Myofascial pain syndrome (MPS) is a disorder that can develop in skeletal muscles and the membranes (fascia) that cover them. Patients have specific areas of deep tenderness in the muscles, called trigger points, that may occur as a result of trauma, a repetitive motion injury, prolonged improper posture, or a disease such as arthritis.
Myofascial pain syndrome (MPS) is a musculoskeletal disorder that can develop in one or more skeletal muscles, resulting in chronic pain. “Myo” refers to muscle, and “fascia” is a membrane that covers muscles.
Osteoarthritis is the most common type of arthritis and is caused by joint cartilage deterioration.MPS is defined by the presence of trigger points (“TrPs”). Responsible for causing the pain, TrPs are localized areas of deep tenderness in the taut bands of skeletal muscles. They which may occur as a result of trauma, a repetitive motion injury, prolonged improper posture or an illness such as arthritis, diabetes or hypothyroidism.
TrPs are commonly found in the muscles of the trunk and head (axial muscles), especially those used for maintaining posture, in people of all ages. When pressure is applied, TrPs cause a local twitch response, also known as a “jump sign,” that is an involuntary shortening of the fibrous muscle band.
When felt (palpated), TrPs feel extremely tender and lumpy, like hardened nodules or peas. Not only are TrPs very painful, but they also transmit (“refer”) pain to other parts of the body. For instance, TrPs in the head, neck and upper back may result in headaches, TMJ-like jaw pain, neck pain, shoulder pain or lower back pain. The referred pain is often described as dull, aching and deep, and it can be constant or sporadic.
Myofascial pain syndrome patients often have TrPs in more than one location. Just applying pressure on a TrP will elicit the referred pain. If the patient has chronic pain, palpation can worsen the pain.
TrPs can be classified as either active or latent. Active TrPs cause ongoing, persistent pain, whereas latent TrPs are inactive until pressure is applied. In addition, psychological stress, muscle tension and physical factors such as poor body mechanics and posture and ergonomics can cause a latent TrP to become active.
The likelihood of developing active TrPs increases with age. Research suggests that sedentary people are more prone to develop active TrPs than individuals who exercise regularly. However, overexertion can aggravate the condition. When palpated, both active and inactive TrPs cause pain, decreased range of motion and weakness in the affected muscle group as well as a decreased ability of the muscle to stretch.
Often, active TrPs can trigger secondary TrPs or satellite myofascial points that respond because of the increased stress to the involved muscle groups.
A secondary TrP can occur when a person avoids using the affected muscle and instead overloads another muscle used in compensation.
A satellite myofascial point occurs when the pain from the affected muscle spreads to a nearby muscle. The new area of pain occurs because the muscle is located within the referred pain region of another TrP.
Though pain is the main component of this syndrome, MPS may also involve fatigue in addition to disturbances in sleep and mood (e.g., insomnia, depression, anxiety). Myofascial pain syndrome is not inflammatory, degenerative (such as osteoarthritis) or life-threatening, but it does impair quality of life. However, prognosis for recovery is good if treatment is started early and factors aggravating the TrPs are corrected or eliminated.
Myofascial pain syndrome is common and can affect men and women alike. However, patients with the syndrome are often misdiagnosed because not enough is known about it and symptoms are similar to various other conditions and disorders, such as, fibromyalgia, migraines, TMJ disorder and chronic fatigue syndrome. In addition, it is possible for Myofascial pain syndrome and fibromyalgia to co-exist in a patient. In such cases, each disorder reinforces and exacerbates the symptoms of the other.
Risk factors and causes of Myofascial pain syndrome
Because of limited clinical research, the causes of myofascial pain syndrome (MPS) are not thoroughly understood. However, physicians have identified several factors that can lead to the development of one or more trigger points (TrPs) resulting in chronic musculoskeletal pain. These include:
- Trauma to the musculoskeletal tissues (e.g., muscles, ligaments, tendons, bursae)
- Repetitive motion injuries, such as bursitis or tennis elbow
- Poor posture and ergonomics
- Skeletal asymmetry (e.g., gait disturbances such as leg-length discrepancies, short upper arms)
- Sedentary lifestyle
- Nervous tension or stress
- Clenching or grinding the teeth (bruxism)
- Sleep deprivation
- Nutritional deficiencies (e.g., low levels of calcium, potassium, iron and vitamins C, B1, B6 and B12)
- Hormonal changes, such as occurs during menstruation and menopause
- Chilling areas of the body (e.g., sitting under an air conditioning vent for long periods of time)
- Smoking cigarettes
Additionally, many chronic illnesses may activate TrPs, such as:
- Viral or bacterial infections
- Inflammatory diseases including: Rheumatoid arthritis. Inflammation of the joints that can lead to damage, pain and reduced movement.
