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Fibromyalgia Basics

Muscle Pain Relief

Almost all fibromyalgia patients are aware of knot-like areas of exquisite tenderness in their tight, ropy muscles. Pressing on these knots hurts and radiates pain elsewhere. Most of these areas were the tender points used for diagnosing fibromyalgia until 2011. Today, these nodules are known to be myofascial trigger points (MTPs) and they may be what is driving your pain through the roof.

Wonder why your doctor has never mentioned them or suggested that they be treated? It is because doctors no longer have to exam fibromyalgia patients for the presence of sore areas in the muscles (what used to be called tender points).  As a result, doctors are not being trained to look for MTPs or how to treat them, but this does not mean they don’t exist.

Understanding MTPs, learning how to find them, and getting these pain-generators treated can offer significant relief of your symptoms. That is why this section of the website is devoted to educating you about MTPs. Otherwise, your MTPs might be overlooked. 

The average fibromyalgia patient has about a dozen MTPs, and each one represents a treatment opportunity.1 If you are curious about what is going on inside these painful nodules and why they hurt so much, learn more.

Researchers can image MTPs, so they are every bit as real as they are painful. MTPs are abnormal areas of densely compacted muscle fibers. These regions are in a sustained contraction, making your muscles feel tight. Blood flow to the area is also greatly reduced. In addition, MTPs are reservoirs of nasty chemicals that irritate nearby nerve endings to cause pain. When the MTP is treated, the muscle relaxes and releases the chemical contents.

MTPs continuously feed your central nervous system with noxious “pain alarms” and medications do not shut these neurological signals down. It’s important to understand  how and why MTPs develop, and you also need to learn ways to minimize their reoccurrence. For an article addressing these issues, read more.

Even if you didn’t know about the role that MTPs play in sustaining your fibromyalgia pain and muscle stiffness, you have probably wondered about these exquisitely sore areas. Research shows that treating just one MTP can lead to a significant reduction in body-wide pain.2 And just think: you probably have lots of them!

The goal should be to eliminate your most bothersome MTPs first, which are often in the upper shoulders, back of the neck, and lower back region. A variety of techniques can be used. Some of the most common methods are described below along with a summary box on the pros and cons of each.

Manual Therapies: Trigger-point focused therapies are often done by a physical therapist (PT) with special training in this area. The therapist may use a tiny needle to poke the area above trigger points to break them up (it’s called dry needling). PTs can perform dry needling in all states except California, Oregon, New York, and Hawaii. In these four states, dry needling can be done by an acupuncturist who specifically treats MTPs (standard acupuncture points are not the same).

Physical therapists use a variety of techniques to relieve MTP pain, in addition to drying needling. The approaches used will depend upon how many MTPs you have and where they are located. For example, the therapist may apply pressure to the MTP nodule while very carefully stretching the muscle, or they may use a coolant spray that numbs the painful area (see below). When seeking out a PT for your care, make sure that they are willing to teach you a home program for addressing MTPs. 

Other providers who may offer MTP-focused manual therapies are massage therapists, osteopaths, and chiropractors. An M.D. whose focus is treating myofascial pain is also a great option, but there are very few of these specialists. Regardless of the type of provider, all of them should help you with lifestyle adjustments to minimize the development and reoccurrence of MTPs.

Stretch with Heat/Coolant: Muscles with trigger points cannot just be stretched because they will recoil and produce more trigger points. Application of heat relaxes the muscle so they can be gently stretched (never stretch to the point of pain). Coolant topicals work as an anesthetic to enable a light stretch of the muscle as well. Both techniques can often ease muscle tightness and pain.

Ideally, you want to seek the care of a physical therapist to perform this technique. If you respond favorably, ask the therapist if they can teach you how to do some of the stretches at home. Follow-up appointments for hard-to-reach areas and stubborn MTPs will still require a trained specialist.

Trigger Point Injections: A needle with anesthetic (such a lidocaine) is injected into the eye of the trigger point to force it to release the knotted contraction. The procedure should be followed by a gentle massage of the area and then on/off application of a cold pack to reduce initial pain. This technique is reserved for stubborn trigger points (i.e., maybe one or two) and is done by a physician.

