Historically, myofascial pain has been described in the literature,

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1 Myofascial Pain: A Manual Medicine Approach to Diagnosis and Treatment By LUCY WHYTE FERGUSON, DC, and BEN DAITZ, MD Editor s note: Myofascial pain is among the most common pain conditions seen in the general population. Unfortunately, the condition is frequently not diagnosed, or is misdiagnosed in many patients. Myofascial pain syndrome (MPS) is diagnosed in a significant majority of patients seen at the University of New Mexico multidisciplinary pain clinic, and in Lucy Whyte Ferguson s private practice in Taos, New Mexico. Here, Drs. Ferguson and Daitz present a case study and a manual medicine approach to diagnosis and treatment. Introduction Historically, myofascial pain has been described in the literature, with varying terminology, for more than 150 years. Over the past half century, Travell and Simons pioneering research, writing, and teaching has rekindled awareness of the condition, enhanced the clinical acumen and skills of practitioners, and led to more extensive research into this primary diagnostic condition. Myofascial pain is what most of us have experienced in our necks, shoulders, and backs when we ve hunched over computer screens, craned our necks painting, dug holes, and picked weeds. We have invariably overstressed a muscle group, or two, or three, or, not uncommonly, a whole region. The usual causes are trauma or microtrauma to the muscle, overuse, repetitive overload, and faulty workplace ergonomics and biomechanics. In general, myofascial pain is usually a deep, dull, aching pain, but, depending on the circumstances and the anatomy, the pain can be both exquisite and continuous. Myofascial pain is generated by trigger points (TrPs) hyperirritable, very tender knots in taut bands in muscle or fascia that typically cause pain, tenderness, restricted motion, and oftentimes autonomic phenomena when they are palpated or strummed effectively. The characteristic and usually predictable hallmark of a TrP in muscle is that the symptoms may be referred to an area distant from the actual TrP, such that a TrP palpated in the right upper trapezius muscles typically refers pain up, behind, and over the ear to the forehead; or a TrP in the gluteus minimus refers pain down the posterior-lateral leg in a radicular pattern; or a biceps TrP can refer pain to the anterior shoulder.

2 Figure 1. Biceps bracii pain pattern and symptoms TrPs can be either active or latent, with the difference that active points produce or provoke pain that your patient complains about and describes. Latent TrPs may have the other typical characteristics of TrPs, but are largely silent until the examiner finds them. TrPs are found by first asking the right questions, and over time, relearning anatomy so that you know what muscles your patient is pointing to, where they typically refer pain, and most importantly, how to examine and treat them. The pathophysiology of TrP formation is still unclear, but the work of Mense and Simons postulates that secondary to trauma, overload, repetitive use, etc., an increased release of acetylcholine at or near the motor endplate A trigger point in the biceps bracii muscle may cause superficial anterior shoulder pain, NOT deep shoulder pain, and diffuse aching over the anterior surface of the upper arm. The patient may experience pain with elevation of the arm above shoulder level during flexion and abduction, as well as aching and soreness in the upper trapezius muscle. Travell J, Simons DG. Myofascial Pain and Dysfunction, The Trigger Point Manual. Vol 1: Upper Half of Body. 2nd ed. Baltimore, MD: Lippincott, Williams & Wilkins; 1999:649. Reprinted with permission. causes a release and inadequate uptake of calcium ions in the sarcoplasmic reticulum, resulting in shortening of sarcomeres. Sustained shortening can then produce local hypoxia and release of a variety of substances that sensitize nociceptors and cause pain. Myofascial pain is best treated by gently and progressively stretching the involved muscle(s), with careful attention to evaluating other regional muscle involvement. Manual medicine techniques, as described here, are one of several modalities that can be effective alone or combined with other treatments such as trigger point injections, massage, acupressure, and acupuncture. Case Study HG, age 62, a competitive, master swimmer and an avid skier, sought treatment for bilateral shoulder pain that had become chronic and limited his activities over the last year. A year ago the patient fell twice while skiing, impacting his right shoulder both times. He subsequently developed pain in both shoulders, worse on the right, and localized in the anterior deltoid and triceps areas bilaterally. X-rays of his shoulders were negative as was an HLA-B27. His pain lessoned with decreased activities, but worsened as soon as these were resumed. Courses of NSAIDS were not helpful. Massage care was only transiently beneficial. His family physician diagnosed a bursitis, and sports medicine physicians in his hometown considered the pain enigmatic because he had no weakness or restriction of shoulder range of motion. He decided to seek care in our community while on an extended ski vacation, and then planned an MRI of the shoulders if his condition did not improve. At the time of examination, the left shoulder was more painful than the right.

