Myofascial Pain Syndrome

Travell and Simons originally defined myofascial pain syndrome (MPS) as “regional pain characterized by the presence of one or more myofascial trigger points.” (1) Myofascial trigger points (TPs) are palpable nodules of fibro-connective tissue within a muscle with direct reference to a hypersensitive or painful area on the body and skin surface. Trigger points can cause focal areas of skeletal muscle contracture, irritation, and stiffness. (2) These palpable nodules are frequently referred to as muscle knots or taut bands and serve as the MPS hallmark clinical feature. (1-3) TPs generate local and referred pain either spontaneously (active TP) or upon digital compression (latent TP). (1,2,4)

There are ample potential sites of involvement for MPS; the body’s 600+ muscles account for nearly half of its weight, and fascia attaches, encloses, or separates almost every tissue. (5) Not surprisingly, myofascial pain syndrome is the most common cause of chronic regional pain. (3)

(See this video from Stecco for a fascinating visual tutorial on fascia.)

Causes

While myofascial pain syndrome’s exact pathophysiology remains uncertain, many experts endorse the following energy crisis hypothesis. (6-14,125) Repetitive activity causes muscle overload, which leads to local capillary constriction, ischemia, and hypoxia. The resultant depletion of energy (ATP) inhibits the normal calcium pump. Calcium build-up propagates sustained local muscle contraction, i.e., palpable taut bands. The process generates a cytotoxic acidic environment filled with multiple biochemical inflammatory mediators that sensitize peripheral nociceptors, eliciting pain.

A sustained altered mechanometabolic environment leads to a more viscous extracellular matrix with increased fibroblastic activity. (13) This promotes tissue transformation, i.e., adhesions, which can impair normal muscle function and healthy neurodynamics. (15,16). Furthermore, while trigger points begin as peripheral pain generators, prolonged irritation may lead to central sensitization. (17) MPS can cause restrictions in normal biomechanical joint function, impairment of neurological function, and impairment of circulation and lymphatic flow. (122)

Myofascial pain syndrome affects all ages, races, and genders. (2,13,18) MPS is thought to be the most common cause of musculoskeletal pain, affecting between 30-93% of symptomatic musculoskeletal patients. (19-22) Various authors have suggested that peak prevalence occurs between ages 27 -50. (23,24) However, one Canadian study found that up to 85% of seniors suffer from MPS. (25)

Saxena et al. separated MPS contributing factors into four general categories: (26)

• Traumatic events – falls, accidents, surgery.
• Ergonomic factors – poor posture, repetitive overuse, sustained pressure.
• Structural factors – osteoarthritis, scoliosis, kyphosis, spondylolisthesis.
• Systemic factors – vitamin D deficiency, iron deficiency, hypothyroidism, stress.

One recent study demonstrated that patients with insomnia were nearly twice as likely to suffer from myofascial pain syndrome. (27) Almost half of all breast cancer surgery patients develop myofascial pain syndrome within one year. (28)

Trigger Points

Myofascial trigger points arise when a combination of contributing factors exceeds tissue capacity. In some cases, this happens abruptly from an injury or a single session of prolonged overuse. More commonly, trigger points develop insidiously, without any specific identifiable precipitating factor. (13) Some experts suggest that trigger points may be initiated by neurogenic mechanisms secondary to central sensitization, and not necessarily by local injury. (123,124)

The muscles most commonly affected by MPS include the upper trapezius, scalene, SCM, levator scapulae, quadratus lumborum, and other postural muscles of the lower back, neck, shoulders, pelvic girdle, and jaw. (2,29,30)

MPS complaints include regional muscular pain or aching that is poorly localized, although a focal center can generally be identified. (13) Symptoms are typically described as deep, dull, and achy. Active trigger points can produce referred pain in reasonably predictable patterns, as documented by Travell and Simons. (1) In some cases, the site of referred pain is not contiguous with the trigger point location; i.e., wrist extensor trigger points near the elbow generate dorsal wrist pain. (1,13) Referred pain from a myofascial trigger point is often described as deep, dull, aching, tingling, or burning. (31)

Accompanying mechanical complaints might include tightness, stiffness, or crepitus. (23,33) MPS sufferers may report difficulty finding a comfortable sleep position. (34) Occasionally, patients will report paresthesia, numbness, vague weakness, or autonomic phenomena. (12,32,34)