- Fibromyalgia. A rheumatic condition characterized by widespread pain in the joints, muscles, tendons and other soft tissues, among other symptoms. MPS can also co-exist with fibromyalgia.
- Appendicitis, gallbladder or stomach inflammation.
- Lupus. An autoimmune disorder that can affect many systems, including the skin, joints and internal organs.
- Other conditions, such as abnormal levels of blood sugar (e.g., diabetes, hypoglycemia), heart attack, hyperuricemia (buildup of uric acid in the blood, associated with gout and kidney stones), and hypothyroidism (underactive thyroid gland).
Signs and symptoms of Myofascial pain syndrome
Myofascial pain syndrome (MPS) is primarily associated with chronic regionalized musculoskeletal pain. The pain may be aggravated by poor sleep, inactivity, anxiety and stress. Other signs and symptoms include:
Multiple trigger points (TrPs). Areas of extreme tenderness in a skeletal muscle or muscle group, which are associated with local or regional pain. These points can also cause referred pain to other areas of the body, such as the jaw, neck, back, buttocks, thigh, leg, knees, calf, foot and/or heel.
Muscle stiffness or weakness with a tendency to drop objects. However, there is no sign of muscle atrophy.
- Difficulty in sustaining repetitive motor tasks because of increased pain and fatigue.
- Migraines and other headaches.
- Mood disturbances (e.g., irritability, depression, anxiety).
- Sleep disturbances (e.g., insomnia, sleep apnea).
- Other symptoms, including:
- Joint pain
- Earaches, ringing in the ears (tinnitus), orofacial pain, dental pain or teeth grinding and clenching (bruxism)
- Heartburn or irritable bowel syndrome
- Excessive menstrual pain (dysmenorrhea)
- Painful intercourse
- Increased sweating, lacrimation (secretion of tears) and salivation
- Shortness of breath
- Vision problems
Diagnosis methods for Myofascial pain syndrome
As with fibromyalgia, there are no diagnostic laboratory or imaging tests available for myofascial pain syndrome (MPS), and many physicians are not adequately informed or educated about it.
Medical history and physical examination are the keys for making the diagnosis. The medical history should include a detailed pain history, including when and how the pain began, the exact location of pain, which treatment therapies have been attempted (and their results) as well as any incidences of trauma, repetitive motion injuries or illness present.
When performing the physical examination, the physician will focus on the areas of pain and discomfort and observe the patient’s movements and posture. To enable the identification of the characteristic trigger points (TrPs), the patient should be as relaxed as possible. The physician will feel the muscles by palpation (applying pressure with one to three fingers and the thumb) to locate the TrPs, which consist of tender, hard (or ropy) knots or nodules surrounded by what feels like normal muscle tissue. Once a TrP has been located, the local twitch response may be elicited as muscle or skin twitching.
A physician will look for the four types of TrPs associated with Myofascial pain syndrome:
- Active TrPs. Areas of extreme tenderness located in skeletal muscles resulting in local or regional chronic pain.
- Latent TrPs. Dormant (inactive) areas in the muscles that can potentially become painful when activated by factors, such as palpation, trauma, stress or illness.
- Secondary TrPs. Hyper-irritable areas in the muscles, which become active due to the presence of other TrPs and muscular overload in other muscles.
- Satellite myofascial points. Hypersensitive spots in the muscles that become active because they are located within the region of other TrPs.
Physicians may perform additional diagnostic tests to help exclude certain other conditions with similar symptoms or identify conditions exacerbating the symptoms. These can include:
- Blood tests such as:
Complete blood count. Measures the number of red blood cells, white blood cells and platelets in a patient’s blood as well as the amount of hemoglobin (a substance that carries oxygen throughout the body) in the red blood cells and a number of other factors. Some rheumatic conditions or certain drugs used in the treatment of arthritis are associated with low counts of white blood cells (leukopenia), red blood cells (anemia) or platelets (thrombocytopenia).
- Enzyme test. A group of blood and/or urine tests that measure enzymes (proteins required for chemical reactions to take place in cells) levels in the blood. These tests assess how well the body’s systems are functioning and whether any tissue damage has occurred.
- Sedimentation rate. Can indicate the presence of inflammation typical of many forms of arthritis (e.g., rheumatoid arthritis, ankylosing spondylitis) and many of the connective tissue diseases (e.g., lupus).
- Testing for levels of vitamins C, B1, B6, B12 and folic acid in the blood. Deficiencies of these vitamins have been associated with Myofascial pain syndrome.
Other tests, such as:
- Ultrasound. An imaging technique that uses high-frequency sound waves to obtain images inside the body. It is more effective than an x-ray in displaying soft tissue masses and can show tears in ligaments, muscles, tendons and other soft tissue masses in the back that may be responsible for the pain.
- Thermography. A safe and noninvasive technique that uses infrared or liquid crystal light recorders to take thousands of pictures of the body. The information is then converted into electrical signals, which results in a computer-generated two-dimensional picture of abnormally cold or hot areas indicated by color or shades of black and white. Thermography may be used to detect vascular disease of the head and neck, soft tissue injury, various neuromuscular disorders, and the presence or absence of nerve root compression.Electrodiagnostics assess muscle function (e.g., electromyography [EMG], nerve conduction study).
- Electromyography (EMG). A test that measures the electrical activity generated by active muscles to assess nerve function and diagnose causes of neuromuscular problems.
Physicians may also require formal or informal assessments to detect potential mood and sleep disturbances, such as depression, anxiety and insomnia, which are common related symptoms of MPS.
Treatment options for Myofascial pain syndrome
The prognosis for myofascial pain syndrome (MPS) is good if treatment is started before symptoms become acute and aggravating factors, such as poor posture or excessive muscle overload, are eliminated. Other conditions, including many that are symptoms of or occur simultaneously with MPS (e.g., migraines, depression, anxiety, diabetes, fibromyalgia, insomnia) should be treated, as they may aggravate other Myofascial pain syndrome symptoms when uncontrolled.
Finding the right physician is crucial in treating Myofascial pain syndrome because not all physicians have experience treating this type of pain disorder. It is recommended that patients seek care with a physician specializing in pain management, a growing medical specialty incorporating anesthesia and physical medicine and rehabilitation.
Treatment of Myofascial pain syndrome centers on reducing the musculoskeletal pain and improving muscular function. All treatment options, including those the individual can do on their own, should be discussed with a physician. These may include:
- Physical therapy. Therapists focus on correction of muscle shortening by targeted stretching and strengthening of the affected muscles, and correction of aggravating factors (e.g., improper posture and ergonomics). Modalities such as diathermy and ultrasound therapy can be used to reduce pain.
Therapists may also perform a spray and stretch technique. This involves spraying a muscle with a topical anesthetic to numb the area and then stretch out the painful, contracted muscle to reduce pain and stiffness. Many therapists use ice instead of the spray, because the spray is costly and ice usually is just as effective.
- Manipulation therapy. Myofascial release therapy involves working on tight, contracted muscles and TrPs to release or stretch out the problem areas. Massage therapists generally work lightly and progress slowly in doing deep muscle work. The results of massage can last a considerable time.
Occupational therapy. This type of therapy can be helpful in assessing and setting up ergonomically correct workstations to prevent exacerbation and/or recurrence of symptoms. Properly set-up work sites can help to decrease aggravating factors, such as poor posture. Occupational therapists can also offer expertise on home modifications, task simplification and energy conservation to reduce fatigue and pain.
Cryotherapy (cold therapy). Therapy using a cold substance can reduce pain and inflammation; however, prolonged use can injure skin.
- Thermotherapy (heat therapy). Heat therapy is usually used in rehabilitation to relieve joint stiffness. Moist heat, done by combining hydrotherapy with thermotherapy, penetrates deeper into the muscle and offers more relaxation than dry heat. Too much heat can cause burns. Heat should not be used on sensitive skin and may need to be avoided when using analgesics.
- Cognitive behavioral therapy. This form of psychological treatment can help people replace negative thoughts with positive ones and provide coping strategies.
- Injection therapy. Physicians may inject medication directly into the TrPs to relieve pain. A physician may recommend trigger point injections only when other, less invasive methods fail to eliminate the pain. These treatments can be very effective in individuals who have long standing pain.
Other complementary and alternative medicine techniques can be tried in some patients:
- Dental appliances. A mouth guard worn at night can help in cases caused or exacerbated by clenching or grinding of the teeth.
- Biofeedback. Information about typically unconscious bodily functions (e.g., muscle tension and blood pressure) is used to help gain conscious control over those functions. Electrodes are placed on the muscles to identify which are in use. People can then try to consciously lower muscle tension in that area.
- Acupressure. Pressure is used on target points of the body to control symptoms.
- Acupuncture. Thin needles are inserted into target points of the body to ease pain and improve sleep patterns. Controversy remains as to its effectiveness, but some studies show significant beneficial results.
When used in conjunction with active treatment therapies, the use of certain medications may help alleviate symptoms. These include:
- Nonsteroidal anti-inflammatory drugs (NSAIDs). Usually used to treat inflammation, NSAIDs also help ease muscle aches and may help make patients more comfortable in exercising and returning to daily activities.
