Five Years of Facial Twitching — Resolved After One Trapezius Injection

By Jacques Courseault, MD, CAQSM, FAAPMR · The Fascia Institute and Treatment Center®  |  De-identified case report published with patient and guardian permission.

01 · The Presentation

A 16-year-old male presented with a five-year history of involuntary twitching on the right side of his face. The movement was intermittent, non-rhythmic, and centered over the right cheek and jaw — the region of the right masseter. It worsened with stress, fatigue, and long stretches of schoolwork. There was no facial weakness, no numbness, no hearing change, no headache, and no history of head trauma, facial palsy, or dental surgery.

The clinical history that mattered most, though, was not neurological. It was social. He had been teased about the twitching since middle school. He had stopped raising his hand in class. He kept his right hand near his jaw in photographs. His mother described a child who had gradually gone quiet.

Five years is a long time in a teenager’s life. By the time he reached our clinic, the twitch itself was almost the smaller problem.

On examination, he carried his right shoulder high, with a visibly guarded, elevated right upper trapezius. Palpation of the right upper trapezius and right cervical paraspinals reproduced a deep, dense, ropey resistance that did not match the other side. Cranial nerve examination was normal. There was no vermicular, wavelike rippling to suggest true facial myokymia, and no suppressible, semi-purposeful quality to suggest a tic.

02 · The Prior Workup

Over five years he had been worked up appropriately and thoroughly:

· Brain MRI — negative. No mass, no demyelinating lesion, no evidence of neurovascular conflict at the cerebellopontine angle.
· EEG — negative. No epileptiform discharges; a focal motor seizure was excluded.
· No diagnosis reached. He was told the imaging was reassuring and that the movement would likely be outgrown.
· No treatment offered beyond observation.

This is a familiar and reasonable pathway. In classic hemifacial spasm, MRI is the study of choice precisely because it looks for a structural lesion or vascular loop compressing the facial nerve, and EEG is used to exclude a seizure focus (Jesuthasan et al., 2025). Both tests did their job. Both were correctly negative.

But neither test images fascia. MRI protocols for facial spasm are built to interrogate the brainstem and the cerebellopontine angle. EEG interrogates cortical electrical activity. Neither one is designed to detect a densified, mechanically loaded fascial plane in the neck and shoulder. When both come back clean, the differential too often ends rather than widens. What we eventually found sat entirely outside the field of view of both studies — see Figure 1.

03 · What Fascial Mapping Showed

Figure 1. The fascial chain identified on mapping: right upper trapezius → right cervical paraspinals → masseteric fascia. The injection site (blue marker) is at the trapezius — not the face. Schematic; not to anatomical scale.

We performed ultrasound fascial mapping — a dynamic, high-resolution survey of the fascial layers, glide planes, and densification patterns across the involved region. Unlike MRI, it is performed with the patient moving, and it images the connective tissue itself rather than the structures MRI is optimized for.

Mapping identified marked fascial densification and loss of glide in the right upper trapezius and the right cervical paraspinals. Critically, the abnormality was not an isolated spot. It formed a continuous taut line that could be traced superiorly along the cervical fascial plane and followed into the fascia overlying the right masseter — the precise muscle that was twitching. The left side was unremarkable. Figure 1 shows that line as it was mapped: the hatched band marks where densification and loss of glide were found, and the blue tracing follows it from the trapezius to the jaw.

There is supporting literature for a functional cervical–masticatory relationship. Active myofascial trigger points in the upper trapezius are associated with measurable changes in the electromyographic activity of the ipsilateral masseter and anterior temporalis (Zieliński et al., 2021). A published case report has described chronic craniofacial and cervicobrachial pain resolving after treatment directed at densified points along the deep cervical fascial continuum (Prabu Raja et al., 2020). And fascial hydrodissection has been reported to resolve craniocervical neurologic symptoms in cases where conventional workup was unrevealing (Kaga, 2022).

What that literature describes as pain, this patient expressed as motor irritability. The working hypothesis was that sustained abnormal tension along the right cervical fascial chain was the driver, and that the face was the downstream symptom, not the source.

