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Myofascial Pain Syndrome
From WikiSM
Contents
Other Names
- Myofascial Neck Pain
- MPS
- Myofascial trigger points (MTrPs)
Background
- This page refers to 'myofascial pain syndrome' (MPS), a myalgic condition
- Definition: non-inflammatory disorder of musculoskeletal origin, associated with pain and muscle stiffness, characterized by the presence of trigger points
Epidemiology
- Not well described in the literature
- One study estimated 30% of patients with musculoskeletal complaints suffered from MPS[1]
- Average age range is typically 27-50 years[2]
Pathophysiology
- Pathophysiology is poorly understood
- Energy crisis of muscle fibers is one postulated theory
- Repetitive or pronged activity leads to overload myofibrils with subsequent hypoxia, ischemia
- Dysfunctional intracellular calcium pumps
- Inflammatory state
- Other proposed theories include:
- Neurogenic inflamation
- Sensitization and limbic dysfunction
- Trigger points (TP) can be more accurately defined as "hyperirritable palpable nodules in the skeletal muscle fibers"
- Also described as tender points in a taut band of muscles
- Defined as detectable superficial palpable tenderness in the muscle or located in areas of spasm
- Typical size is 2-10 mm
- Sensitivity of spot generally increases with increased tension/ pressure
- Patients may have active or latent trigger points
- Trigger points may oscillate between active and latent depending on internal or external stressors
- Perpetuating and aggravating factors may lead from an acute to a more chronic syndrome
- Other diseases can look like MPS making it a challenging diagnosis
- No diagnostic gold standard, imaging, or laboratory modality for MPS
Etiology
- Traumatic events
- Muscular overloads such as overuse activities, abnormal posture
- Structural factors such as spondylosis, scoliosis and osteoarthritis
- Psychological stress
- Systemic pathology including hypothyroidism, vitamin D deficiency and iron deficiency.
- Physical deconditioning
Risk Factors
- Structural
- Systemic
Differential Diagnosis
Differential Diagnosis Neck Pain
- Fractures
- Subluxations and Dislocations
- Neuropathic
- Muscle and Tendon
- Pediatric/ Congenital
- Other Etiologies
Differential Diagnosis Back Pain
- Fractures
- Neurological
- Musculoskeletal
- Autoimmune
- Infectious
- Pediatric
Clinical Features
- General: Physical Exam Neck, Physical Exam Back
- History
- Patients often suffer from localized muscle pain and referred pain in patterns
- Infraspinatus pain can be referred to the Deltoid area
- Onset of symptoms may be acute or more insidious
- Some patients may have precipitating illness or trauma, others have no clear cause
- Physical Exam
- Digital pressure on a tender spot elicits pain similar to their usual pain distribution and/or aggravate current pain
- May reproduce a loccal twitch response by repetitive stimulation of the trigger point
- Pain may be referred to other areas
- Range of motion can be restricted
- Special Tests
- Jump Sign: Palpation of tender nodule cause spontaneous exclamation or movement
Evaluation
- Primarily a clinical diagnosis
Radiographs
- Can be useful to exclude other etiology of the affected area(s)
Ultrasound
- Trigger points may be more hypoechoic compared to surrounding muscle (need citation)
- Useful to exclude other pathology
EMG/NCS
- End plate noise
Classification
- Acute MPS
- Chronic MPS (persists longer than 6 months)
Management
Prognosis
- By definition, non surgical
- Primary goal should be to treat suspected underlying causal or contributing factors
- Acute patients tend to have a favorable prognosis
- In chronic cases, the average duration of symptoms is 63 months, with a range between 6 and 180[3]
Analgesics
- NSAIDS
- Oral formulations not studied in MPS however shown to help in MSK conditions
- Hsieh et al: Topical diclofenac patch helped with symptoms of myofascial pain of the trapezius[4]
- Tropisetron
- Used for fibromyalgia, myofascial pain
- One study showed it was superior to local anesthetics when used for local trigger point injections[5]
- Opiates are not generally indicated
- Lidocaine Patch
- Limited studies showing some benefit[6]
Muscle Relaxants
- Tizanidine
- Malanga et al: effective in treating spasticity, pain in up to 89% of patients and 79% of physicians[7]