3 Figure 2. Anterior, posterior, and middle pain patterns and symptoms related to scalene muscle trigger points Scalene muscle trigger points typically refer pain into the shoulder area, indicated by patients rubbing the upper half of their arm and reporting disturbed sleep, to the point of sitting up while sleeping for relief. 2nd ed. Baltimore, MD: Lippincott, Williams & Wilkins; 1999:506. Reprinted with permission. deltoid area pain. The biceps were hypertonic enough that there was abnormal stress and concomitant tenderness of the biceps tendons with abduction and external rotation of the humerus. The left humerus was anterior and not located centrically in the glenoid. In other words, scapulohumeral mobility was more compromised on the left side. There was also minor joint restriction in the upper cervical spine and the base of the cervical spine, and the left upper rib/spinal joints. Examination The patient s cervical range of motion was slightly restricted, particularly in cervical rotation, and palpation during this movement revealed that the bilateral scalene muscles did not lengthen enough to allow full left and right cervical rotation. This restricted mobility did not appear to be due to boney or arthritic restriction in the cervical spine. Cervical compression, and compression with lateral flexion to either side did not increase pain in general, and did not refer pain into the shoulder area. The scalene muscles had taut bands with tender TrPs, but palpation of these TrPs did not reproduce the patient s pain. There were also taut bands with TrPs in the levator scapulae, although the hypertonicity was not as severe as that of the scalenes, and the levator scapulae also did not refer pain into the sites of the patient s pain. Biceps and triceps reflexes were equal and active bilaterally. Both scapulae were protracted, with taut bands and tender TrPs in the subscapularis and anterior serratus muscles. Likewise, there were TrPs and hypertonicity palpated in the triceps, deltoids, latissimus dorsi, and pectoralis major and minor muscles, but these were not severe and were not sufficient to explain the patient s pain. The pectoral hypertonicity did contribute to the forward position of both shoulders. The biceps muscles were very hypertonic bilaterally with very tender TrPs, and palpation of these TrPs reproduced the patient s Discussion of Diagnoses and Treatment The most definitive findings we have are the active biceps muscle TrPs (because palpating them reproduces the patient s pain). We will want to release these TrP knots and elongate the taut muscle bands in the biceps muscles. The tenderness of the biceps tendons may be related to actual tendon inflammation, although antiinflammatory medications did not provide significant benefit. The tenderness may also be a referred phenomenon. Furthermore, the short length of the biceps muscles due to the taut bands likely causes significant repetitive strain on the biceps tendons. It is important to treat not only the active TrPs, but the entire functional unit including agonists, antagonists, and to treat bilaterally when indicated. It is always useful to treat muscles in the shoulders whenever we want to treat the neck muscles, and vice versa. Colleagues have also found that it is easier to treat myofascial pain and dysfunction when we also treat the fascia associated with the muscles that are taut and have tender TrPs. In this case, we will want to treat taut bands and tender TrPs and related fascia in most, if not all, of the muscles of the neck and shoulders and including the biceps in the upper arms. In this patient s case, all of his upper biceps area symptoms may be due to the active TrPs in his lower biceps muscles (Figure 1). On the other hand, the

4 Figure 3. Pectoralis major pain pattern and symptoms A trigger point in the pectoralis major may result in chest constriction and hypersensitivity of the nipple. Pain may run down the ulnar aspect of the arm and hand, and the pain can disturb sleep. Clavicular trigger points may restrict horizontal abduction. 2nd ed. Baltimore, MD: Lippincott, Williams & Wilkins; 1999:820. Reprinted with permission. Figure 4. Pectoralis minor pain pattern and symptoms The patient with a trigger point in the pectoralis minor muscle may experience difficulty reaching forward and up and may have difficulty reaching back with the arm at shoulder level. There may be neurovascular symptoms because of entrapment of the brachial plexus. 