Unlike the tiny needles used for dry needling, syringes are larger and cause more trauma to the injected area. This leads to post-injection soreness, which limits the  technique to one or two muscles. Conversely, lidocaine patches worn around-the-clock may be an alternative for patients who experienced serious post-injection soreness.

If you are wondering which is more effective for fibromyalgia, trigger point injections or lidocaine patches, and how accurate the injection must be to work, read more.

Low-Level Laser Therapy (LLLT): A focused beam of light in the infrared frequency range is emitted during LLLT to aid the cellular processes beneath the surface. Theoretically, it improves blood flow, increases energy distribution to the tissues, and reduces chemical waste products that irritate nerve endings. Most trials of this nondrug therapy involve applying the LLLT probe for 1-3 minutes to each painful area (usually areas where patients have sore muscle nodules or myofascial trigger points).3,4

The fibromyalgia studies vary in the number and frequency of treatments. Some trials  performed LLLT daily (except weekends) for two weeks, while others gave treatments three times per week for 3-8 weeks. Significant improvements were obtained for overall pain levels, number of pain sites, fatigue, physical function, and morning stiffness. The percentage of fibromyalgia patients responding is unclear, but more intense sessions applied to the MTPs provided the best results.

The downside of LLLT is cost, but the upside is lack of side effects. Physical therapists and chiropractors may offer this therapy in the United States, and insurance coverage may be minimal. Also, if you are tempted to try the inexpensive devices advertised on the Internet, don’t waste your money. The effective machines cost $20,000 to $40,000.

Topical Ointments & Patches: Topicals that contain lidocaine or aspirin may help soothe sore muscles. Menthol is another analgesic. Although you may not like the odor, it initially provides a cool feeling, followed by warmth to relax the muscles. The most cost-effective topical is Bengay Ultra Strength with 30% aspirin and 10% menthol at $1.30 per ounce.

Lidocaine-containing patches are available in two common strengths: 5% and 4%. The 5 % patches are only available with a doctor’s prescription (they go by the brand name, Lidoderm but generally you will get the generic). Most health insurance companies cover the generic version of Lidoderm, but they may charge you a high co-pay and require the hassle of pre-authorization. Conversely, you can bypass your insurance company and use a pharmacy coupon program (such as The Good Rx …  30 patches for $70).

The patches that are 4% lidocaine are available over the counter and cost anywhere between $1.20 to $2 per patch. You can purchase a pack of 5-10 to see if they help before paying more money for larger quantities.

Topicals may be used in conjunction with any type of MTP therapy to enhance the effects and reduce post-treatment soreness that may arise. In addition, if you are interested in learning self-help application of pressure to relieve MTPs (see articles below), these ointments come in handy.

Ways to Improve Results: Heat wraps and warm water help relax muscles, improve circulation, and reduce the impact of MTPs. Use heat before and after therapy sessions. Alternate with ice after trigger point injections with a syringe. A gentle massage of the area after treatment and drinking lots of water will help flush out the chemicals from the MTPs so they don’t irritate the nearby nerve endings. Minimize over-straining muscles that have been treated; they need time to recover.

Do It Yourself MTP Relief: Treating your MTPs is essential for getting your fibromyalgia pain under control. Even if your town has skilled experts in this area, relying solely upon a therapist is costly and time-consuming. The best approach is to know how to treat most MTPs yourself and rely upon your healthcare providers to handle the stubborn ones.

Identifying & Treating MTPs is a must-read article for all fibromyalgia patients. It will teach you what to look for when you self-examine your muscles for MTPs and then how to apply self-help techniques to treat them.

Check back for links to the following articles offering “how-to” help with diagrams on treating MTPs in specific body regions:

  • Headaches & Neck Pain Caused by MTPs
  • Painful MTPs in the Chest & Abdominal Regions
  • Pelvic Pain & MTPs
  • Low Back Pain
  • Pain Around the Hips & Buttocks
  • Treating Heel & Calf Pain

A series of self-help articles have been prepared for fibromyalgia patients with the guidance of Ken Lamm, P.T., an experienced physical therapist in Tucson, Arizona. Check back for article postings.

1. Ge HY, et al. J Pain 11(7):644-51, 2010.
2. Affaitati G, at al. Eur J Pain 15:61-9, 2011.
3. Gur A, et al. Rheumatol Int 22(5):188-93, 2002.
4. Yeh SW, at al. Pain Physician 22:241-254, 2019.