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Myofascial pain syndrome

Contributors
Charles Argoff MD, author. Dr. Argoff, Director of the Comprehensive Pain Program at
Albany Medical College and Albany Medical Center, has no relevant financial
relationships to disclose.

Howard Smith MD, author. Dr. Smith, Academic Director of Pain Management at
Albany Medical College, has no relevant financial relationships to disclose.

Randolph W Evans MD, editor. Dr. Evans of Baylor College of Medicine received
honorariums from Allergan, Astellas, DepoMed, GlaxoSmithKline, Lilly, Merck,
Nautilus, Teva, and Zogenix for speaking engagements.

Publication dates
Originally released June 9, 1998; last updated October 23, 2012; expires October 23,
2015

Historical note and nomenclature
It has been nearly a century since Sir William Gowers introduced the term fibrositis
for a common, but idiopathic, localized form of muscular rheumatism that is now
recognized as myofascial pain syndrome (Gowers 1904). Despite the intervening
years, myofascial pain syndromes constitute the largest group of unrecognized and
undertreated acute and chronic medical problems in clinical practice today, and these
are among the most commonly overlooked causes of chronic pain and disability in
medicine (Simons 1988).
Historical perspectives. As first defined by Gowers in 1904, the term “fibrositis”
referred to the local tenderness and regions of palpable hardness in the muscle, which
he attributed to inflammation of fibrous tissue. Though initially embraced in the
literature, the concept of fibrositis as inflamed connective tissue fell into disfavor as
subsequent biopsy data failed to substantiate inflammatory pathology. It was not until
the late 1930s that the first physiologic-based evidence came with Kellgren's
observations on the nature of pain originating from deep connective tissue
structures (Kellgren 1938). Using hypertonic saline injections to irritate different
anatomical areas including fascia, tendon, and muscle, he demonstrated that pain was
produced that differed not only in quality but also in its specific referral pattern.
Although the term "myofasciitis" was first introduced in 1927 by Albee, it was not until
1939, in a paper read on low back pain, that Steindler first used the terms
"myofascial pain" and "trigger point" (Albee 1927;Steindler 1940). Travell and
colleagues used the term trigger point in 1942 to describe the site from which pain
was referred, and in 1952, adopted the expression "myofascial pain
syndrome" (Travell et al 1942; Travell and Rinzler 1952). In 1954, Schwartz reported
that inactivation of trigger points by procaine injection was often an important part of
the management of pain in the temporomandibular joint region (Schwartz 1954).
According to Travell, it was Good who recognized the pathognomonic trademark of
myofascial pain syndrome, now called the “jump sign,” where a patient responded
with a cry, grimace, or wince to palpation of the painful muscle focus (Travell 1983).
Travell first published a paper describing the diagnostic criteria and treatment
protocols for myofascial pain syndrome in 1942. This paper established the foundation
for the modern approach to this syndrome. In 1953, Bonica published a text
separating myofascial pain syndrome from fibrositis (Bonica 1953). Janet G Travell
(1901 to 1997) relieved then-Senator John F Kennedy of disabling back pain using her
trigger point management techniques in 1955. She was appointed as the White House
physician during the presidencies of John F Kennedy as well as that of Lyndon B
Johnson. The subsequent work of Travell and Simons elucidated trigger points and
zones of radiating pain, as well as the taut bands of myofascial pain syndrome,
codifying their locations in virtually every muscle of the body (Travell and Simon