2nd ed. Baltimore, MD: Lippincott, Williams & Wilkins; 1999:845. Reprinted with permission. Figure 5. Latissimus pain pattern and symptoms Trigger points in the latissimus dorsi may result in pain with depressor movements as well as pain when reaching upward and far out in front of the body. 2nd ed. Baltimore, MD: Lippincott, Williams & Wilkins; 1999:572. Reprinted with permission. tautness of the scalenes (Figure 2), pectoralis major (Figure 3), and pectoralis minor (Figure 4) when considered together with the numerous tender TrPs in these muscles raises the possibility that these muscles may also contribute to the patient s upper arm pain. Each of these muscles has been identified as a possible contributor to anterior upper arm pain. The triceps is not tender, but bilateral latissimus dorsi (Figure 5), subscapularis (Figure 6), anterior serratus (Figure 7), and the left posterior serratus superior muscles (Figure 8) have very significant taut bands with numerous very tender TrPs. Because these muscles and the scalenes are all known to refer pain into the triceps area, we must consider that they may be contributing to the patient s posterior upper arm pain so we will want to focus on treating and reducing this myofascial involvement. While the clinician who performs TrP injections may not want to treat all of these muscles at the same time, the manual therapist faces no such limitation, and is encouraged to address all of these muscles in the neck and shoulders simultaneously (although the therapist is free to decide how many muscles to treat during any particular visit), focusing particularly on treating those muscles known as possible contributors to the patient s pain. Mechanically, when the scapulae are protracted, we can view the result of protraction to be akin to tilting a bowl forward as though to empty out its contents. The tilt of the scapulae automatically places the humerus in a more superficial position in the glenoid. This changes the stresses on the tendons in the anterior shoulder. This patient s left scapulohumeral function was more compromised than the right, and this may have been directly responsible for the fact that the patient was in more pain on the left. Clinically, there is usually a significant increase in muscle hypertonicity in a shoulder in which the humerus is not centrically located in the glenoid. There are also patterns of weakness that result from this mechanical dysfunction. Therefore, it is worthwhile to learn how to address this mechanical dysfunction, because it makes myofascial treatment much more likely to be successful. Furthermore, most of the time, the mechanical dysfunctions can be treated by releasing the taut muscle bands that are holding the scapulae

5 and humerus in dysfunctional relationship. Therefore in this patient s care, it was important to release the taut subscapularis and anterior serratus in order to mobilize the scapulae toward the spine. It was also important to release the pectoralis major and minor in order to release the tethering that is holding the humerus too far forward. If the rib/spinal dysfunction does not automatically shift as the scapulae move more posterior, then the rib/spinal dysfunction will need to be addressed as well. Cervical spine restrictions that have not released with the myofascial procedures can also be directly addressed. This patient did not have significant imbalance in the lower body, but if he had such an imbalance, the clinician would also have to consider addressing that imbalance if it might contribute to the stresses on the upper body. By addressing mechanical dysfunctions and myofascial dysfunctions including muscles that do not necessarily harbor active TrPs, we have a high likelihood of successful treatment of a patient s chronic pain condition. By adopting this kind of comprehensive approach, and verifying and refining our hypotheses by observing the patient s response to care, we are likely to successfully address the patient s pain. The clinician who can keep in mind and juggle multiple possible theories of the causes of a patient s pain, and can proceed to systematically test these out during the treatment process, has discovered the true artistry of myofascial diagnosis and treatment. Treatment of this patient s myofascial dysfunction and pain included passive stretch through range of motion and the application of manual myofascial