AUTHOR AND EDITOR INFORMATION

Section 1 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

INTRODUCTION

Section 2 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Background

Descriptions of myofascial pain date back to the mid 1800s when Froriep described muskelschwiele or muscle calluses. He described these calluses as tender areas in muscle that felt like a cord or band associated with rheumatic complaints. In the early 1900s, Gowers first used the term fibrositis to describe muscular rheumatism associated with local tenderness and regions of palpable hardness. In 1938, Kellgren described areas of referred pain associated with tender points in muscle. In the 1940s, Janet Travell, MD, began writing about myofascial trigger points. Her text, written in conjunction with David Simons, MD, continues to be viewed as the foundational literature on the subject of myofascial pain.

Pathophysiology

Pain attributed to muscle and its surrounding fascia has been termed myofascial pain. The diagnosis of this syndrome in clinical, with no confirmatory laboratory tests available. Thus, myofascial pain in any location is characterized on examination by the presence of trigger points located in skeletal muscle. In the cervical spine, the muscles most often implicated in myofascial pain are the trapezius, levator scapulae, rhomboids, supraspinatus, and infraspinatus. A trigger point is defined as a hyperirritable area located in a palpable taut band of muscle fibers. According to Hong and Simon's recent review on the pathophysiology and electrophysiologic mechanisms of trigger points, the following observations help to define them further:

• Trigger points are known to elicit local pain and/or referred pain in a specific recognizable distribution.
• Palpation in a rapid fashion (ie, snapping palpation) may elicit a local twitch response (LTR), a brisk contraction of the muscle fibers in or around the taut band. The LTR also can be elicited by rapid insertion of a needle into the trigger point.
• Restricted range of motion (ROM) and increased sensitivity to stretch of muscle fibers in a taut band are noted frequently.
• The muscle with a trigger point may be weak because of pain. Usually, no atrophic change is observed.
• Patients with trigger points may have associated localized autonomic phenomena (eg, vasoconstriction, pilomotor response, ptosis, hypersecretion).
• An active myofascial trigger point is a site marked by generation of spontaneous pain or pain in response to movement. This phenomenon is in contrast to the case of latent trigger points, which may not produce pain until they are compressed.

Frequency

United States

Myofascial pain is thought to occur commonly in the general population. As many as 21% of patients seen in general orthopedic clinics have myofascial pain. Of patients seen at specialty pain management centers, 85-93% have a myofascial pain component.

Mortality/Morbidity

Increased mortality is not associated with cervical myofascial pain.

Race

No studies clarify whether racial differences exist in frequency of cervical myofascial pain.

Sex

While fibromyalgia occurs more commonly in women than in men, cervical myofascial pain occurs in both sexes, also with a predominance among women.

Age

Myofascial pain seems to occur more frequently with increasing age until mid life. Incidence declines gradually after middle age.

CLINICAL

Section 3 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

History

Typical findings reported by the patient with myofascial pain may include the following:

• The patient may present with a history of acute trauma associated with persistent muscular pain. In contrast, myofascial pain also manifests insidiously, without a clear antecedent accident or injury. It may be associated with repetitive tasks, poor posture, stress, or cold weather.
• Cervical spine ROM is often limited and painful.
• The patient may describe a lumpiness or painful bump in the trapezius or cervical paraspinal muscles.
• Massage is often helpful, as is superficial heat.
• The patient's sleep may be interrupted because of pain. The cervical rotation required for driving is difficult to achieve.
• The patient may describe pain radiating into the upper extremities, accompanied by numbness and tingling and making discrimination from radiculopathy or peripheral nerve impingement difficult.
• Dizziness or nausea may be a part of the symptomatology.
• The patient experiences typical patterns of radiating pain referred from trigger points.

Physical

Common findings noted upon physical examination may include the following:

• Patients with cervical myofascial pain often present with poor posture. They exhibit rounded shoulders and protracted scapulae.
• Trigger points frequently are noted in the trapezius, supraspinatus, infraspinatus, rhomboids, and levator scapulae muscles.
• The palpable taut band is noted in the skeletal muscle or surrounding fascia. An LTR often can be reproduced with palpation of the area.
• Cervical spine ROM is limited with pain reproduced in positions that stretch the affected muscle.
• While the patient may complain of weakness, normal strength in the upper extremities is noted on physical examination.
• Sensation typically is normal when tested formally. No long tract signs are observed on examination.

Causes

Cervical myofascial pain is thought to occur following either overuse or trauma to the muscles that support the shoulders and neck. Common scenarios are that the patient recently was involved in a motor vehicle accident or has performed repetitive upper extremity activities. Trapezial myofascial pain commonly occurs when a person with a desk job does not have appropriate armrests or must type on a keyboard that is too high. Other issues that may play a role in the clinical picture include endocrine dysfunction, chronic infections, nutritional deficiencies, poor posture, and psychological stress.

DIFFERENTIALS

Section 4 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Other Problems to be Considered

Myopathy

WORKUP

Section 5 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Lab Studies

• Myofascial pain traditionally does not produce abnormalities in the results of the patient's lab work. Travell and Simons describe a study looking at lactate dehydrogenase (LDH) isoenzymes. A shift was noted in distribution of the isoenzymes with higher levels of LDH1 and LDH2, while the total LDH remained within normal limits. In clinical practice, myofascial pain is diagnosed by way of a thorough physical examination in conjunction with an adequate medical history.
• Depending on the clinical presentation, it may be reasonable to check for indicators of inflammation, assess thyroid function, and perform a basic metabolic panel to rule out a concomitant medical illness.

Imaging Studies

• Imaging studies often reveal nonspecific change only and typically are not helpful in making the diagnosis of cervical myofascial pain; however, x-rays and a cervical spine magnetic resonance imaging (MRI) may be helpful in ruling out other pathology that may be present at the same time.

Other Tests

• Several research articles have attempted to identify changes on electromyograms/nerve conduction velocity studies that may be unique to patients with myofascial pain. The research has been somewhat contradictory, with some studies finding no real electromyographic activity and others finding nonspecific electrical activity. Studies by Simons and by Hobbard and Berkoff describe low-amplitude action potentials recorded at the region of the myofascial trigger point. Spontaneous electrical activity apparently can be detected using high-sensitivity recordings at the site of the trigger point. The spontaneous electrical activity may be a type of endplate potential.

TREATMENT

Section 6 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Rehabilitation Program

Physical Therapy

The primary goal of physical therapy is to restore balance between muscles working as a functional unit. The physical therapist may progress toward that goal initially by attempting to diminish pain. This goal can be accomplished using a modality-based approach performed in conjunction with myofascial release techniques and massage. Cervical stretch and stabilization are integral parts of the approach as well. Postural retraining is crucial in cervical myofascial pain. An ergonomic evaluation may be indicated if overuse in the work setting is contributing to the patient's symptoms.

Medical Issues/Complications

The primary concern for patients with cervical myofascial pain is chronicity. Recurrence of myofascial pain is a common scenario. Prompt treatment prevents other muscles in the functional unit from compensating, thereby producing a more widespread and chronic problem. Migraine headaches and muscle contraction headaches are known to occur frequently in the patient with myofascial pain. Temporomandibular joint (TMJ) syndrome also may be myofascial in origin.

Other Treatment

Several treatment options for cervical myofascial pain are discussed in the literature. Trigger point injection probably is one of the most accepted means of treating myofascial pain besides physical therapy and exercise. Injection is performed most commonly with local anesthetic, although dry needling has been shown to be equally effective.

Palpate the trigger point in the taut band, and place the muscle in a slightly stretched position to prevent it from moving. Hold the trigger point between 2 fingers while injecting with the other hand. Then redirect the needle in the area to assure widespread infiltration of the anesthetic. Instruct the patient to be aggressive about compliance with stretching protocols, as they increase effectiveness of the injection. Production of a local twitch response helps confirm the diagnosis. Hong and Simon's article describes a fast-in fast-out method as more successful in eliciting the local twitch response. This approach, therefore, generally is the most helpful technique for reducing myofascial pain.

Stretch and spray is another method of treating cervical myofascial pain. This technique is performed using a vapo-coolant spray applied to the affected muscle after it has been placed in passive stretch. Apply the vapo-coolant spray to the region around the trigger point and the area of referred pain using parallel strokes in the same direction. Some authors recommend first spraying, then stretching, and only then repeating the spraying.

Ischemic compression involves application of sustained pressure on the trigger point. Have the patient place the muscle in a fully stretched position. Press firmly on the trigger point with a thumb. Gradually increase the pressure as the pain lessens.

Botulinum toxin injection therapy has gotten mixed reviews in the literature. Injection directly into the trigger point produces inconsistent results. The best use of botulinum toxin may be for correcting abnormal biomechanics that incite a myofascial response.

MEDICATION

Section 7 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

The goals of pharmacotherapy are to reduce morbidity and prevent complications.

Drug Category: Nonsteroidal anti-inflammatory drugs

The goal of medication for patients with cervical myofascial syndrome is to reduce pain. NSAIDs are the drugs DOC for initial treatment of myofascial pain. Keep narcotic analgesics at a minimum if at all possible. If the clinical picture is one of more chronic pain accompanied by sleep dysfunction, consider use of a TCA.

Drug Category: Tricyclic antidepressants

TCAs are commonly used for chronic pain. They help treat insomnia and reduce painful dysesthesia. They treat both nociceptive and neuropathic pain syndromes.

Drug Category: Muscle relaxants

Muscle relaxants are commonly used to treat muscle pain, but must be used cautiously because of sedation and because of addictive potential of some of the medications in this category of drugs (benzodiazepines).