- Benzodiazepines
- One study showed statistically significant decrease in pain[8]
- Cyclobenzaprine has not been studied in MPS
Anticonvulsants
- Gabapentin not studied in MPS
- Pregabalin not studied in MPS
Antidepressants
- Tricyclic Antidepressants not studied in MPS
- Duloxetine not studied in MPS
- Sumatriptan
Other Pharmacotherapy
- Botox (Botulinum Toxin)
Nonpharmacologic Therapies
- Dry Needling
- Hong et al showed benefit with or without lidocaine[11]
- Trigger Point Injections
- systematic review article concluded the ‘‘nature of the injected substance makes no difference to the outcome and that wet needling is not therapeutically superior to dry needling’[12]
- Corticosteroid Injections are not currently recommended
- Manual Therapy
- Considered one of the more effective treatments for MPS
- Definition is broad and includes deep pressure massage, spretch therapy, superficial heat, myofascial release among others
- No high quality studies evaluating manual therapy
- Therapeutic Ultrasound
- Most studies have found mixed results, although they are generally of poor quality
- Gam et al found no benefit for therapeutic ultrasound in any MSK disorder[13]
- Transcutaneous Electric Nerve Stimulation (TENS)
- Multiple studies appear to show some benefit among non-invasive modalities
- One study compared it to trigger points and showed no statistically significant difference[14]
- Magnetic Stimulation
- Physical Therapy
- Patients should be educated on stretching exercises
Rehab and Return to Play
Rehabilitation
- Needs to be updated
Return to Play
- Needs to be updated
Complications
- Chronic pain
See Also
- Internal
- External
- Sports Medicine Review Neck Pain: https://www.sportsmedreview.com/by-joint/neck/
References
- ↑ Skootsky SA, Jaeger B, Oye RK. Prevalence of myofascial pain in general internal medicine practice. West. J. Med. 1989 Aug;151(2):157-60
- ↑ Vázquez-Delgado E, Cascos-Romero J, Gay-Escoda C. Myofascial pain syndrome associated with trigger points: a literature review. (I): Epidemiology, clinical treatment and etiopathogeny. Med Oral Patol Oral Cir Bucal. 2009 Oct 01;14(10):e494-8.
- ↑ Gerwin RD. Classification, epidemiology, and natural history of myofascial pain syndrome. Curr Pain Headache Rep. 2001 Oct;5(5):412-20.
- ↑ Hsieh L, Hong C, Chern S. Efficacy and side effects of diclofenac patch in treatment of patients with myofascial pain syndrome of the upper trapezius. J Pain Symptom Manag. 2010;39:116–25
- ↑ Muller W, Stratz T. Local treatment of tendinopathies and myofascial pain syndromes with the 5-HT3 receptor antagonist tropisetron. Scand J Rheumatol Suppl. 2004;119:44–8.
- ↑ Affaitati G, Fabrizio A, Savini A, et al. A randomized, controlled study comparing a lidocaine patch, a placebo patch, and anesthetic injection for treatment of trigger points in patients with myofascial pain syndrome: evaluation of pain and somatic pain thresholds. Clin Ther. 2009;31:705–20.
- ↑ Malanga G, Gwynn M, Smith R, Miller D. Tizanidine is effective in the treatment of myofascial pain syndrome. Pain Physician. 2002;5:422–32.
- ↑ Fishbain D, Cutler R, Rosomoff H, Rosomoff R. Clonazepam open clinical treatment trial for myofascial syndrome associated chronic pain. Pain Med. 2000;1:332–9
- ↑ Benecke R, Heinze A, Reichel G, Hefter H, Gobel H, Dysport Myofascial Pain Study Group. Botulinum type A toxin complex for the relief of upper back myofascial pain syndrome: how do fixed-location injections compare with trigger point-focused injections? Pain Med. 2011;12:1607–14.
- ↑ Lew H, Lee E, Castaneda A, Klima A, Date E. Therapeutic use of botulinum toxin type A in treating neck and upper-back pain of myofascial origin: a pilot study. Arch Phys Med Rehabil. 2008;89:75–80.
- ↑ Hong, Chang-Zem. "Lidocaine injection versus dry needling to myofascial trigger point. The importance of the local twitch response." American journal of physical medicine & rehabilitation 73.4 (1994): 256-263.
- ↑ Cummings T, White A. Needling therapies in the management of myofascial trigger point pain: a systemic review. Arch Phys Med Rehabil. 2001;82:986–92.
- ↑ Gam A, Johannsen F. Ultrasound therapy in musculoskeletal disorders: a meta-analysis. Pain. 1995;63:85–91
- ↑ Gu¨l K, Onal SA. Comparison of non-invasive and invasive techniques in the treatment of patients with myofascial pain syndrome. Agri. 2009;21:104–21.