release techniques, TrP compression, percussion of TrPs, and related fascial release techniques. Treatment of joint dysfunction included scapular mobilization, mobilization of the left humerus into a more centric location in the glenoid, and mobilization of the cervical spinal restrictions and the upper thoracic/rib restrictions. Post isometric relaxation was also used to release the cervical spine into improved joint mobility. Treatment of this patient s joints and muscles was approached with the patient in numerous positions: seated, side-lying on either side, prone, and supine in order to free up more normal patterns of mobility in each of these circumstances. The patient was treated weekly for eight weeks and had weekly massages also. Muscle maps were Figure 6. Subscapularis pain pattern and symptoms In frozen shoulder, abduction is restricted to 45o. Patients are unable to reach across to opposite shoulder or to reach backward with arm at shoulder level. 2nd ed. Baltimore, MD: Lippincott, Williams & Wilkins; 1999:598. Reprinted with permission. Figure 7. Serratus anterior pain pattern and symptoms Patients with a serratus anterior trigger point will report shortness of breath, inability to take a deep breath due to pain, and a stitch in the side while running. 2nd ed. Baltimore, MD: Lippincott, Williams & Wilkins; 1999:888. Reprinted with permission. Figure 8. Serratus posterior superior pain pattern and symptoms A trigger point in the serratus posterior muscle results in steady, deep aching at rest and numbness into the 4th and 5th fingers (C8-T1 distribution). The pain is increased by lifting with outstretched arms or activities causing the scapula to press against the serratus posterior superior, such as lying on the same side. 2nd ed. Baltimore, MD: Lippincott, Williams & Wilkins; 1999:901. Reprinted with permission.

6 highlighted for the massage therapist to help focus the massage care to complement his other care. In order to speed the patient s progress, the patient was also referred for acupuncture dry needling of TrPs, again with a map detailing the target TrPs. During the patient s care, he had five of these sessions with the acupuncturist. The patient was given systematic stretches carefully planned not to stress the biceps tendon. Later in his care, he was given scapular retraction exercises. Early in the patient s care, he fell once on each shoulder while skiing. Despite this, the patient was pain free when he completed the eight weeks of care, and he had been able to resume normal activities without aggravation. He left our community for his home city with a map for his home massage therapist. This case study shows how care planned according to a myofascial diagnostic process differs from localized care of the patient s pain. It also demonstrates that efficient care of chronic pain very often entails a team approach, with a number of care givers. LUCY WHYTE FERGUSON, DC, is in private practice in Taos, New Mexico, and is slated to become an adjunct faculty member of the University of New Mexico School of Medicine (UNMSOM) this summer. BEN DAITZ, MD, is Professor Emeritus at the UNMSOM and attending physician in the Pain Treatment Center. Drs. Whyte Ferguson and Daitz were mentored by Janet Travell, MD, and David Simons, MD, pioneers in the research, diagnosis, and treatment of myofascial pain. They are colleagues in Project ECHO, the UNMSOM s innovative telemedicine clinic, where they are consulting faculty in the Chronic Pain and Headache Clinic, recently selected as a Center of Excellence by the American Pain Society. They will be conducting a hands-on introductory course on the diagnosis and treatment of myofascial pain, December 1-2 in Albuquerque ( BIBLIOGRAPHY Travell JG, Simons DG, Myofascial Pain and Dysfunction: The Trigger Point Manual. Vols 1 & 2. Philadelphia: Lippincott, Williams & Wilkins; 1987, Mense S, Simons DG, Russell IJ, Muscle Pain: Understanding Its Nature, Diagnosis, and Treatment. Philadelphia: Lippincott Williams & Wilkins;2001:385. Gerwin RD. Classification, epidemiology, and natural history of myofascial pain syndrome. Curr Pain Headache Rep. 2001;5: Shah JP, Phillips TM, Danoff JV, Gerber LH. An in vitro microanalytical technique for measuring the local biochemical milieu of human skeletal muscle. J Appl Physiol. 2005;99: Cummings M. Regional myofascial pain: diagnosis and management. Best Prac Res Clin Rheumatol. 2007;21(2):