Have we missed the point? Myofascial trigger points, dry needling and a case for a bidirectional reframe

OBJECTIVES: Myofascial trigger points (MTrPs) have long been framed as local tissue abnormalities that initiate peripheral nociceptive input through a predominantly bottom-up cascade. This clinical commentary proposes a bidirectional, patient-centered lens for interpreting myofascial sensitivity that extends beyond isolated tissue pathology without ignoring its clinical relevance. METHODS: A narrative review and clinical commentary synthesizing contemporary pain neuroscience, myofascial literature, and mechanism-based clinical reasoning frameworks was conducted to examine how provocative palpation findings may be reinterpreted through a bidirectional neurophysiologic lens. RESULTS: While biochemical, electrophysiological, vascular, and imaging studies suggest regionally distinct tissue characteristics in areas identified as MTrPs, it remains unclear whether these represent stable local phenomena or transient, state-dependent expressions of nervous system modulation. Clinically, provocative palpation findings frequently occur in conditions where muscle is unlikely to be the primary nociceptive driver, supporting interpretation as secondary hyperalgesia within a sensitized system. DISCUSSION: Rather than viewing MTrPs as the initiating source of nociception, provocative palpation is conceptualized as a fluctuating clinical signal shaped by interacting peripheral, spinal, supraspinal, and contextual influences. Emphasizing pain phenotyping and neurophysiologically guided clinical reasoning over lesion identification may better align myofascial constructs and related interventions, including dry needling, with contemporary pain neurophysiology and support more precise, adaptable clinical management.