Understanding Myofascial Pain

Robert Bennett MD

It has been estimated that some 44 million Americans have myofascial pain problems (1). A study from an internal medicine roup practice found that !"# of patients $ith pain complaints had active myofascial tri er points (%). A report from a clinic speciali&in in head and nec' pain reported a myofascial etiolo y in ((# of cases (!). )atients evaluated in one pain mana ement center $ere found to have a myofascial component to their pain in *(# of cases (4). +here is increasin a$areness that active myofascial tri er points often play a role in the symptoms of patients $ith tension headaches ((), lo$ bac' pain, nec' pain (-), temporomandibular pain (.), forearm and hand pain (/), postural pain (*), pelvic0uro enital pain syndromes.

In interpretin the results of prevalence studies, it is important to distin uish bet$een active myofascial tri er points and latent myofascial tri er points. 1atent myofascial tri er points are defined as tender areas in muscle, in association $ith the other clinical features of the tri er point (see table 1), in the absence of associated pain syndrome. Active myofascial tri er points are associated $ith a pain syndrome that is reproduced by firm palpation of the tri er area.

2or instance, 3ola found latent tri er points in the shoulder irdle muscles of (4# of female and 4(# of male sub4ects $ho $ere completely asymptomatic (1").

+here have been no prevalence studies of myofascial pain syndromes in the conte5t of rheumatolo y practice, but it is the author6s e5perience that myofascial pain problems are often undia nosed 0 untreated components of pain in osteoarthritis, rheumatoid arthritis, systemic lupus and other common rheumatic disorders.

Dia nosis

+he clinical dia nosis of myofascial pain is critically dependent on your doctor bein a$are of this dia nosis as a possible cause for some of your pain (11). Myofascial pain syndromes may mimic a lar e number of other disorders, thus there is a necessity to perform a thorou h physical e5amination, $ith appropriate investi ations. Myofascial pain characteristically presents as a dull deep achin sensation $hich is a ravated by use of the involved muscles as $ell as psycholo ical stressors that cause increased muscle tension (1%). +he definin clinical characteristic of myofascial pain is the findin of a tri er point. +his is a $ell7defined point of focal tenderness $ithin a muscle. 3ometimes firm palpation of this focus elicits pain in a referred distribution that reproduces the patient8s symptoms. Importantly, referred pain from a tri er point does not follo$ a nerve root distribution (i.e. it is not dermatomal). )alpation usually reveals a ropeli'e induration of the associated muscle fibers, often referred to as the 9taut band:. 3ometimes, snappin this band or needlin the tri er point produces a locali&ed t$itch response of the involved muscle. +his t$itch response can only be reproducibly elicited in fairly superficial muscles.

Myofascial pain often results from muscle in4ury or repetitive strain. In the current medical climate, especially in ;nited 3tates, a $hole array of often e5pensive investi ations have usually been underta'en before the possibility of a myofascial pain dia nosis is considered. 3ome patients, $ho already have a $ell7defined cause for their musculos'eletal pain (e. . rheumatoid arthritis), may develop a myofascial pain syndrome that oes unreco ni&ed, as it is assumed that all their pain emanates from their primary dia nosis. Myofascial pain has certain clinical characteristics that aid in considerin this dia nosis. +he pain is typically described as a deep achin sensation, often $ith a feelin of stiffness in the involved area< this is sometimes described in terms of 4oint stiffness. Myofascial pain is a ravated by use of the involved muscle(s), psycholo ical stressors, an5iety, cold and postural imbalance. Radiation from a tri er point may be described in terms of paresthesiae and thus mimic the symptoms of a cervical or lumbar radiculopathy. Muscle $ea'ness secondary to disuse may present $ith symptoms $ea'ness, poor coordination, reduced $or' tolerance, fati ue and sleep disturbance. )atients $ith myofascial pain involvin the nec' and face muscles may e5perience symptoms of di&&iness, tinnitus and poor balance.

