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
1983; 1991). Using the classification of the International Association for the Study of
Pain, such localized disease is now currently termed "specific myofascial pain
syndrome" (Merskey and Bogduk 1994).
Controversies in nomenclature. 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. The term fibrositis, in particular, has
been used erroneously to include both myofascial pain syndrome and fibromyalgia, as
well as almost any unexplained musculoskeletal pain problem. The confusion in
nomenclature has been compounded by the widespread belief that these
musculoskeletal pain syndromes are psychogenic in nature. As late as the 1970s,
most major textbooks considered fibrositis to be a disease with strong psychogenic
overtones (Rosen 1993). The terms nonarticular and psychogenic rheumatism, soft
tissue disability, tension myalgia, and muscle contraction states also have remained in
use, suggesting psychologic dysfunction as their primary cause as opposed to physical
factors. Similarly, current terms, including overuse syndromes, repetitive trauma
syndromes, and repetitive injury or strain syndromes fail to address the more critical
issues regarding pathogenesis, with many of these overlapping disorders representing
local forms of myofascial pain, which apparently have not been appreciated as such.
Currently, no universally accepted terminology allows clinicians to more accurately
codify the dysfunction seen in patients who present with musculoskeletal pain and
dysfunction (Thompson 1990).

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; Simons 1991).
Myofascial pain syndrome is now understood to refer to a spectrum of clinical
presentations distinct from other musculoskeletal conditions, such as fibromyalgia,
strains, and sprains. Myofascial syndrome is defined as a pain disorder involving pain
referred from trigger points within myofascial structures, either local or distant from
the pain. Atrigger point is defined as a localized tender area within a taut band of
skeletal muscle or its associated fascia. These points occur most frequently in the
head, neck, shoulders, and lower back. Active trigger points are also characterized by
specific patterns of pain radiation during palpation that depend on the location of the
trigger point. The patterns of referral for each trigger point are consistent among
different persons. Myofascial pain due to active trigger points can present as an acute,
recurrent, or chronic pain syndrome. The patient with acute-onset myofascial pain
usually associates the onset of pain with a specific overload of the muscles and,
therefore, expects it to be self-limited as is postexercise soreness. The mechanisms
that produce the symptoms of myofascial pain are also largely speculative. Travell and
Simon have proposed that the initial changes may be precipitated by such factors as
local trauma, fatigue of the muscles from repeated overuse, chronic postural
imbalance, and psychological distress(Travell and Simon 1991). The characteristics of
myofascial pain syndrome may long outlast the initiating events, setting up a self-
generating pain cycle that is perpetuated through lack of proper treatment, sustained
muscle tension, distorted muscle posture, pain-reinforcing behavior, and the failure to
reduce other contributing factors, such as sleep disturbances. Generally, no neurologic
deficits are associated with this syndrome, unless neurovascular compression with
weakness and diminished sensation coincide with the muscle trigger points.
Signs and symptoms. 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. Palpation of the affected muscles
reveals a hyperirritable focus of localized pain, which is discrete and lies within a
structure known as the "taut band." 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. The localized pain within the taut band is knows as a "trigger point."
 Trigger points are classified as either active or latent, and range from 2 to 5 mm in
diameter. 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. Most commonly, a sharp localized pain that is well demarcated can be
elicited, as can a radiating or referred pain, described as deep (subcutaneous and
muscular) and aching in character with slightly blurred edges that project well beyond
the originating trigger point. The region of referred pain within the myotome specific
for each individual muscle-derived trigger point displays continuous pain in a "zone of
reference." These pain reference zones, which remain stereotypic between individuals,
may or may not mimic more traditionally recognized dermatomal, myotomal, or
sclerotomal referred pain patterns. The associated symptoms observed with active
trigger points, including decreased muscle strength, endurance, and range of motion,
have been documented by measuring the effect of experimental muscle pain on static
and dynamic muscle function (Graven-Nielsen et al 1997). Without perpetuating
factors, referred pain may spontaneously subside within a few days or weeks, and an
active trigger point tends to revert to and persist as a latent trigger point. When
latent, the trigger points are quiescent and result primarily in muscle tightness and
dysfunction without the presence of persistent or spontaneous pain except when
palpated. In the presence of 1 or more perpetuating factors, trigger points usually
persist and become chronic. They may then propagate to other muscles as secondary
and satellite trigger points

Table 1. 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.