The terms nonarticular and psychogenic rheumatism. shoulders. The confusion in nomenclature has been compounded by the widespread belief that these musculoskeletal pain syndromes are psychogenic in nature. suggesting psychologic dysfunction as their primary cause as opposed to physical factors. chronic postural imbalance. Myofascial pain due to active trigger points can present as an acute. Simons 1991). with many of these overlapping disorders representing local forms of myofascial pain. Signs and symptoms. pain-reinforcing behavior. no neurologic deficits are associated with this syndrome. and the failure to reduce other contributing factors. strains. The localized pain within the taut band is knows as a "trigger point. neck. Palpation of the affected muscles reveals a hyperirritable focus of localized pain. setting up a self- generating pain cycle that is perpetuated through lack of proper treatment. therefore. sustained muscle tension. As late as the 1970s. such as sleep disturbances. Using the classification of the International Association for the Study of Pain." A taut band is defined as an area within skeletal muscle of increased consistency or hardness that extends along the length of the muscle and runs parallel to the direction of the muscle fibers at that point in the muscle. as well as almost any unexplained musculoskeletal pain problem. most major textbooks considered fibrositis to be a disease with strong psychogenic overtones (Rosen 1993). either local or distant from the pain. These points occur most frequently in the head. expects it to be self-limited as is postexercise soreness. Clinical manifestations Current studies indicate that myofascial pain is the most common single source of musculoskeletal pain and that it compares in severity with other painful conditions that cause the patient to seek medical assistance (Fricton et al 1985. or chronic pain syndrome. A source of controversy relative to the acceptance of the concepts of myofascial pain and dysfunction has been the varied terminology used throughout the literature. and repetitive injury or strain syndromes fail to address the more critical issues regarding pathogenesis. The patterns of referral for each trigger point are consistent among different persons. recurrent." . The patient with acute-onset myofascial pain usually associates the onset of pain with a specific overload of the muscles and. Similarly. distorted muscle posture. and sprains. unless neurovascular compression with weakness and diminished sensation coincide with the muscle trigger points. The characteristics of myofascial pain syndrome may long outlast the initiating events. no universally accepted terminology allows clinicians to more accurately codify the dysfunction seen in patients who present with musculoskeletal pain and dysfunction (Thompson 1990). such as fibromyalgia. and psychological distress(Travell and Simon 1991). The principal clinical features of myofascial pain syndrome include pain and tenderness localized to a single muscle or region. associated with a unique and stereotypic pattern of radiating pain. The term “fibrositis. soft tissue disability. Active trigger points are also characterized by specific patterns of pain radiation during palpation that depend on the location of the trigger point. such localized disease is now currently termed "specific myofascial pain syndrome" (Merskey and Bogduk 1994). which apparently have not been appreciated as such. including overuse syndromes. Generally. which is discrete and lies within a structure known as the "taut band. and lower back. Myofascial pain syndrome is now understood to refer to a spectrum of clinical presentations distinct from other musculoskeletal conditions. The mechanisms that produce the symptoms of myofascial pain are also largely speculative. has been used erroneously to include both myofascial pain syndrome and fibromyalgia. fatigue of the muscles from repeated overuse.1983. tension myalgia.” in particular. Controversies in nomenclature. repetitive trauma syndromes. Atrigger point is defined as a localized tender area within a taut band of skeletal muscle or its associated fascia. 1991). Currently. current terms. Travell and Simon have proposed that the initial changes may be precipitated by such factors as local trauma. and muscle contraction states also have remained in use. Myofascial syndrome is defined as a pain disorder involving pain referred from trigger points within myofascial structures.

When latent. Latent trigger point A subclinical trigger point that does not spontaneously cause pain but elicits a zone of muscle-specific referred pain on palpation. Clinical Features of Myofascial Pain Local pain and Usually limited to 1 or a few discrete muscles within a tenderness specific region or miotic unit. Without perpetuating factors. have been documented by measuring the effect of experimental muscle pain on static and dynamic muscle function (Graven-Nielsen et al 1997). trigger points usually persist and become chronic. and an active trigger point tends to revert to and persist as a latent trigger point. In the presence of 1 or more perpetuating factors. The region of referred pain within the myotome specific for each individual muscle-derived trigger point displays continuous pain in a "zone of reference. psychosocial dysfunction. Zone of reference A unique region within the myotome specific for each muscle-derived trigger point and to which pain. a sharp localized pain that is well demarcated can be elicited.paresthesias. and range from 2 to 5 mm in diameter. which remain stereotypic between individuals. Myotatic unit A group of agonist and antagonist muscles. Taut band A discrete area of increased consistency or hardness within a muscle and associated with a trigger point. Trigger points are classified as either active or latent. and tenderness may refer. and deconditioning. Epiphenomena Neurovascular entrapment. which function together as a unit because they share common spinal reflex responses. endurance. referred autonomic phenomena. the trigger points are quiescent and result primarily in muscle tightness and dysfunction without the presence of persistent or spontaneous pain except when palpated. described as deep (subcutaneous and muscular) and aching in character with slightly blurred edges that project well beyond the originating trigger point. Most commonly. or sclerotomal referred pain patterns." These pain reference zones. The associated symptoms observed with active trigger points. may or may not mimic more traditionally recognized dermatomal. and range of motion. Active trigger points are hypersensitive and can be associated with 2 types of pain that may occur spontaneously with muscle use or with palpation on examination. They may then propagate to other muscles as secondary and satellite trigger points Table 1. . Satellite trigger point A trigger point that becomes active because it falls within the zone of reference of another trigger point. including decreased muscle strength. referred pain may spontaneously subside within a few days or weeks. Trigger point inactivation The immediate alleviation of pain and weakness by elongation of the muscle or trigger point injection. myotomal. Active trigger point A hyperirritable focus within a taut band that is tender on palpation and refers pain in a characteristic pattern unique to the muscle. as can a radiating or referred pain.

