Myofascial Pain Syndrome

Myofascial Made Simple

The word myofascial means muscle tissue (myo) and the connective tissue in and around it (fascia).

Myofascial pain syndrome has been defined by the International Association for the Study of Pain (IASP) as a painful regional condition associated with the presence of trigger points. Myofascial trigger points are spot of hyper-irritability, which, when subjected to mechanical pressure, give rise to characteristic patterns of referred pain. Trigger points have both a sensory and a motor component.

Clinical characteristics of a trigger point include circumscribed point tenderness of a hard nodule that is part of a palpably tense taut band of muscle fibers, patient recognition of the pain that is evoked by pressure on the tender spot as being familiar, and pain referred to in the pattern characteristic of the trigger points in that muscle, a local twitch response or “jump” sign, painful limitation of stretch range of motion (ROM), and weakness of that muscle. Often multiple muscles are involved.

Myofascial pain syndrome is a chronic pain disorder. In this condition, pressure on sensitive points in your muscles (trigger points) causes pain in the muscle and sometimes in seemingly unrelated parts of your body. This is called referred pain.

This syndrome typically occurs after a muscle has been contracted repetitively. This can be caused by repetitive motions used in jobs or hobbies or by stress-related muscle tension.

The terms trigger points and tender points are often incorrectly used interchangeably. A tender point is a widespread, nonspecific, soft tissue pain often associated with fibromyalgia, as compared to a trigger point which is a localized area within a taut band of skeletal muscle which has a characteristic nodular texture and, upon palpation, generates a twitch response or referral pattern as seen in the myofascial pain syndrome. Trigger points can be active or latent. An active trigger point is associated with spontaneous pain present without palpation, either at the site of the myofascial trigger point or remote from it. Palpation increases pain locally and usually reproduces the subject’s remote pain. A latent trigger point is not associated with spontaneous pain. However, pain can often be elicited in an asymptomatic issue by a mechanical stimulus. The exact mechanism of myofascial trigger points is still unclear. They can develop after trauma, overuse, or prolonged spasm of muscles. The “energy crisis” hypothesis states that an overload of the muscle causes an increase in calcium release, which stimulates prolonged contractility and increased metabolic activity causing localized ischemia.

Key elements of the physical examination include evaluation of posture (symmetry, stance, and scoliosis), palpation, ROM of the lumbar spine and restrictions due to pain, neurological examination, and palpation (flat or pincer palpation) of superficial and deep soft tissue looking for: tenderness, taut bands, twitch responses, and referral patterns.

Potential tools for diagnosis under study include measurement of biochemicals associated with pain and inflammation in the trigger point region, sonographic studies, magnetic resonance elastography for taut band imaging, and infrared thermography.

Many methods have been used to treat myofascial pain, including stretching, massage, trigger point pressure release, laser therapy, heat, ultrasound, transcutaneous electrical nerve stimulation (TENS), biofeedback, pharmacological treatments, trigger point injections with local anesthetic and/or steroid solutions, shockwave therapy, and botulinum toxin type A injection.

While nearly everyone has experienced muscle tension pain, the discomfort associated with myofascial pain syndrome persists or worsens. Myofascial pain occurs in about 85% of people sometime during their life. Even this high percentage may not be accurate. Myofascial pain is often under-diagnosed, misdiagnosed or overlooked because it’s hidden in another type of diagnosis such as headache, neck and shoulder pain, pelvic pain, limb pain or nerve pain syndrome. Men and women are equally affected, though middle-aged inactive women are at the highest risk.

This information is not intended to provide medical advice or to replace the advice of a licensed physician. Portions of this information, however, may be used to provide material to your physician for review.

What are the symptoms of myofascial pain syndrome?

Symptoms are different for each person with myofascial pain syndrome. Sometimes the pain happens suddenly and all at once, and that is called a “flare-up” of symptoms. At other times it’s a constant, dull pain that sort of lingers in the background.

Symptoms of myofascial pain syndrome include:

• Pain that’s described as deep aching, throbbing, tight, stiff or vice-like.

• Trigger points (a small bump, nodule or knot in the muscle that causes pain when touched and sometimes when it’s not touched).

• Muscles that are tender or sore.

• Weakness in the affected muscle(s).

• Reduced range of motion in the affected areas (e.g., you may be unable to completely rotate your head).

People with myofascial pain syndrome often have other health problems that coincide. Commonly reported problems include:

• Headaches.

• Poor sleep.

• Stress, anxiety, depression.

• Feeling tired (fatigue).

What causes myofascial pain syndrome?

The jury is still out about all of the causes, contributing factors and exactly how the pain mechanism works.

Causes of myofascial pain syndrome include:

• Muscle injury.

• Muscle strain/repetitive muscle use (e.g. hammering).

• Muscle weakness/lack of muscle activity (e.g. a leg in a cast will not get enough movement).

• Poor posture.

• Working in or living in a cold environment.

• Emotional stress (can cause muscle tension).

• Pinched nerve.

Other factors thought to contribute to the development of myofascial pain syndrome include:

• Metabolic or hormonal problems such as thyroid disease or diabetes-related neuropathy.

• Vitamin deficiencies, including vitamin D and folate.

• Presence of chronic infections.

Where does myofascial pain syndrome most commonly occur?

Myofascial pain and trigger points can develop in any muscle in the body. However, the most commonly affected muscles are those in the upper back, shoulder and neck. These muscles include the:

Sternocleidomastoid:

This large muscle helps rotate your head to the opposite side and flexes your neck. It is located on both sides of your neck, running from your skull behind your ear area to your collarbone and breast bone.

Trapezius:

This large, broad, flat triangular back muscle tilts and turns your head and neck, shrugs and steadies your shoulders, and twists your arms. The muscle extends from the base of your skull to the middle of your back.

Levator scapulae:

This pair of strap-like muscles help raise and rotate each of your shoulder blades. They run from the first four cervical vertebra to the top edge of your shoulder.

Infraspinatus:

This triangular muscle, located on the back side of each of your shoulder blades, helps rotate and stabilize your shoulder joints. It’s one of four muscles of the rotator cuff.

Rhomboids:

This pair of upper back muscles pull your shoulder blades together when they contract and attach the upper limbs to your shoulder blade. These muscles run diagonally from the neck and chest vertebrae of the spine down to the back of the shoulder blades.

How can I describe my pain?

Different categories are used when describing or attempting to gather information about pain. These include:

• oLocation, Site: where the pain is felt(ie Head, Neck, Shoulder, Shoulder Blade, Low Back, Glute, Buttock etc)

• Intensity: how severe the pain is (ie Most pain scales use numbers from 0 to 10).

• Frequency: how often the pain occurs (ie morning, night time)

• Quality: the type of pain (ie. Deep, Ache, Dull, Sharp, tender, shooting etc.)

• Duration: how long the pain lasts when it occurs

• Pattern: what causes the pain and what improves it

• Movement: what movement causes the pain

Dull pain is often chronic, lasting a few days, months, or more. Commonly, dull pain results from an old injury or a chronic condition. If you have a new, dull pain that doesn’t improve in two to three weeks, bring it to your doctor’s attention.

Questions your therapist may ask to assess myofascial pain syndrome:

Your healthcare provider may order a few tests to rule out other conditions and ask you questions about your pain and symptom, including:

• Where do you feel the pain?

• How would you describe your pain?

• How often do you experience pain?

• What makes your pain better?

• What makes your pain worse?

• Have you had any recent injuries?

• Do your symptoms get better at certain times during the day?

• What does your work day look like (to look for activities in which there is muscle strain/repetitive motion)?

Can myofascial pain syndrome be prevented?

There are certain factors that can put you more at risk for developing myofascial pain syndrome. Managing these risk factors may not prevent you from developing the syndrome, but could help reduce the severity of the condition.

Many of the prevention suggestions to follow are also pain management strategies:

• Maintain proper sleep hygiene.

• Reduce your stress.

• Get exercise.

• Avoid preventable muscle injury. (e.g., is the shoulder bag/purse you carry too heavy and digging into the muscles in your shoulder?).

• Practice relaxation methods.

How do I take care of myself?

Living with myofascial pain syndrome is uncomfortable at best, unbearable at worst. Take care of yourself by following your healthcare provider’s treatment plan and using your at-home remedies listed above. Exercise, change your diet, soak in warm water, get massages, etc. You’ll likely have to experiment to figure out what treatments work best to reduce your pain.

References:

• National Association of Myofascial Trigger Point Therapists. Myofascial Therapy. (https://www.myofascialtherapy.org/myofascial-therapy) Accessed 7/1/2020.

• American Society of Anesthesiologists. Myofascial Pain Syndrome. (https://www.asahq.org/whensecondscount/pain-management/types-of-pain/myofascial-pain-syndrome/ ) Accessed 7/1/2020.

• Mayo Clinic. Myofascial pain syndrome. (https://www.mayoclinic.org/diseases-conditions/myofascial-pain-syndrome/symptoms-causes/syc-20375444)

• Cleveland Clinic. Myofascial pain syndrome. (https://my.clevelandclinic.org/health/diseases/12054-myofascial-pain-syndrome)