+he characteristic features of a myofascial tri

er point=

1. 2ocal point of tenderness to palpation of the involved muscle

%. Reproduction of pain complaint by tri

er point palpation (about ! ' pressure)

!. )alpation reveals an induration of the ad4acent muscle (the 9tau ht band:)

4. Restricted ran e of movement in the involved muscle

(. >ften pseudo7$ea'ness of the involved muscle (no atrophy)

-. >ften referred pain on continued (?( secs) pressure over tri

er point.

@ommon 3ymptoms of Myofascial )ain

A myofascial pain syndrome may be due to 4ust one tri er point, but more commonly there are several tri er points responsible for any iven re ional pain problem. It is not

uncommon for the problem to be initiated $ith a sin le tri er point $ith the subseAuent development of satellite tri er points that evolve over time due to the mechanical imbalance resultin from reduced ran e of movement and pseudo7$ea'ness. +he persistence of a tri er point may lead to neuroplastic chan es at the level of the dorsal horn $hich results in amplification of the pain sensation (i.e. central sensiti&ation) $ith a tendency to spread beyond its ori inal boundaries (i.e. e5pansion of receptive fields) (1!). In some instances se mental central sensiti&ation leads to the phenomena of mirror ima e pain (i.e. pain on the opposite side of the body in the same se mental distribution) and in other instances a pro ressive spread of se mental central sensiti&ation ives rise to the $idespread pain that characteri&es fibromyal ia (14).

1o$ bac' pain

Acute lo$ bac' pain has many causes. 3ome are potentially serious, such as cancer metastases, osteomyelitis, massive dis' herniations (e. . cauda eAuina syndrome), vertebral fractures, pancreatic cancer and aortic aneurysms. Bo$ever the commonest cause of acute bac' pain is so7called lumbosacral strain. In *(# of cases this resolves $ithin three months. In those cases that do not resolve the development of a chronic lo$ bac' pain syndrome is usually accompanied by the findin of active myofascial tri er points. 3imons of describes 1( torso and pelvic muscles $hich may be involved in lo$ bac' pain (1"). +he most commonly involve muscle roup is the Auadratus lumborum< pain emanatin from tri er points in these muscles is felt fin the lo$ bac' $ith occasional radiation in a sciatic distribution or into the testicles. +ri er points involvin the iliopsoas are also a common cause of chronic lo$ bac' pain. +he typical distribution of iliopsoas pain is a vertical band in the lo$ bac' re ion and the upper portion of the anterior thi h. +ri er points at the ori in of the luteus medius from the iliac crest are common cause for lo$ bac' pain in the sacral and buttoc' $ith a referral pattern to the outer hip re ion.

Cec' and shoulder pain

1atent tri er points are universal findin in many of the muscles of the posterior nec' and upper bac'. Active tri er points commonly involve the upper portion of the trape&ius and levator scapula. ;pper trape&ius tri er points referred pain to the bac' of the nec' and not uncommonly to the an le of 4a$. 1evator scapula tri er points cause pain at the an le of the nec' and shoulder< this pain is often described as lancinatin , especially on active use of this muscle. As many of the muscles in this area have an important postural function they are commonly activated in office $or'ers and

developmental problems causin spinal malali nment (e. . short le syndrome, hemipelvis and scoliosis). As the upper trape&ius and levator scapulae act syner istically $ith several other muscles in elevation and fi5ation of the scapula it is common for a sin le tri er point in this re ion to initiatin a spread of satellite tri er points throu h ad4acent muscles $hich are part of the same functional unit.

Bip pain

)ain arisin from disorders of the hip 4oint is felt in the roin and the lo$er medial aspect of the anterior thi h. +his distribution is uncommon in myofascial pain syndromes e5cept for iliopsoas pain. +he reat ma4ority of patients complain of hip pain in fact locali&e their pain to the outer aspect of the hip. In some patients this is due to a trochanteric bursitis, but in the ma4ority of cases it is related to myofascial tri er points in the ad4acent muscles. By far the commonest tri er points ivin rise to outer hip pain are those in the attachments of the luteus medius and minimus muscles into the reater trochanter.

)elvic pain

+he pelvic floor musculature is a common si ht for myofascial tri er points. +here is increasin reco nition by ynecolo ists and urolo ists that pain syndromes described in terms of prostatitis, coccydnia, vulvodynia and endometriosis are often accompanied by active myofascial tri er points. >ne of the most commonly involved intrapelvic muscles is the levator ani< its pain distribution is central lo$ buttoc'.

Beadaches

Active myofascial tri er points in the muscles of the shoulder nec' and face are a common source of headaches (1(). In many instances the headache has the features of so7called tension headache, but there is increasin acceptance that myofascial tri er points may initiate classical mi raine headaches or be part of a mi5ed tension0mi raine headache comple5. 2or instance sterno7cleido mastoid tri er points refer pain to the anterior face and supraorbital area. ;pper trape&ius tri er points refer pain to the verte5 forehead and temple. +ri er points in the deep cervical muscles of the nec' may cause post occipital and retro7orbital pain.

Da$ pain

+here is a comple5 interrelationship bet$een temporomandibular 4oint dysfunction and myofascial tri er points (!) @ommon tri er points involved in 4a$ pain syndromes are the massetters, ptery oids, upper trape&ius and upper sterno7cleido mastoid.

;pper 1imb pain

+he muscles attached to the scapula are common sites for tri er points that can cause upper limb pain (1-). +hese included the subscapularis, infraspinatus, teres ma4or and serratus anterior. It is not uncommon for tri er points in these locations to refer pain t$o the $rist hand and fin ers. E5tension fle5ion in4uries to the nec' often activate a tri er point in the pectoralis minor $ith a radiatin pain or do$n the ulnar side of the arm and into the little fin er. Myofascial pain syndromes of the upper limb are often misdia nosed as fro&en shoulder, cervical radiculopathy or thoracic outlet syndrome (1").

1o$er limb pain

+ri er points in the tensor fascia lata and ilio tibial band may be responsible for lateral thi h pain and lateral 'nee pain respectively. Anterior 'nee pain may result from tri er points in various components of the Auadriceps musculature. )osterior 'nee pain can result from tri er points in the hamstrin muscles and popliteus. +ri er points in the anterior tibialis and the peroneus lon us muscles may cause pain in the anterior le and lateral an'le respectively. Myofascial pain syndromes involvin these muscles are often associated $ith an'le in4uries or an e5cessively pronated foot. 3ciatica pain may be mimic'ed by a tri er point in the posterior portion of the luteus minimus muscle.

@hest and abdominal pain

Disorders affectin intrathoracic and intra7abdominal or ans are some of the commonest problems encountered in internal medicine. 2or instance, anterior chest pain is a freAuent cause for the emer ency room admissions, but in the ma4ority of patients a myocardial infarction is not found. In some cases the chest pain is caused by tri er points in the anterior chest $all muscles (1.). )ectoralis ma4or tri er points cause

ipsilateral anterior chest pain $ith radiation do$n the ulnar side of the arm F thus mimic'in cardiac ischemic pain. A tri er point in the sternalis muscle typically causes a deep substernal achin sensation. +ri er points at the upper and lo$er insertions of the rectus abdominus muscles may mimic the discomfort of all bladder and bladder infections respectively. It is important to note that myofascial tri er points may accompany disorders of intrathoracic and intra7abdominal viscera, and thus a dia nosis of an isolated myofascial cause for symptoms should never be made $ithout an appropriate $or'up.

@ausation

+he precise basis for the tri er point phenomena is still not fully understood. +here is a eneral a reement that electromyo raphic recordin s from tri er points sho$ lo$ volta e spontaneous activity resemblin endplate spi'e potentials (1/). 3imons envisions a myofascial tri er point to be 9a cluster of numerous microscopic loci if intense abnormality that are scattered throu hout the tender nodule: (1"). It is thou ht that these loci result from a focal ener y crisis (from in4ury or repetitive use) that results in contraction of focal sarcomeric units due to calcium release from the sarcoplasmic reticulum. 2actors commonly cited as predisposin to tri er point formation include deconditionin , poor posture, repetitive mechanical stress, mechanical imbalance (e. . le len th ineAuality), 4oint disorders, non7restorative sleep and vitamin deficiencies.