and (2) nerve compression effects of numbness and tingling. Tinnitus has been reported to be associated with trigger point palpation in the masseter muscle as well. Several common neurovascular entrapment syndromes are now associated with specific. Visual disturbances are also reported with sternocleidomastoid trigger points. Neurovascular Entrapment in Myofascial Pain Syndrome Nerve or vessel Muscle Clinical syndrome Greater occipital nerve Semispinalis capitis Occipital neuralgia Brachial plexus (lower trunk) Scalenes Thoracic outlet syndrome subclavian vessels Sciatic and pudendal nerve. The signs and symptoms of partial neurapraxia may sometimes be relieved within minutes after inactivation of the responsible myofascial trigger point. and pilomotor activity. Disturbance of vestibular function and space perception may originate in trigger points in the clavicular division of the sternocleidomastoid muscle. Occasionally. and sometimes hyperesthesia. The seminal work by Louis and Kellgren documented and mapped the stereotypic referred pain patterns of many major muscles by injecting hypertonic saline into the muscles of numerous volunteers and themselves (Kellgren 1938). peptic ulcer disease. myocardial ischemia. EMG evidence shows a minor degree of neurotmesis (axonal loss) in addition to neurapraxia. is often associated with trigger point presentation. diaphoresis. hypesthesia. or when a nerve lies between taut trigger point bands and bone. the pressure exerted on the nerve can produce neurapraxia--the loss of nerve conduction--but only in the region of compression. When a nerve passes through a muscle between taut bands. including localized vasoconstriction. and pancreatitis). single muscle myofascial syndromes. Patients' pattern of referred pain elicited from trigger points in a muscle are reproducible. In light of these associated findings. Referred pain. Focal or regional autonomic dysfunction. lacrimation. which immediately relaxes the taut bands. Autonomic phenomena. coryza. Neurovascular entrapment. salivation. Table 2. The patient with one of these entrapments is likely to have 2 kinds of symptoms: (1) aching pain referred from trigger points in the involved muscle. Piriformis Piriformis syndrome or gluteal vessels "pseudosciatica" Ulnar nerve Flexor carpi ulnaris Ulnar nerve palsy Buccinator nerve Lateral pterygoid Focal facial numbness Posterior primary rami Paraspinal Paraspinal dysesthesias musculature Brachial plexus and axillary Pectoralis minor Costoclavicular syndrome artery . Effects of severe compression may require days or weeks for full recovery. predictable. Less appreciated is an associated phenomena--referred tenderness--which can often be elicited at the site of pain referral. the fact that irritable areas such as myofascial trigger points in skeletal muscle may cause pain to be perceived in distant locations is not. and are often the key to the diagnosis of a myofascial pain syndrome. Though pain referred from visceral internal organs to somatic body structures is well recognized by physicians (ie. They can cause imbalance and disorientation of the body in space and postural dizziness. and include blurring of vision and intermittent double vision without pupillary changes. myofascial pain syndrome may represent one of the milder variants of the autonomically mediated reflex neurovascular syndromes. persistent hyperemia after palpation.