Taut band A discrete area of increased consistency or hardness

within a muscle and associated with a trigger point.

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.

Latent trigger point A subclinical trigger point that does not spontaneously
cause pain but elicits a zone of muscle-specific referred
pain on palpation.

Satellite trigger point A trigger point that becomes active because it falls
within the zone of reference of another trigger point.

Zone of reference A unique region within the myotome specific for each
muscle-derived trigger point and to which
pain,paresthesias, and tenderness may refer.

Trigger point inactivation The immediate alleviation of pain and weakness by

elongation of the muscle or trigger point injection.

Epiphenomena Neurovascular entrapment, referred autonomic

phenomena, psychosocial dysfunction, and
deconditioning.

Myotatic unit A group of agonist and antagonist muscles, which

function together as a unit because they share common
spinal reflex responses.
 Referred pain. Patients' pattern of referred pain elicited from trigger points in a
muscle are reproducible, predictable, 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, myocardial ischemia,
peptic ulcer disease, and pancreatitis), the fact that irritable areas such as myofascial
trigger points in skeletal muscle may cause pain to be perceived in distant locations is
not. 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). Less appreciated is
an associated phenomena--referred tenderness--which can often be elicited at the site
of pain referral.
Autonomic phenomena. Focal or regional autonomic dysfunction, including
localized vasoconstriction, persistent hyperemia after palpation, diaphoresis,
lacrimation, coryza, salivation, and pilomotor activity, is often associated with trigger
point presentation. In light of these associated findings, myofascial pain syndrome
may represent one of the milder variants of the autonomically mediated reflex
neurovascular syndromes. Disturbance of vestibular function and space perception
may originate in trigger points in the clavicular division of the sternocleidomastoid
muscle. They can cause imbalance and disorientation of the body in space and
postural dizziness. Visual disturbances are also reported with sternocleidomastoid
trigger points, and include blurring of vision and intermittent double vision without
pupillary changes. Tinnitus has been reported to be associated with trigger point
palpation in the masseter muscle as well.
Neurovascular entrapment. When a nerve passes through a muscle between taut
bands, 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. Occasionally, EMG evidence shows a minor degree of
neurotmesis (axonal loss) in addition to neurapraxia. 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; and (2) nerve compression effects of numbness
and tingling, hypesthesia, and sometimes hyperesthesia. The signs and symptoms of
partial neurapraxia may sometimes be relieved within minutes after inactivation of the
responsible myofascial trigger point, which immediately relaxes the taut bands.
Effects of severe compression may require days or weeks for full recovery. Several
common neurovascular entrapment syndromes are now associated with specific,
single muscle myofascial syndromes.

Table 2. 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, 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
 Pterygoid venous plexus Masseter Hemifacial edema

Deep radial nerve Supinator Extensor weakness of

hand, wrist dysesthesias

Psychosocial dysfunction. As with many chronic pain conditions, concomitant

social, behavioral, and psychological disturbances may precede or follow the
development of pain. Patients may report psychological symptoms, such as
frustration, anxiety, depression, and anger if acute cases become chronic through
inadequate treatment. Few studies have assessed psychological factors in myofascial
pain syndrome. Fricton and Kroening studied 164 patients with myofascial pain of the
head and neck and noted that anxiety, depression, and anger occurred in about one
quarter of them(Fricton and Kroening 1982). Several studies comparing patients with
myofascial pain to those with other chronic pain disorders (low back pain, reflex
sympathetic dystrophy) found no statistical difference in behavioral symptoms
between the groups (Fricton et al 1985; Nelson and Novy 1996).
Myotatic dysfunction. 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, which may develop trigger points as
well (Travell and Simon 1983). 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. Though the myotoxic unit is defined as including the synergists,
which help the prime mover (agonist), and the antagonists that oppose the agonist,
the definition is sometimes extended to include the proximal stabilizer muscles of the
shoulder or hip.
Common myofascial 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. Particularly with the patient
who has regional pain, it is important to break the problem into its component parts.
The most frequently encountered muscles developing myofascial trigger points,
categorized by anatomical region include:
(1) head: masseter, temporalis, lateral pterygoid, 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.
Following is a description of the component parts of these frequently encountered
single muscle syndromes, categorized by anatomical region in the body. The individual
descriptions of each single muscle syndrome are uniformly arranged relative to
symptoms, typical referred pain patterns, common activating and perpetuating
mechanisms, and associated entrapments. Several of the more common myofascial
syndromes reviewed will be immediately recognized as a cause of pain and
dysfunction that confront the clinician daily.

