A trigger point is a discrete, exquisitely tender spot in a taut band of muscle. Injecting it is one of the simplest procedures in pain practice and one of the most commonly performed — and it is also the injection where the usual assumption about what is being injected turns out to be wrong.
The injection that does not contain steroid
Gisele J. Girault, MD uses steroid for most of the injections she performs. Trigger points are the stated exception: “I use steroids for most of my injections, with the exception of trigger point injections.”
The reasoning follows from what a trigger point is. This is not an inflamed joint or an inflamed bursa. It is a contracted, ischaemic band of muscle, and the aim is to interrupt that contraction rather than to suppress inflammation that is not the problem.
So a trigger point injection is typically local anaesthetic alone — and in some cases nothing at all.
Dry needling: the injection with no injectate
If local anaesthetic is not essential, the logical question is whether anything needs to be injected. Often it does not.
Girault performs dry needling as part of her practice, describing it as “going in to the trigger point and not injecting anything.” She uses a 30 gauge, half-inch needle, and notes that acupuncture needles serve the same purpose, as many practitioners use them.
The implication is that a meaningful part of the therapeutic effect comes from mechanical disruption of the taut band by the needle itself, not from a drug. That reframes the procedure usefully: the needle is the treatment, and anything injected is an adjunct.
Finding trigger points: the patient usually knows
Localisation is by examination, and the most reliable instrument is the patient.
Girault's observation is that trigger points are “very sensitive to pressure” and that “most patients can identify their trigger points very specifically.” Asked to point, they point — usually with one finger, to the same spot every time.
On palpation the target is a taut band within the muscle with a discrete tender nodule, reproducing the patient's recognised pain on pressure. The combination of a patient who can localise it and an examiner who can feel it is what confirms the diagnosis. There is no imaging test for this.
What else works, and why that matters
Girault lists several treatments that help trigger points: massage, acupuncture, local anaesthetic injection and dry needling.
That list is worth taking seriously rather than treating as a preamble to the injection. If massage and acupuncture work, the injection is one option among several rather than the definitive treatment — and a patient who improves with manual therapy has been spared a needle.
It also sets expectations properly. A treatment that shares its effect with massage is not a treatment that should be sold as a cure.
Where trigger points are treated, and where to be cautious
Trigger points occur throughout the skeletal musculature, and the ones that bring patients in most often are in the neck, upper back and shoulder girdle.
Head and facial trigger points exist and can be confused with migraine or other headache and facial pain syndromes — but Girault is notably restrained about treating them: “I tend not to do a lot of trigger points in the head.”
That restraint is the point. A trigger point that mimics migraine is a diagnostic trap in both directions, and injecting it does not establish which condition the patient has.
Coding: two codes, decided by muscle count
Trigger point injections are coded by the number of muscles treated, not the number of injections given.
- 20552 — one or two muscles
- 20553 — three or more muscles
Girault emphasises that the documentation must support the code — which muscles were treated needs to be recorded, since that is the variable the code turns on.
Her standing caveat applies: these are the codes she uses in South Carolina, and codes “differ from state to state and sometimes from area to area.” The CMS Physician Fee Schedule Lookup Tool is her recommended reference, since many commercial insurers follow Medicare's lead.
What to expect afterwards
Soreness at the injected muscle for a day or two is usual — a needle has been passed repeatedly through contracted muscle.
Because steroid is generally not used, the classic steroid flare Girault describes after joint injection — increased pain over 24 to 48 hours in roughly one in ten injections — is less of a consideration here. Post-injection soreness is mechanical rather than pharmacological.
Gentle movement and stretching of the treated muscle is usually encouraged rather than rest, since the underlying problem is a muscle that has stopped lengthening properly.
The honest limitation
Trigger point injection treats a symptom in a muscle. It does not address why the muscle is behaving that way.
A trigger point in the trapezius of someone with cervical facet arthropathy, poor workstation ergonomics or an unrehabilitated shoulder will recur, because the driver is untreated. Repeated injections to the same point without asking that question is not a treatment plan.
The reasonable framing is that trigger point injection creates a window of reduced pain and improved movement in which the underlying problem can be addressed — which is the same logic that applies across interventional pain practice, and is set out in the joint and extremity injection reference.
Learn blocks with your hands, not from a page
Empire’s Pain Management Training (THE Pain Show) is accredited for 25.25 AMA PRA Category 1 Credits™, jointly provided by AKH, Inc, and Empire Medical Training. For narrower peripheral work, Joint, Extremity and Non-Spinal Injection Training carries 6.75 credits for the complete in-person hybrid program, and Advanced Musculoskeletal Ultrasound Guided Injections builds the guidance skills above.
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