and the antagonists that oppose the agonist. temple to jaw. reflex sympathetic dystrophy) found no statistical difference in behavioral symptoms between the groups (Fricton et al 1985. Though the myotoxic unit is defined as including the synergists. such as frustration. categorized by anatomical region include: (1) head: masseter. concomitant social. As with many chronic pain conditions. Fricton and Kroening studied 164 patients with myofascial pain of the head and neck and noted that anxiety. The most frequently encountered muscles developing myofascial trigger points. upper teeth and gums. which help the prime mover (agonist). “sinusitis-like" pain. (A) Maxilla. and associated entrapments. categorized by anatomical region in the body. and anger occurred in about one quarter of them(Fricton and Kroening 1982). (D) Pain deep in ear and TMJ. wrist dysesthesias Psychosocial dysfunction. the definition is sometimes extended to include the proximal stabilizer muscles of the shoulder or hip. The myotatic unit is emphasized because the presence of an active trigger point in 1 muscle of the myotoxic unit is often accompanied by dysfunction in other muscles of the unit. anxiety. it is important to break the problem into its component parts. HEAD Trigger Point: Masseter (both superficial and deep points) • Signs and symptoms: TMJ pain and trismus. Common myofascial syndromes. depression. The propensity for myofascial foci to spread and to develop secondary and satellite trigger points in adjacent muscles of the myotoxic unit provides a mechanism by which myofascial pain from single muscle syndromes can become regional. Several of the more common myofascial syndromes reviewed will be immediately recognized as a cause of pain and dysfunction that confront the clinician daily. ipsilateral tinnitus. behavioral. (B) Eyebrow. The individual descriptions of each single muscle syndrome are uniformly arranged relative to symptoms. • Activation and perpetuation: Bruxism and occlusional disorders as in dental procedures. depression. adjacent teeth and gums. Particularly with the patient who has regional pain. Few studies have assessed psychological factors in myofascial pain syndrome. . upper or lower molar pain. and psychological disturbances may precede or follow the development of pain. normal chewing tolerated. and anger if acute cases become chronic through inadequate treatment. gross trauma. • Referred pain patterns: Jaw. and medial pterygoid (2) head and neck: trapezius and sternocleidomastoid (3) neck: levator scapulae and scalenes (4) shoulder and arm: infraspinatus and supinator (5) back and hip: quadratus lumborum and piriformis. Several studies comparing patients with myofascial pain to those with other chronic pain disorders (low back pain. common activating and perpetuating mechanisms. lateral pterygoid. producing infraorbital puffiness and hemifacial edema. Pterygoid venous plexus Masseter Hemifacial edema Deep radial nerve Supinator Extensor weakness of hand. Patients may report psychological symptoms. which may develop trigger points as well (Travell and Simon 1983). temporalis. and hypersensitivity of teeth. • Entrapment syndromes: Compression of pterygoid venous plexus results in engorgement. (C) Lower molars and jaw. Myotatic dysfunction. Nelson and Novy 1996). typical referred pain patterns. Following is a description of the component parts of these frequently encountered single muscle syndromes. Myofascial pain syndrome was traditionally viewed as single muscle syndromes that may combine to form complex patterns involving many muscles in several regions of the body.

Postspinal headaches that can activate sternocleidomastoid muscle trigger points have been reported to produce a chronic myofascial headache. Trigger Point: Lateral pterygoid • Signs and symptoms: Frequent cause of TMJ dysfunction and misalignment. Trigger Point: Temporalis • Signs and symptoms: Temporal headache. • Referred pain patterns: Posterolateral neck and temple cervico-occipital and acromion. Ear stuffiness. • Activation and perpetuation: Usually activated secondary to lateral pterygoid involvement. or overloading its key role in neck stabilization with tilt of the shoulder-girdle axis. HEAD AND NECK Trigger Point: Trapezius • Signs and symptoms: Tension head and neck ache. • Entrapment syndromes: The trapezius contributes a shearing stress to the primary entrapment of the greater occipital nerve by the semispinalis capitus as it emerges below the occiput. pain above and behind the eye. Occlusional imbalance. . Medial scapular and paraspinal TP-7 causes a nonpainful "shivery" sensation on lateral arm with pilomotor erection. Below and behind the TMJ. • Entrapment syndromes: Entrapment of the buccal nerve causes paresthesias of the cheek and gum and weakness of the buccinator muscle. and ptosis (orbicularis spasm) are seen with sternal sternocleidomastoid muscle trigger points. aching on top of shoulder. Trigger Point: Sternocleidomastoid • Signs and symptoms: Atypical facial pain associated with visual blurring. Repetitive stress from prolonged elevation and extension of the arms as when typing. Autonomic symptoms of excess sinus secretions mimic sinusitis. difficult and painful swallowing. pharynx. and maxillary toothache. interscapular burning pain. Clavicular trigger points cause tension headaches. postural dizziness. • Activation and perpetuation: Protracted neck rotation (from sleeping on 2 pillows) or neck extension (working overhead). • Referred pain patterns: Primary source of referred pain to TMJ and maxilla. • Referred pain patterns: Vague pain referred to the back of the mouth. • Activation and perpetuation: Malocclusion and bruxism. dizziness most likely due to coactivation of sternocleidomastoid muscle trigger points. Pain with chewing is proportional to the vigor of the movement. • Referred pain patterns: Temporoparietal and supraorbital pain. Throat pain and focal swelling have been reported. maxillary teeth. • Entrapment syndromes: Entrapment of the spinal accessory nerve as it emerges through the sternocleidomastoid muscle may cause paresis of the ipsilateral trapezius muscle. and deep into the ear. • Activation and perpetuation: Acute trauma as with falls or whiplash. tearing. and disequilibrium with veering. • Activation and perpetuation: Same as masseter. which restrict the tensor veli palatini from opening the eustachian tube. downward to upper incisor. • Entrapment syndromes: Ear stuffiness (barohypoacusis) due to medial pterygoid trigger points. Restricted jaw opening. and tongue but not the teeth. and TMJ. • Entrapment syndromes: None. neither refers pain to the neck. as it is rarely involved alone. deep suprascapular ache. • Referred pain patterns: Although the 2 divisions of the sternocleidomastoid muscle have distinct facial and cranial pain patterns. Trigger Point: Medial pterygoid • Signs and symptoms: Sore throat.