HEAD
Trigger Point: Masseter (both superficial and deep points)
Signs and symptoms: TMJ pain and trismus, sinusitis-like" pain, upper or lower
molar pain, and hypersensitivity of teeth, ipsilateral tinnitus.
Referred pain patterns: Jaw, adjacent teeth and gums; (A) Maxilla, upper teeth
and gums; (B) Eyebrow, temple to jaw; (C) Lower molars and jaw; (D) Pain deep in
ear and TMJ.
Activation and perpetuation: Bruxism and occlusional disorders as in dental
procedures; gross trauma; normal chewing tolerated.
Entrapment syndromes: Compression of pterygoid venous plexus results in
engorgement, producing infraorbital puffiness and hemifacial edema.
 Trigger Point: Temporalis
Signs and symptoms: Temporal headache, pain above and behind the eye, and
maxillary toothache.
Referred pain patterns: Temporoparietal and supraorbital pain, downward to upper
incisor, maxillary teeth, and TMJ.
Activation and perpetuation: Same as masseter.
Entrapment syndromes: None.

Trigger Point: Lateral pterygoid

Signs and symptoms: Frequent cause of TMJ dysfunction and
misalignment. Autonomic symptoms of excess sinus secretions mimic sinusitis.
Referred pain patterns: Primary source of referred pain to TMJ and maxilla.
Activation and perpetuation: Malocclusion and bruxism. Pain with chewing is
proportional to the vigor of the movement.
Entrapment syndromes: Entrapment of the buccal nerve causes paresthesias of
the cheek and gum and weakness of the buccinator muscle.

Trigger Point: Medial pterygoid

Signs and symptoms: Sore throat, difficult and painful swallowing. Ear stuffiness.
Restricted jaw opening.
Referred pain patterns: Vague pain referred to the back of the mouth, pharynx,
and tongue but not the teeth. Below and behind the TMJ, and deep into the ear.
Activation and perpetuation: Usually activated secondary to lateral pterygoid
involvement, as it is rarely involved alone. Occlusional imbalance.
Entrapment syndromes: Ear stuffiness (barohypoacusis) due to medial pterygoid
trigger points, which restrict the tensor veli palatini from opening the eustachian tube.

HEAD AND NECK

Trigger Point: Trapezius
Signs and symptoms: Tension head and neck ache; deep suprascapular ache;
interscapular burning pain; aching on top of shoulder; dizziness most likely due to
coactivation of sternocleidomastoid muscle trigger points.
Referred pain patterns: Posterolateral neck and temple cervico-occipital and
acromion. Medial scapular and paraspinal TP-7 causes a nonpainful "shivery"
sensation on lateral arm with pilomotor erection.
Activation and perpetuation: Acute trauma as with falls or whiplash. Repetitive
stress from prolonged elevation and extension of the arms as when typing, or
overloading its key role in neck stabilization with tilt of the shoulder-girdle axis.
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.