- Muscle relaxants. By reducing the ability of the muscles to contract, these drugs help alleviate muscle pain.
- Antidepressants. Used in lower doses when treating MPS than when treating depression unless the patient is also suffering with depression. Even at low doses, side effects are common, including dry mouth, weight gain, constipation and lack of concentration. Tricyclic antidepressants relax muscles and heighten the effects of endorphins and may be taken at bedtime to help promote restorative sleep. The U.S. Food and Drug Administration (FDA) has approved a selective serotonin and norepinephrine reuptake inhibitor (SSNRI) to relieve some types of nerve pain.
Patients should be aware that a physician may need to adjust the dosage or change medications to achieve the best results with minimal side effects. In addition, the U.S. Food and Drug Administration has advised that antidepressants may increase the risk of suicidal thinking in younger patients and all people being treated with them should be monitored closely for unusual changes in behavior.
- For improvement to be significant, patients must adhere to an active medical treatment plan as outlined by their physician. In addition, patients should continue seeing their physician until symptoms have resolved or stabilized at maximum medical improvement.
Prevention of Myofascial pain syndrome
By eliminating factors that contribute to the musculoskeletal pain, patients with myofascial pain syndrome (MPS) have reported vast improvement and prevented recurrent activation of trigger points. This can be done by:
- Correcting physical asymmetries. Some people are born with gait disturbances, such as one leg that is slightly longer than the other. Leg-length discrepancy due to an anatomically shorter limb or a locked sacroiliac joint can also lead to significant myofascial back pain. The asymmetry caused by these anatomic variations may be corrected with the use of heel lifts, dynamic insoles or buttock lifts.
- Using good posture. Good posture minimizes stress and improves efficiency in the use of muscles. Correcting poor body posture and alignment is an important component of treating patients with Myofascial pain syndrome.
- Proper ergonomics and body mechanics. Certain jobs and work activities (e.g., data entry, construction, assembly-line workers) are associated with an increased risk of developing cumulative trauma that leads to musculoskeletal disorders, including MPS. Modifying the workplace or the patient’s work habits is important in reducing pain and discomfort. However, in some cases patients may need to change careers.
- Nutrition. Getting proper nutrition ensures that the body has what it needs to function and heal. Deficiencies in vitamins C, B1, B6, B12 and folic acid have been linked to MPS. In addition, eating a well-balanced diet is believed to help improve symptoms of pain, depression, fatigue and headaches.
- Relaxation techniques. Psychological stress may aggravate Myofascial pain syndrome symptoms by activating TrPs. Relaxation and stress management techniques may be employed to manage stress and pain. Deep breathing, visual imagery and relaxing audio may be used as effective tools for relaxation.
- Exercise. Regular exercise has been shown to decrease pain and increase endurance and is essential for long-term recovery of Myofascial pain syndrome. A rehabilitation program should include postural and strengthening exercises as well as aerobic conditioning. Posture-enhancing exercises improve musculoskeletal alignment, thereby enhancing balance and promoting relaxation. Strengthening and aerobic conditioning improve not only strength and endurance, but also blood circulation in the muscles.
- Muscle soreness may be minimized with relaxation, heat, steady breathing and drinking adequate water. Stretching prior and after exercising is also extremely important to lengthen muscles and maintain their length, help muscles relax, improve ability to move muscles and decrease pain.
- Limiting or avoiding alcohol consumption and cigarette smoking.
- Getting enough rest. Striving for restful sleep is important in the treatment of Myofascial pain syndrome. Sleep deprivation can be a major factor in the continuation of musculoskeletal pain. Patients are encouraged to get seven to eight hours of sleep each night. A healthy sleep regimen is crucial to improving sleep and includes going to bed at the same time every night, avoiding exercise three hours before going to bed and limiting caffeine and sugar intake before bedtime.
Questions for your doctor regarding Myofascial pain syndrome
- Preparing questions in advance can help patients to have more meaningful discussions with their physicians regarding their conditions. Patients may wish to ask their doctor the following questions about myofascial pain syndrome (MPS):
- What is your experience in diagnosing and treating patients with MPS?
- Can you recommend a physical therapist experienced with MPS treatment?
- Should I make any changes to my living and working environments?
- What kind of fitness regimen should I consider?
- Are there changes I should make in my diet?
- Are there any complementary treatments that may be helpful for me?
- How will any of my pre-existing conditions affect MPS?
- How might I reduce the likelihood of symptom flare-ups?
- Can you refer me to a counselor or support group for MPS?
- Is my MPS curable?
- Can you refer me to a pain management specialist?