. SHOULDER AND ARM Trigger Point: Infraspinatus • Signs and symptoms: “Shoulder joint pain” causing difficulty sleeping on either side. or tugging. lifting. • Referred pain patterns: Deep trigger points refer to sacroiliac joint and lower buttock. • Activation and perpetuation: Acute trauma as with awkward lifting or repetitive trauma as when walking with a limp. paresthesias.NECK Trigger Point: Levator scapulae • Signs and symptoms: The most common cause of "stiff neck. • Entrapment syndromes: Deep radial nerve may cause weakness with extension of the hand. BACK AND HIP Trigger Point: Quadratus lumborum • Signs and symptoms: Deep aching "low back pain" at rest and severe aching in unsupported standing or sitting. • Referred pain patterns: Deep anterior deltoid pain. and thumb. • Entrapment syndromes: Lower trunk of brachial plexus compression elicits ulnar pain. hand weakness. • Entrapment syndromes: None. Trigger Point: Supinator • Signs and symptoms: "Tennis elbow. Edema of fingers due to subclavian vein. Trigger Point: Scalene's • Signs and symptoms: Thoracic outlet symptoms of ulnar pain and numbness. • Referred pain patterns: Pectoral and medial scapular pain. or sustained supination of the hand. Superficial trigger points refer to hip. shoulder and radial aspect of arm and hand. fingers. thumb. Inability to reach behind. and swelling combine with myofascial pain. • Entrapment syndromes: None. and index finger. At times. repetitive. radial aspect of hand." Trigger points entrap the nerve (neurogenic symptoms) and gluteal vessels and contribute to sacroiliac joint dysfunction and referred hip pain." or lateral epicondyle pain with activity or rest. hand weakness. • Entrapment syndromes: None. • Activation and perpetuation: Usually results from overload reaching backward and up. and groin." Painful limitation of ipsilateral neck rotation. extending to the medial scapular border and posterior shoulder. • Activation and perpetuation: Prolonged turning of head and neck and unilateral shoulder shrugging. extending down lateral arm and radial aspect of forearm. and the unexpected dropping of objects. • Activation and perpetuation: Pulling. • Referred pain patterns: At the angle of the neck. At times. Trigger Point: Piriformis • Signs and symptoms: "Pseudosciatica. iliac crest. • Referred pain patterns: Lateral epicondyle. • Activation and perpetuation: Excessively forceful. extending to anterolateral arm. Referred pain from cervical spine frequently activates and perpetuates scalene trigger points. and often the dorsal aspect of the web and base of thumb.

Anderson and colleagues evaluated painful myofascial trigger points and pain sites in men with chronic prostatitis/chronic pelvic pain syndrome (Anderson et al 2009). Trigger Points: Puborectalis/Pubococcygeus/Rectus abdominis. • Activation and perpetuation: Acute overload from forceful rotations on 1 leg or a fall. sitting or standing. and groin pain in at least 80% of the patients at the respective pain sites (p <0.01). please choose one of the following options: . • Entrapment syndromes: Trigger points entrap multiple nerves and vessels at the sciatic foramen. Trigger point pain is increased with walking. External oblique muscle palpation elicited suprapubic. • Referred pain patterns: Sacroiliac region.3% of men. The most prevalent pain sites were the penis. and the rectum in 70. Sciatic and gluteal neurovascular compression evoke numbness and pain with the pudendal nerve causing sexual dysfunction. please log in at the MedLink Home page. If you are not a subscriber. Prolonged positioning during obstetric or urologic procedures with knees spread apart. in 90. Current subscribers.8%.8%. buttock. and posterior thigh.01) (Anderson et al 2009). The remainder of this Clinical Summary is available to subscribers only. testicular. Puborectalis/pubococcygeus and rectus abdominis trigger points reproduced penile pain more than 75% of the time (p <0. the perineum in 77.