04 · The Intervention

Treatment was a single Hydrofascia Release™ (HFR-A) procedure, performed under direct ultrasound guidance, targeting only the densified fascial planes of the right upper trapezius. Fluid was used to separate and rehydrate the adherent layers, restoring glide between planes that had lost the ability to slide on one another. The marker at the lower end of the chain in Figure 1 is the only place a needle entered.

05 · The Outcome

The twitching resolved immediately following the injection, before the patient left the treatment room. Palpable densification in the right upper trapezius and cervical paraspinals softened, and the taut line into the masseteric fascia was no longer reproducible on repeat scan.

At scheduled follow-up, he remained symptom-free at six months with no recurrence, no additional injections, and no medication. No further procedures have been required. He needed no botulinum toxin, no anticonvulsant, and no surgical consultation.

The clinical measure that mattered to this family was not on any scale we use. He started raising his hand in class again. He stopped covering his jaw in photographs.

Five years of being made fun of ended in a single office visit — because the problem was finally looked for in the right tissue.

06 · Discussion

07 · Limitations

We publish this because it is instructive, not because it is definitive. It should be read with clear limits:

· This is a single patient. There is no control group, no blinding, and no comparison arm.
· Immediate resolution after a procedure cannot fully separate treatment effect from expectation and procedural placebo, though a five-year symptom duration and six-month durability make coincidence less likely.
· The mechanism is a hypothesis. Fascial continuity between trapezius and masseter is anatomically established; that densification along that chain caused this patient’s twitching is inferred, not demonstrated.
· Facial twitching has many causes. Structural and neurologic evaluation should come first, exactly as it did here.
· Individual results vary. Not every patient with facial twitching has a fascial driver, and not every fascial driver resolves in one session.

What the case does establish is worth stating plainly: a fascial evaluation was the only remaining step that had not been taken, and it was the one that changed the outcome. For patients told their imaging is clean and nothing more can be done, that step is worth taking earlier than five years in.

08 · Who Should Be Evaluated

Ultrasound fascial mapping is worth considering when a patient presents with any of the following:

· Persistent facial twitching, jaw tension, or eyelid twitching with a negative MRI and EEG
· Symptoms that are unilateral and track with a stiff, elevated, or guarded shoulder on the same side
· Twitching or jaw pain that clearly worsens with stress, posture, or screen time
· TMJ-type symptoms that have not responded to dental splints or bite therapy
· Chronic neck, shoulder, or craniofacial complaints where no structural cause has been identified
· Any patient who has been told “everything looks normal” and offered nothing further

Red-flag features — facial weakness, hearing loss, progressive spread, sudden onset, or associated neurologic deficit — warrant neurologic and imaging evaluation first. Fascial assessment complements that workup; it does not replace it.

References

Jesuthasan, A., Natalwala, A., Davagnanam, I., et al. (2025). Hemifacial spasm: an update on pathophysiology, investigations and management. Journal of Neurology, 272, 502. doi.org/10.1007/s00415-025-13220-y

Prabu Raja, G., Fernandes, S., Cruz, A. M., & Prabhu, A. (2020). The plausible role of deep cervical fascia and its continuum in chronic craniofacial and cervicobrachial pain: A case report. Heliyon, 6(7), e04560. PMID: 32760842

Zieliński, G., Byś, A., Szkutnik, J., Majcher, P., & Ginszt, M. (2021). Electromyographic patterns of masticatory muscles in relation to active myofascial trigger points of the upper trapezius and temporomandibular disorders. Diagnostics, 11(4), 580. doi.org/10.3390/diagnostics11040580

Kaga, M. (2022). First case of occipital neuralgia treated by fascial hydrodissection. American Journal of Case Reports, 23, e936475. PMID: 35578561

Anatomy, head and neck, deep cervical neck fascia. (2024). StatPearls. StatPearls Publishing. NBK541091

This case report is provided for educational purposes and is not medical advice. It describes the experience of a single de-identified patient, published with patient and guardian permission. Individual results vary, and outcomes described here should not be expected in every case. Facial twitching requires appropriate neurologic evaluation. Please consult a qualified physician regarding your own symptoms. Hydrofascia Release™ and The Fascia Institute and Treatment Center® are marks of The Fascia Institute and Treatment Center.