Bere is a cartoon of a tri er point comple5 seen in a lon itudinal section of muscle. +he top component represents a muscle $ith a taut band. +he middle component represents a ma nified vie$ of the taut band containin an active tri er point focus. +he lo$er component represents further ma nification of the taut band and tri er point focus sho$in contraction 'nots (contracted sarcomere units). It is envisa ed that these contraction 'nots are responsible for the nodularity of the taut band.

)ro nosis

;ncomplicated myofascial pain syndromes usually resolve $ith appropriate correction of predisposin factors and myofascial treatment (1%). If the symptoms are persistent, due to ineffective mana ement, the development of se mental central sensiti&ation may lead to a stubbornly recalcitrant pain disorder. In some such cases, the spread of central sensiti&ation leads to the $idespread pain syndrome of fibromyal ia.

+reatment

2or effective mana ement of myofascial pain syndromes reAuires attention to the follo$in issues (1*).

)ostural and er onomic

+he most critical element in the effective mana ement of myofascial pain syndromes is the correction of predisposin factors (see above). +hese interfere $ith the ability of the muscle to fully recover and are the commonest reason for treatment failures.

3tretchin

+he muscles involved in myofascial pain syndromes are shortened due to the aforementioned focal contractions of sarcomeric units. It is thou ht to these focal contractions result in on prolon ed A+) consumption and that the restoration of a muscle to its full stretch len th brea's the lin' bet$een the ener y crisis and contraction of sarcomeric units. Effective stretchin is most commonly achieved throu h the techniAue of spray and stretch (%"). +his involves the cutaneous application, alon the a5is of the muscle, of ethyl chloride spray $hile at the same time passively stretchin the involved muscle. >ther techniAues to enhance effective stretchin include tri er point to pressure release, post isometric rela5ation, reciprocal inhibition and deep stro'in massa e (1")

3tren thenin

Muscles harborin tri

er points usually become $ea' due to the inhibitory effects of

pain. A pro ram of slo$ly pro ressive stren thenin is essential to restore full function and minimi&e the ris' of recurrence and the perpetuation of satellite tri er points.

+ri

er point in4ections

In4ection of tri er points it enerally considered to be the most effective means of direct inactivation. A pepperin techniAue usin a fine needle to inactivate all the foci $ithin a tri er point locus is the critical element of successful tri er point therapy (%1). Accurate locali&ation of the tri er point is confirmed if a local t$itch response is obtained< ho$ever this may not be obvious $hen needlin deeply lyin muscles. 3uccessful elimination of the tri er point usually results in a rela5ation of the taut band. Althou h dry needlin is effective, the use of a local anesthetic (1# lidocaine or 1# procaine) helps confirm the accuracy of the in4ection and provides instant ratification for patients (%%). +here is no evidence that the in4ection of corticosteroids provides any enhanced effect. A beneficial role for botulinum to5in in tri er point in4ections has not so far been conclusively demonstrated.

Medications

@urrently there is no evidence that any form of dru treatment of men ei hths myofascial tri er points (%"). C3AIDs and other anal esics usually provide moderate symptomatic relief. +ricyclic antidepressant dru s, $hich modulate pain at the central level, are often of benefit especially in those patients $ith an associated sleep disturbance. In the author8s e5perience, ti&anidine (a muscle rela5ant $hich also ameliorates pain by activatin alpha % adrener ic receptors) is often a useful ad4unct in difficult to treat myofascial pain syndromes.

)sycholo ical techniAues

In severe myofascial pain syndromes, that are not respondin to treatment, patients often become an5ious and depressed. +hese mood disorders need to be reco ni&ed and appropriately treated. )ersistent muscle tension e5acerbates the pain of myofascial tri er points and can often one be effectively mana ed $ith EMG biofeedbac', co nitive behavioral therapy and hypnotic0meditation rela5ation techniAues.

References

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er point

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er

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