target smaller, specific muscles associated with myofascial trigger points to minimize the risk of widespread effects.

Conclusion

Studies show that botulinum toxin can help your patients with MPS. However, there are also studies that don’t support (or even advise against) its use in MPS. This means it’s best to use this treatment modality cautiously and combine it with more traditional treatments for MPS.

It’s also important to source botulinum toxin from a reliable supplier to keep your patients safe and pain-free. If you’re looking for such a supplier, contact Doctor Medica today. Our sales team will help you source a range of botulinum toxin products at wholesale prices.

FAQ

Is BOTOX® Approved for Myofascial Pain?

BOTOX® injections for myofascial pain are not FDA-approved. However, they have been approved to reduce pain in similar neurological conditions, such as cervical dystonia, temporomandibular joint dysfunction, strabismus, blepharospasm, and hemifacial spasm. 

How Long Do BOTOX® Trigger Point Injections Last?

BOTOX® trigger point injections usually last for about three months. 

Does BOTOX® Damage Muscles Over Time?

Limited usage of BOTOX® is safe and well-tolerated. However, injecting a significantly high amount of botulinum toxin A has been reported to decrease the function of skeletal muscles and cause harm to both fibrillar and non-fibrillar structures within the muscle.

Can BOTOX® Remove Muscle Knots?

Muscle knots are essentially abnormally contracted points that cause pain and discomfort. BOTOX® relaxes and removes these knots to help restore the normal state of the muscle. 

References

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