Drug Category: Non-narcotic analgesics

Tramadol is both a weak opioid and an inhibitor of serotonin and norepinephrine reuptake in the dorsal horn. Studies have shown efficacy when treating fibromyalgia though no formal studies have been done for myofascial pain. Tramadol is known to help with chronic low back pain and osteoarthritis pain, both of which are commonly associated with myofascial pain.

Drug Category: Anticonvulsants

Anticonvulsants used as neuropathic analgesics may be helpful because myofascial pain may, at its core, be a spinal-mediated disorder affected by neuropathic dysfunction. Gabapentin has been shown to be effective in treating myofascial pain and neuropathic pain.

FOLLOW-UP

Section 8 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Deterrence/Prevention:

• Cervical myofascial pain may be prevented if overuse is avoided. Appropriate ergonomic considerations for jobs that require repetitive use of the arm or shoulders are always important. Any activity that requires sustained muscle contraction without rest puts the patient at risk. Appropriate posture also makes a significant difference in reduction of cervical myofascial pain. Because stress may play a role, relaxation techniques in conjunction with other stress relievers are integral to any treatment program for the patient prone to development of cervical myofascial pain. Advise the patient that reasonable nutrition and rest help to avoid pain from trigger points.

Complications:

• Chronic pain and disability
• Migraine and/or muscle contraction headaches
• TMJ syndrome

Prognosis:

• When the patient with cervical myofascial pain undergoes appropriate treatment(s) (eg, physical therapy, massage therapy, stretch and spray, trigger point injections), the prognosis is generally good. Recurrence can be a common scenario. Outcomes seem to be better when treatment is initiated early in order to prevent compensation patterns that exacerbate pain.

Patient Education:

• Patients with cervical myofascial pain need to be educated on the factors or underlying problems that may contribute to their pain and loss of mobility. The physical therapist can educate the patient on proper exercise habits and instruct them in a home exercise program for stretching and reconditioning. The patient also may benefit from specific exercises and strategies to improve posture awareness and body mechanics with activities of daily living. If poor workplace ergonomics contribute to the patient's condition, offer instruction in proper ways to modify and revamp the workstation. Cervical myofascial pain is a treatable condition, as long as the patient is educated on the condition and takes an active role in the recovery process.
• For excellent patient education resources, visit eMedicine's Back, Ribs, Neck, and Head Center and Muscle Disorders Center. Also, see eMedicine's patient education articles Temporomandibular Joint (TMJ) Syndrome, Fibromyalgia, and Chronic Pain.

MISCELLANEOUS

Section 9 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Medical/Legal Pitfalls

• Remember that cervical myofascial pain can be present at the same time as other more serious medical conditions. The term myofascial pain tends to imply that the patient does not have a serious illness. If the patient's symptoms are resistant to traditional treatment for cervical myofascial pain, further workup is indicated. If a history of trauma exists, order cervical flexion/extension films to rule out the possibility of instability. MRI also may be helpful to rule out any significant abnormality within the structure of the cervical vertebrae or spinal canal. The cervical discs also may be evaluated. If the pain is in the shoulders or chest wall, be aware that visceral pain may refer to these areas and even produce some myofascial findings on examination. Be open-minded to the possibility that another problem also may be present.

REFERENCES

Section 10 of 10

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

• Borg-Stein J, Simons DG. Focused review: myofascial pain. Arch Phys Med Rehabil. Mar 2002;83(3 Suppl 1):S40-7, S48-9. [Medline].
• De Andrés J, Cerda-Olmedo G, Valía JC, et al. Use of botulinum toxin in the treatment of chronic myofascial pain. Clin J Pain. Jul-Aug 2003;19(4):269-75. [Medline].
• Gnatz SM. Referred pain syndromes of the head and neck. In: Physical Medicine and Rehabilitation: State of the Art Reviews. Vol 5. 1991:585-596.
• Hong CZ, Simons DG. Pathophysiologic and electrophysiologic mechanisms of myofascial trigger points. Arch Phys Med Rehabil. Jul 1998;79(7):863-72. [Medline].
• Hou CR, Tsai LC, Cheng KF, et al. Immediate effects of various physical therapeutic modalities on cervical myofascial pain and trigger-point sensitivity. Arch Phys Med Rehabil. Oct 2002;83(10):1406-14. [Medline].
• Jacob AT. Myofascial pain. In: Physical Medicine and Rehabilitation: State of the Art Reviews. Vol 5. 1991:573-583.
• Rosen NB. Myofascial pain: the great mimicker and potentiator of other diseases in the performing artist. Md Med J. Mar 1993;42(3):261-6. [Medline].
• Travell JG, Simons DG. In: Myofascial Pain and Dysfunction. Vol 2. Baltimore:. Lippincott Williams & Wilkins;1992.
• Wheeler AH. Myofascial pain disorders: theory to therapy. Drugs. 2004;64(1):45-62.

Article Last Updated: Jan 23, 2006