Perpetuating factors include the triggers mentioned above, particularly, muscle overload, sustained stretch from poor posture, and exposure to cold. Additional potential perpetrators for muscle pain include infection, polymyalgia rheumatica, and the use of statin-class medications. Symptoms may persist for many years if the perpetuating factors are not resolved. The numeric pain rating scale (NPRS) and the visual analog scale (VAS) are valid tools to measure pain intensity in patients with myofascial pain syndrome. (36)

Diagnosis

Myofascial pain syndrome is a relatively straight-forward clinical diagnosis based upon history and palpation. The characteristic MPS trademarks, trigger points, are readily identifiable via clinical evaluation. (37) A 2017 Delphi study suggested that the diagnosis of a myofascial trigger point includes at least two of the following three criteria: (38)         

1.  Presence of a taut band.
2. A hypersensitive spot.
3. Referred pain.

A fourth commonly cited diagnostic trait is a local twitch response, i.e., muscle fasciculation upon snapping palpation of the trigger point. (13,32,35)

Active trigger points may produce symptoms spontaneously, while latent trigger points require manual compression. Latent trigger points are frequently identified during a palpatory examination of asymptomatic patients. (13) Clinicians may use a pressure algometer to quantify and track the pressure pain threshold (PPT) of trigger points. Loss of range of motion is another potential clinical finding for MPS. (33,39)

Imaging

Since MPS is primarily a clinical diagnosis, imaging, lab, and neurodiagnostic studies are generally only appropriate for ruling out alternate conditions. (13) Diagnostic ultrasound can identify TPs by their hypo-echoic signal. (40)

In addition to ruling out neuromuscular disease, needle electromyography can identify an active locus of a trigger point by its spontaneous electromyographic activity, i.e., endplate noise/potential. (13,41,42) Clinically, elevated EMG activity over trigger points may correlate with lower skin temperatures secondary to local ischemia. (43,44)

While there is no specific blood test for myofascial pain syndrome, lab testing can identify several known predisposing conditions, including Vitamin D deficiency, hypothyroidism, and hypoglycemia. (13,45) Vitamin B12 and folic acid insufficiencies have been identified in patients with chronic myofascial syndromes. Deficient levels of trace elements may also play a role in MPS. Serum zinc levels were found to be reduced in MPS and fibromyalgia patients. (127)

A fundamental differential diagnostic consideration entails distinguishing myofascial pain syndrome from fibromyalgia. Myofascial pain syndrome and fibromyalgia share several overlapping features and may coincide; however, they are uniquely distinct conditions. Myofascial pain syndrome consists of local trigger points in one or more muscles with specific pain patterns, whereas fibromyalgia encompasses widespread hypersensitive tender points, affecting almost every palpable tissue. Clinically, trigger points are focal and palpably identifiable irritations of particular muscles that produce referred pain. In contrast, fibromyalgia involves multiple tender points that are not palpably distinguishable from the surrounding tissue. Fibromyalgia is often accompanied by other symptoms, including migraines, fatigue, mood changes, irritable bowel, and TMD.

Download this chart on differentiating myofascial pain syndrome from fibromyalgia here.

Myofascial pain syndrome frequently coexists with various other neuromusculoskeletal or systemic disorders. (4) Even threatening conditions may have incidental trigger points in symptomatic areas. Clinicians should not be lulled into a false sense of security when conservative TP therapy provides palliative relief. Any recurrent MSK complaint requires careful evaluation to rule out more sinister underlying causes. (46)

Treatment

Rudimentary isolated treatment modalities may resolve trigger points of recent onset. (47) However, cases become recalcitrant when perpetuating factors are not adequately addressed. One study defined the average MPS duration as greater than five years. (47)

Treatment goals should include short-term pain relief, plus correction of the precipitating factors mentioned earlier. (49) The passive treatment spectrum includes modalities, dry needling, manual therapy (i.e., ischemic compression, myofascial release, etc.), injections, and medications. (50) Long-term strategies must address flexibility, strength, and restoration of optimal body mechanics, including posture.

Various therapeutic modalities have been advocated for managing myofascial pain syndrome, including interferential current and TENS. (51-54) Low-level laser therapy (LLLT) has been shown to help pain and disability in patients with myofascial pain syndrome. (53,55-58, 119) Extracorporeal shock wave therapy (ESWT) has also been employed successfully. (55,59) Therapeutic ultrasound has low-level support (55,60-62) but without conclusive benefit. (54) Local heat applied over trigger points is a primitive modality that has demonstrated some merit. (63) Conversely, several studies have effectively incorporated cold therapy in the management of myofascial pain syndrome. (64,87,90) The primary benefit of any passive modality lies in its ability to provide short-term palliative relief, thereby allowing the patient to participate in a more active, self-managed program. (53,67)

Several studies have suggested that dry needling may relieve pain and lessen disability for MPS patients. (68-74) Some studies document the utility of acupuncture and electroacupuncture for the management of myofascial pain syndrome. (74-75) Interestingly, one study found that over 70% of myofascial trigger points correspond with defined acupuncture points. (76)

In addition to restoring muscular flexibility, clinicians should address any associated joint restrictions. Various studies have demonstrated that spinal manipulation provides benefit for MPS patients. (53,77-79) Combining manual therapy with an active exercise program improves outcomes compared to exercise alone. (118)

Myofascial release technique and soft tissue manipulation are broad terms that encompass a plethora of treatment techniques, including any combination of hands, knuckles, elbows, or instruments applied over myofascial tissues, with or without movement by the clinician and patient. (80) Extensive literature endorses the use of myofascial release techniques for the management of myofascial pain syndrome. (82,83,85-99) Conversely, validation via high-quality blinded research remains challenging, because the application of myofascial release techniques is quite variable and requires considerable subjective interaction. (121)

Myofascial release techniques have shown merit in relieving trigger point pain (83,84,88-90,95,97), lowering pain pressure thresholds (87,90,93,96,116), and improving range of motion and flexibility. (86,88-90,92,95,96,99) Myofascial release technique has demonstrated various other benefits, including decreased swelling, reduced analgesic use, and improved quality of life. (86,88,93,116) Trigger point pressure release, aka manual ischemic compression for 10-60 seconds, has been shown to decrease trigger point activity and relieve symptoms. (53,120) Likewise, massage therapy may be a useful modality. Instrument Assisted Soft Tissue Manipulation (IASTM) may be an effective tool for managing trigger points in myofascial pain syndrome patients. (85,88,96,100)

Rehabilitation exercise is a crucial component of any successful MPS treatment program. The goal of exercise is to improve flexibility and strength while correcting faulty biomechanics and postures. (101) Rehab must seek to eliminate postural stressors, including sustained stretch, a known risk factor for muscular problems.

Some experts believe that trigger points may develop in an effort to stabilize the neighboring joints. Thus, some trigger points may be a brain problem (meaning, dysfunction in the stability and movement pattern results in faulty corrections) and not necessarily a pure muscle problem. Stabilizing the correct closed chain and open-chain functions of the surrounding joints would likely be useful in the treatment of MPS.

Stretching exercises are appropriate for affected and kinetically-related hypertonic muscles. Vapocoolant application during stretching of the affected muscle (spray & stretch) has been shown to decrease trigger point activity.  Strengthening exercises should address specific weaknesses, emphasizing functional deficits like upper crossed and lower crossed syndrome. Application of therapeutic elastic tape prior to rehabilitation exercise may provide symptomatic and functional benefits in MPS patients. (128)  Clinicians should not ignore foundational issues, such as foot hyperpronation or leg length inequalities.

Home rehab programs have proven merit in the treatment of myofascial pain syndrome. (102) Patients need to clearly understand the importance of home exercise recommendations and ergonomic advice. (103) Self-myofascial release tools such as balls, foam rollers, rods, and massagers may provide an effective ancillary means of home rehab. (126) General aerobic conditioning can be helpful, with several studies showing the benefit of physical exercise for MPS patients. (104,105) Patients should consider stress reduction techniques, including yoga, tai-chi, meditation, and breathing. Patients with Vitamin B or D deficiency may require supplementation. (13) Dehydration can reduce muscle strength and endurance. Clinicians may need to provide proper hydration recommendations to optimize body functions, including muscle function, metabolism, joint lubrication, and cell structure. (126)

NSAIDs and muscle relaxants are frequently used for the management of MPS, despite their lack of proven effectiveness. (106) Trigger point injections employing a variety of medications are commonly performed for MPS patients. (106) Combining injections with myofascial release techniques has shown merit. (107) Topical anesthetic patches, including transdermal lidocaine, may provide pain relief without the potential adverse effects and discomfort of injections. (106,108) Botulinum toxin (Botox®) has shown some long-term benefits for myofascial pain syndrome. (109-113)

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