Trigger Point: Sternocleidomastoid

Signs and symptoms: Atypical facial pain associated with visual blurring, tearing,
and ptosis (orbicularis spasm) are seen with sternal sternocleidomastoid muscle
trigger points. Clavicular trigger points cause tension headaches, postural dizziness,
and disequilibrium with veering.
Referred pain patterns: Although the 2 divisions of the sternocleidomastoid muscle
have distinct facial and cranial pain patterns, neither refers pain to the neck. Throat
pain and focal swelling have been reported.
Activation and perpetuation: Protracted neck rotation (from sleeping on 2 pillows)
or neck extension (working overhead). Postspinal headaches that can activate
sternocleidomastoid muscle trigger points have been reported to produce a chronic
myofascial headache.
Entrapment syndromes: Entrapment of the spinal accessory nerve as it emerges
through the sternocleidomastoid muscle may cause paresis of the ipsilateral trapezius
muscle.
NECK
Trigger Point: Levator scapulae
Signs and symptoms: The most common cause of "stiff neck." Painful limitation of
ipsilateral neck rotation.
Referred pain patterns: At the angle of the neck, extending to the medial scapular
border and posterior shoulder.
Activation and perpetuation: Prolonged turning of head and neck and unilateral
shoulder shrugging.
Entrapment syndromes: None.

Trigger Point: Scalene's

Signs and symptoms: Thoracic outlet symptoms of ulnar pain and numbness, hand
weakness, and swelling combine with myofascial pain, shoulder and radial aspect of
arm and hand.
Referred pain patterns: Pectoral and medial scapular pain, extending down lateral
arm and radial aspect of forearm, thumb, and index finger.
Activation and perpetuation: Pulling, lifting, or tugging. Referred pain from cervical
spine frequently activates and perpetuates scalene trigger points.
Entrapment syndromes: Lower trunk of brachial plexus compression elicits ulnar
pain, paresthesias, and the unexpected dropping of objects. Edema of fingers due to
subclavian vein.

SHOULDER AND ARM

Trigger Point: Infraspinatus
Signs and symptoms: Shoulder joint pain causing difficulty sleeping on either
side. Inability to reach behind.
Referred pain patterns: Deep anterior deltoid pain, extending to anterolateral arm.
At times, radial aspect of hand.
Activation and perpetuation: Usually results from overload reaching backward and
up.
Entrapment syndromes: None.

Trigger Point: Supinator

Signs and symptoms: "Tennis elbow," or lateral epicondyle pain with activity or
rest. At times, hand weakness.
Referred pain patterns: Lateral epicondyle, and often the dorsal aspect of the web
and base of thumb.
Activation and perpetuation: Excessively forceful, repetitive, or sustained
supination of the hand.
Entrapment syndromes: Deep radial nerve may cause weakness with extension of
the hand, fingers, and thumb.

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 trigger points refer to sacroiliac joint and lower
buttock. Superficial trigger points refer to hip, iliac crest, and groin.
Activation and perpetuation: Acute trauma as with awkward lifting or repetitive
trauma as when walking with a limp.
Entrapment syndromes: None.

Trigger Point: Piriformis

Signs and symptoms: "Pseudosciatica." Trigger points entrap the nerve
(neurogenic symptoms) and gluteal vessels and contribute to sacroiliac joint
dysfunction and referred hip pain.
 Referred pain patterns: Sacroiliac region, buttock, and posterior thigh. Trigger
point pain is increased with walking, sitting or standing.
Activation and perpetuation: Acute overload from forceful rotations on 1 leg or a
fall. Prolonged positioning during obstetric or urologic procedures with knees spread
apart.
Entrapment syndromes: Trigger points entrap multiple nerves and vessels at the
sciatic foramen. Sciatic and gluteal neurovascular compression evoke numbness and
pain with the pudendal nerve causing sexual dysfunction.

Trigger Points: Puborectalis/Pubococcygeus/Rectus abdominis. Anderson

and colleagues evaluated painful myofascial trigger points and pain sites in men with
chronic prostatitis/chronic pelvic pain syndrome (Anderson et al 2009). The most
prevalent pain sites were the penis, in 90.3% of men, the perineum in 77.8%, and
the rectum in 70.8%. Puborectalis/pubococcygeus and rectus abdominis trigger points
reproduced penile pain more than 75% of the time (p <0.01). External oblique muscle
palpation elicited suprapubic, testicular, and groin pain in at least 80% of the patients
at the respective pain sites (p <0.01) (Anderson et al 2009).

The remainder of this Clinical Summary is available to subscribers only. Current

subscribers, please log in at the MedLink Home page. If you are not a subscriber,
please choose one of the following options: