Journal of Bodywork & Movement Therapies xxx (2017) 1e6

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Journal of Bodywork & Movement Therapies

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A myofascial component of pain in knee osteoarthritis

Adi Dor, BPT, Leonid Kalichman, PT, PhD *
Department of Physical Therapy, Recanati School for Community Health Professions, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer
Sheva, Israel

a r t i c l e i n f o a b s t r a c t

Article history: Background: Osteoarthritis (OA) is the most common cause of musculoskeletal pain and disability. The
Received 30 January 2017 knee is the most common site of OA. Numerous studies have shown an inconsistency between patients'
Received in revised form reports of pain and their radiographic findings. This inconsistency may be partially explained by the fact
25 March 2017
that a portion of the pain originates from the myofascial trigger points (MTrPs) located in the sur-
Accepted 27 March 2017
rounding muscles.
Aim: To assess the role of myofascial pain in OA patients.
Keywords:
Methods: Critical review. PubMed, Google Scholar, Scopus, and PEDro databases were searched from
Knee
Osteoarthritis
inception until December 2016 for the following keywords: “myofascial pain”, “osteoarthritis”, “trigger
Myofascial pain points”, “knee” or any combination of these words. The reference lists of all articles retrieved were
Dysfunction searched as well.
Manual therapy Results: The current review included two observational studies evaluating the prevalence of MTrPs in OA
Soft tissue mobilizations patients and six interventional studies describing the treatment of myofascial pain in OA patients. Data
from two of the interventional studies also included an observational section.
Conclusion: The reviewed observational studies offered initial evidence as to the assumption that
myofascial pain and the presence of MTrPs may play a role in pain and disability of knee OA. Because of
the cross-sectional design of these studies, the causal relationships could not be established. Additional
studies are needed to confirm this assumption as well as to clarify if MTrPs are a portion of OA etiology or
that OA is the basis for MTrPs formation. Each interventional study elaborated on various myofascial
treatment techniques. However, treatment focusing on MTrPs seems to be effective in reducing pain and
improving function in OA patients. Due to the heterogeneity in treatment methods and outcome mea-
sures, it is difficult to attain a definite conclusion and therefore, additional high-quality randomized
controlled trials are warranted.
© 2017 Elsevier Ltd. All rights reserved.

1. Introduction
Osteoarthritis (OA) is the most common cause of musculoskel-
etal pain and disability. It is a chronic degenerative disorder of
multifactorial etiology, including acute and/or chronic insults from
normal wear and tear, age, obesity and joint injury. The true
pathogenesis remains poorly understood. OA is characterized by a
degradation of the articular cartilage, resulting in an alteration of its
biomechanical properties, which in turn contributes to a focal loss
of articular cartilage, loss of joint space, osteophyte formation, focal
areas of synovitis, periarticular bone remodeling and subchondral
* Corresponding author.
E-mail addresses: adidor178@gmail.com (A. Dor), kalichman@hotmail.com
(L. Kalichman).
cysts (Harish and Kashif, 2013; Pollard et al., 2008). OA presents
with symptoms such as joint pain, stiffness, motion limitations,
motor and sensory dysfunction and functional impairments, thus,
preventing patients from participating in regular physical activities
(Harish and Kashif, 2013). The common sites of OA appear on the
knees, hands, and hips, whereas knee OA is the most common
(Joern et al., 2010).
Pain is the most frequent complaint for patients with knee OA to
seek medical attention. If left untreated, pain and stiffness can
result in a loss of physical function and independence during daily
activities. The presence of OA-related knee pain has also been
associated with increased risks of physical disability in the com-
munity (Harish and Kashif, 2013).
Many studies have revealed a discrepancy between patients'
reports of pain and their radiographic findings (Kornaat et al., 2006;
Link et al., 2003; Pollard et al., 2008). A plausible option is that the

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Please cite this article in press as: Dor, A., Kalichman, L., A myofascial component of pain in knee osteoarthritis, Journal of Bodywork &
Movement Therapies (2017), http://dx.doi.org/10.1016/j.jbmt.2017.03.025
2 A. Dor, L. Kalichman / Journal of Bodywork & Movement Therapies xxx (2017) 1e6

pain originates from the myofascial trigger points (MTrPs) in the
surrounding muscles (myofascial pain) and cannot be visualized by
imaging.
The term myofascial pain is defined as “the complex of sensory,
motor, and autonomic symptoms caused by MTrPs” (Simons et al.,
1999). MTrPs, hyperirritable spots found in the skeletal muscles, are
associated with hypersensitive palpable nodules located in a taut
band. The spots are painful on compression and may produce
characteristic referred pain, referred tenderness, motor dysfunc-
tion, and autonomic phenomena. Two different types of MTrPs
have been described: 1) active MTrPs associated with spontaneous
complaints of pain; 2) latent MTrPs that do not cause spontaneous
pain, however, pain may be elicited by manual pressure on the
MTrPs. It has also been hypothesized that latent MTrPs restrict the
range of motion (ROM) and alter motor recruitment patterns (Bron
et al., 2007).
The purpose of this critical review (Grant and Booth, 2009) was
to assess the role of myofascial pain in knee OA patients. Our hy-
potheses were: 1) the pain experienced in knee OA is associated
with the prevalence of MTrPs in the surrounding muscles; 2)
treatment focusing on myofascial pain is effective in reducing pain
and improving function in patients with knee OA.
2. Methods
PubMed, Google Scholar, Scopus, and PEDro databases were
searched from inception until December 2016 using predefined
search strategies. The databases were searched for the following
keywords: “knee pain”, “osteoarthritis”, “myofascial pain”,
“trigger points”, “myofascial release therapy”, “soft tissue
manipulation” or any combination of these words. The search
results were pooled and duplicates removed. The titles and ab-
stracts of all articles were reviewed. Criteria for inclusion in the
review were studies investigating the association between
myofascial pain and knee OA or treatment of OA by MTrPs. We
analyzed all published material with an emphasis on randomized
controlled trials (RCTs). Trials of any methodological quality and
only trials written in English were included in the review.
The reference lists of all articles retrieved in full were also
searched.
3. Results
Eight papers were included in this review: two observational
studies, one quasi-experimental and five RCTs.
3.1. Observational studies on the prevalence of myofascial pain in
knee OA patients
Prevalence of MTrPs in the studied muscles is summarized in
Table 1.
A recent observational cross-sectional study (Alburquerque-
García et al., 2015), examined whether referred pain elicited by
active MTrPs reproduced the symptoms in individuals with painful
knee OA and if a relationship between the presence of active MTrPs
with intensity of ongoing pain, function, quality of life and sleep
quality exists in individuals with painful knee OA. The sample
consisted of 18 women with bilateral knee OA and 18 matched
controls, who had experienced no knee pain during the past year.
All subjects underwent an MTrPs examination by an experi-
enced assessor who examined the tensor fascia lata, sartorius,
rectus femoris, vastus lateralis, vastus medialis, gracilis, biceps
femoris, semitendinosus, gastrocnemius, and the tibialis anterior
muscles. The results demonstrated that women with knee OA
exhibited a significantly greater number of active MTrPs (mean
1 ± 1; p < 0.001) and a similar number of latent MTrPs (mean 4 ± 2)
compared to healthy women (mean 4 ± 3; p ¼ 0.613). The following
muscles were found with the highest prevalence for active MTrPs:
the vastus medialis, vastus lateralis, gastrocnemius and sartorius,
all with an MTrPs prevalence of 11.1%. The muscles with less
prevalence of active MTrPs were the gracilis, tibialis anterior and
rectus femoris, all with 5.5% prevalence. No active MTrPs were
found in the tensor fascia lata, biceps femoris and semitendinosus
muscles. A greater number of active MTrPs was associated with a
higher intensity of ongoing pain (r ¼ 0.605; p ¼ 0.007) and lower
physical function (p < 0.05) (Alburquerque-García et al., 2015).
In another observational study (Bajaj et al., 2001), 28 subjects
were examined (14 with OA of the hip, knee or both and 14 healthy
controls). One experienced assessor examined all subjects in a
randomized sequence of sides and sites to minimize order effects.
The examined muscles were: the tensor fascia lata, rectus femoris,

Table 1
Prevalence of MTrPs in knee OA.

Alburquerque-García et al., 2015 Bajaj et al., 2001 Henry et al., 2012 Itoh et al., 2008

Cases Controls** Cases* Controls**

Iliopsoas 40%
Gluteus medius 7.1% 0%
Gluteus minimus 20%
Gluteus maximus 7.1% 0%
Tensor fascia lata 0% 0% 35.7% 28.6%
Sartorius 11.1% 0% 20%
Rectus femoris 5.5% 0% 64.3% 14.3% 60%
Vastus lateralis 11.1% 0% 7.1% 0% 29%
Vastus medialis 11.1% 0% 21.4% 0% 67%
Gracilis 5.5% 0%
Biceps femoris 0% 0% 21.4% 0% 40%
Semitendinosus 0% 0%
Popliteus 20%
Gastrocnemius 11.1% 0% 57.1% 14.3% 92%
Soleus 21.4% 0%
Tibialis anterior 5.5% 0%
Peroneus longus 7.1% 7.1%
Peroneus brevis 14.3% 14.3%

*examined subjects suffered from OA of the hip, knee or both; **controls were healthy subjects (without OA in low limbs).

Please cite this article in press as: Dor, A., Kalichman, L., A myofascial component of pain in knee osteoarthritis, Journal of Bodywork &
Movement Therapies (2017), http://dx.doi.org/10.1016/j.jbmt.2017.03.025
 A. Dor, L. Kalichman / Journal of Bodywork & Movement Therapies xxx (2017) 1e6 3

gluteus medius, quadratus lumborum, vastus medialis, vastus lat-

off and smoothed were pretended to be

inserted and used in a sparrow pecking

for 5 min adjacent to the knee, exercises

Na-hyaluronate) three times, with one-

strengthening, functional exercises and

sessions that included: 15e20 min of a
extraction was performed after 10 min

hot pack or TENS on the knee area, US

to improve ROM, daily stretching and/

Sham needling - Needles with tips cut

Intra-articular injections of hyaluronic

eralis, biceps femoris, gluteus maximus, gastrocnemius, soleus,

Hot pack and Maitland mobilizations

by touching the patient and noisily

technique on MTrPs sites and then
peroneus brevis and peroneus longus. The results of this study

Conventional physical therapy: 16

acid (2 ml high molecular weight

removed. A simulation of needle
showed a significant positive correlation between the total number

Exercise program: quadriceps

of MTrPs in OA patients and their radiological scores (Spearman's

or strengthening exercises
r ¼ 0.57, p ¼ 0.04) (Bajaj et al., 2001).

dropping the needle.

Greater numbers of MTrPs were associated with pain below the
Control intervention

knee where radiation and pain referral was reported by OA patients

No control group

week intervals.

patellar taping
(p ¼ 0.05) compared to the controls. The prevalence of MTrPs in the
muscles of OA patients compared to the controls were as follows:
the rectus femoris- 64.3% vs 14.3%; the gastrocnemius- 57.1% vs
14.3% and the tensor fascia lata - 35.7% vs 28.6%. The prevalence of
MTrPs in the soleus, vastus medialis and biceps femoris muscles
Standard acupuncture for 10 min in ST34, ST35, ST36, SP9, SP10 and

quadriceps, adductors, iliotibial band, tensor fascia lata, hamstrings

Hyaluronic acid injections plus, 0.5% lidocaine injections to relevant

Exercise program plus MTrPs release by ischemic compression and

was 21.4% compared to no MTrPs in the control group. A prevalence
and gluteus minimus) in an attempt to elicit a local muscle twitch

neuromuscular technique (longitudinal strokes) together with the

MTrP injection of local anesthetics (0.25% Bupivacine) at points of

(quadriceps, iliopsoas, sartorius, hamstrings, adductors, popliteus

response. Subsequently, the needle was held in place for 10 min.

Conventional physical therapy plus myofascial therapy using the

of 14.3% of MTrPs in the quadratus lumborum was found compared

to no MTrPs in the control group; A prevalence of MTrPs of 14.3%
spray and stretching technique on the following muscles:
MTrPs dry needling - Needles were inserted into muscles

was found in the peroneus brevis muscle compared to 14.3% in the

control group. There was also a 7.1% prevalence of MTrPs in the
vastus lateralis and gluteus medius muscles compared to no MTrPs
in the control group. In the peroneus longus muscle, there was a
7.1% prevalence of MTrPs in both OA and control groups. Unilateral
knee joint OA patients had a greater number of MTrPs in muscles
surrounding the knee joint compared to the unilateral hip joint OA
MTrPs in the thigh or calf muscles
Hot pack and myofascial release

patients (Bajaj et al., 2001).

In Henry et al.'s (Henry et al., 2012) study of OA patients wai-
tlisted for total knee arthroplasty (TKA), MTrPs were found in all
maximum tenderness.

participants, especially in the medial head of the gastrocnemius

(92%) and the vastus medialis muscle (67%). The prevalence of
and calf muscles.

MTrPs in the lateral head of the gastrocnemius and the vastus lat-
iliotibial band.
Intervention

eralis were 29% each; MTrPs were found only in the medial muscles
in 62.5% of the subjects and 0% in only the lateral muscles. More
MTrPs e myofascial trigger points; US e therapeutic ultrasound; TENS e transcutaneous electrical nerve stimulation.
GB34.

than a third (37.5%) of the OA patients experienced pain in both the

medial and lateral muscles (Henry et al., 2012).
Itoh et al., (2008) reported in their RCT that the prevalence of
Gender (female N)

MTrPs in knee OA subjects was: quadriceps 60%, iliopsoas 40%,

49 Intervention
25 Control 24

sartorius 20%, adductors 40%, popliteus 20%, gluteus minimus 20%

and hamstrings 40% (Itoh et al., 2008).
N/A
15

23

34

36

3.2. Interventional studies

5.44 Control 59.13 ± 0.3

Intervention 62.1 ± 5.7

Characteristics of the reviewed interventional studies, outcome

64.2 ± 7.14 (51e81)

measures, and results are presented in Tables 2 and 3.

Control 59.8 ± 8.5
Intervention 56 ±

The objective of Henry et al.'s quasi-experimental study (Henry

et al., 2012) was to determine the presence of myofascial pain in OA
Age (years)

patients waitlisted for elective unilateral primary TKA and whether

61e82

50e59

their knee pain would be alleviated by MTrPs injections. Twenty-

N/A

five patients were examined 5 times during the 8-week study: at

the initial examination and possible treatment administered and
30 (n ¼ 15 in each group)
30 (n ¼ 10 in each group)

60 (n ¼ 30 in each group)

34 (n ¼ 17 in each group)

subsequently, one, two, four and eight weeks later. At each visit, the
Characteristics of the reviewed interventional studies.

study investigator examined the patients for MTrPs in the quadri-

intervention ¼ 19)
36 (control ¼ 17,

ceps, hamstrings and gastrocnemius muscles. Patients who were

identified with MTrPs were injected with bupivacaine in that spe-
Participants

cific area. MTrPs injections significantly reduced pain intensity and

pain interference and improved mobility (92% of the subjects re-
ported a reduction of over 20 mm on a 100 mm scale of pain in-
25
N

tensity). An acute reduction in pain and improved functionality was

observed immediately following the intervention and continued
over the 8-week course of the trial. The authors observed that
Harish and Kashif 2013

Gomaa and Zaky 2015

MTrPs appeared in the vastus and gastrocnemius muscles in all

Rahbar et al., 2013

Yentür et al., 2003

Henry et al., 2012

patients, with 92% experiencing significant pain relief by MTrPs

Itoh et al., 2008

injections at the first visit, thus, indicating that a significant pro-

portion of OA knee pain was myofascial in origin (Henry et al.,
2012).
Study
Table 2

In Harish & Kashif's RCT (Harish and Kashif, 2013), 30 subjects

with knee OA were recruited from the Meerut Medical College

Please cite this article in press as: Dor, A., Kalichman, L., A myofascial component of pain in knee osteoarthritis, Journal of Bodywork &
Movement Therapies (2017), http://dx.doi.org/10.1016/j.jbmt.2017.03.025
4 A. Dor, L. Kalichman / Journal of Bodywork & Movement Therapies xxx (2017) 1e6
Table 3
Studied variables and findings.
Study Outcome measures
Henry et al., 2012  Brief Pain Inventory (BPI)
 Short-Form McGill Pain
Questionnaire
 Timed Up and Go (TUG) test
Harish and Kashif 2013  Knee ROM (Goniometer)
 Knee pain (VAS)
Itoh et al., 2008  Knee pain (VAS)
 WOMAC
Rahbar et al., 2013  WOMAC
 Knee ROM (Goniometer)
 TUG test
Yentür et al., 2003  Intensity of pain at rest or during
daily activities by a 5-point scale
 Knee ROM (Goniometer)
Gomaa and Zaky 2015  Iliotibial band flexibility
(hip adduction angle) on
digital protractor.
 Lateral patellar malalignment
using Herrington's method.
 Pressure pain threshold (PPT)
MTrPs e myofascial trigger points; VAS e visual analog scale; ROM e range of motion.
Physiotherapy Outpatient Department to compare the effect of the
Maitland mobilization and the myofascial release technique on
knee pain level and ROM. All subjects received treatment for 14
consecutive days and were evaluated before the first treatment and
following the last one. The outcome measures were the ROM of the
knee measured by a goniometer and knee pain evaluated by the
visual analog scale (VAS). The results showed a significant
improvement in the ROM and pain level in both groups (p < 0.005),
however, no difference was found between groups (p > 0.05)
(Harish and Kashif, 2013).
Itoh et al., (2008) performed a blinded, sham-controlled RCT in
which subjects with knee OA were divided into three groups: one
group received standard acupuncture needles positioned around
the knee (the selected points were ST34, ST35, ST36, SP9, SP10,
and GB34); the second group received dry needling in the MTrPs
(the muscles examined and treated for MTrPs were the quadri-
ceps, iliopsoas, sartorius, adductors, popliteus, gluteus minimus,
and hamstrings); the third group was given a sham needling
treatment in the MTrPs in the same muscles as above, however,
the needle tips were cut off and smoothed, hence, the needles did
not actually penetrate the skin. All subjects received 5 treatments,
one per week, each lasting 30 min. Knee pain (VAS) and the
Western Ontario and McMaster Universities Osteoarthritis Index
(WOMAC) scores were taken 10 and 20 weeks after the first
treatment. The VAS score showed a significant reduction in both
the MTrPs (p < 0.0001) and the standard acupuncture group
(p ¼ 0.006). The difference was statistically significant between
the MTrPs and the sham acupuncture group (p ¼ 0.025), but no
significant difference was found between the MTrPs and the
standard acupuncture group (p ¼ 0.47). The WOMAC scores
Please cite this article in press as: Dor, A., Kalichman, L., A myofascial component of pain in knee osteoarthritis, Journal of Bodywork &
Movement Therapies (2017), http://dx.doi.org/10.1016/j.jbmt.2017.03.025
Results
 Pain intensity right now- 92% reported a reduction of >20 mm on 100 mm scale (p < 0.001).
 Pain interference- 78% reported a reduction of >20 mm on a 100 mm scale (p < 0.001).
 TUG- Significantly improved after the first intervention (t ¼ 5.62, p ¼ 0.0001) and was
significantly different between first and fifth treatment (t ¼ 5.35, p < 0.0001).
 Significant improvement in VAS and ROM in both groups (p < 0.005), but no
 significant improvement was found between the groups (p > 0.05).
 VAS showed a significant reduction in the standard acupuncture group (p ¼ 0.006) and the MTrPs
needling group (p < 0.001).
 WOMAC showed a significant reduction in both the MTrP needling and the standard acupuncture
group (p < 0.001 in both). The lowest WOMAC score was found in the MTrP needling group. A
significant difference was detected between the MTrP needling and sham acupuncture groups
(p ¼ 0.03). No significant difference was detected between the standard acupuncture and sham
acupuncture groups (p ¼ 0.72).
 Pain- a significant improvement in both groups (p < 0.001 in the right knee in both groups,
p < 0.004 in the left knee in both groups), but the intervention group showed a greater
improvement than the control group (p < 0.001 on both sides).
 Stiffness- improvement in both groups (p < 0.001), more in intervention than control (p < 0.001).
 ROM- increased in both groups (p ¼ 0.003 in right knee, p < 0.001 in left knee), no difference was
found between the groups (p > 0.05).
 TUG- a significant reduction in intervention group (p < 0.001) but not in control group (p ¼ 0.47).
 Pain - significantly better in the MTrPs group than in the hyaluronic acid group, one week after the
third injection (p < 0.001).
 ROM- significantly improved in the MTrPs group (p < 0.001) while no changes were observed in
the hyaluronic acid group.
 Iliotibial band flexibility- no significant difference between groups in the post-treatment
adduction angle values (F ¼ 3.711, p ¼ 0.062). While the control group showed no significant
(F ¼ 0.813; p ¼ 0.373) improvement in the adduction angle (25.69%) after treatment, the inter-
vention group showed highly significant improvement in the adduction angle by 45.35%
(F ¼ 8.356; p < 0.001).
 Patellar malalignment- Comparing the median values of patellar mal-alignment values between
the two groups post-treatment, showed significant improvement (Mann-Whitney U ¼ 58;
p ¼ 0.000) in favor of the intervention group.
 Comparing the median values of pressure-pain threshold between the two groups post-
treatment, showed significant improvement (Mann-Whitney U ¼ 35; p < 0.001) in favor of the
intervention group.
showed a significant reduction in both the MTrPs and the standard
acupuncture group (p < 0.001 in both). There was a statistically
significant difference between the MTrPs and the sham needling
group (p ¼ 0.031), but no significant difference between the
MTrPs dry needling and the standard acupuncture group
(p ¼ 0.72). In conclusion, the study found that MTrPs dry needling
was superior to non-penetrating sham needling in a small group
of elderly patients (Itoh et al., 2008).
Rahbar et al., (2013) examined the efficacy of MTrPs therapy in
patients with bilateral knee OA. Sixty recruited patients were
equally divided into intervention and control groups. The controls
received 16 treatments of conventional physical therapy which
included ultrasound, transcutaneous electrical nerve stimulation
(TENS), hot packs, ergonomic consultations, guidance on lifestyle
modifications, ROM exercises and stretching and/or strengthening
exercises for hamstring and calf muscles, quadriceps, hip adduc-
tors and the iliotibial bands (ITB). The intervention group received
the same physical therapy supplemented by the spray & stretch-
ing technique to the muscles surrounding the knee (quadriceps,
hip adductors, ITB and tensor fascia lata, hamstring and calf
muscles). The authors found a significant improvement in pain in
the right and left knees in both groups (p < 0.001 and p < 0.004,
correspondingly). However, the intervention group showed
greater improvement in pain scores than the controls (p < 0.0001
for right knee pain and p < 0.01 for left knee pain). A significant
improvement in joint stiffness scores was noted in both groups
(p < 0.001 in both groups). Once again, this improvement in the
intervention group was greater than in the control group
(p < 0.001). The disability index improved in both groups
(p < 0.001 in both groups). Improvement of the disability index in
 A. Dor, L. Kalichman / Journal of Bodywork & Movement Therapies xxx (2017) 1e6
the intervention group was significant compared with the control
group (p ¼ 0.022). Post treatment, the ROM of the knees in both
two groups increased (p ¼ 0.003 in the right knee and p < 0.001 in
the left knee in the control group and p < 0.001 in both knees in
the intervention group). Although there was a further improve-
ment of the ROM in the intervention group, no significant statis-
tical differences were noted between the intervention and control
groups (p ¼ 0.322 and p ¼ 0.226 in the right and left knee,
respectively). The Timed Up and Go test improved in both groups,
however, in the control group it was not statistically significant
(p ¼ 0.47) but in the intervention group, it was significant
(p < 0.001) (Rahbar et al., 2013).
Yentür et al., (2003) examined 34 female patients with knee OA
as to whether a lidocaine injection to the MTrPs, combined with an
intra-articular hyaluronic acid injection, would be more effective in
pain reduction and assist in daily activities rather than a hyaluronic
acid injection alone (control group). Patients in the MTrPs group
received intra-articular 2 ml Na-hyaluronate injections followed by
MTrPs injections, three times with a one-week interval. The MTrPs
0.5% lidocaine injections were given in the relevant MTrPs (rectus
femoris, vastus medialis, vastus lateralis, sartorius, adductor longus,
tensor fascia lata, gracilis, pectineus, iliopsoas, biceps femoris,
semitendinosus, semimembranosus, adductor magnus, gastrocne-
mius, and soleus) (Yentür et al., 2003).
Prior to treatment and 7 days after the third injection, the same
assessor, blinded to the type of intervention, evaluated the pain
intensity at rest and during normal daily activities, activity re-
strictions and joint ROM. The results showed a significant
improvement in pain and reduction of activity restrictions in the
MTrPs group (p < 0.001) while in the control group, there were
significant improvements only in squatting and walking (p ¼ 0.03).
At the end of the third week, only one patient in the control group
and 10 in the MTrPs group experienced no pain. Six patients in the
control group and no patients in the MTrPs group experienced
severe pain. A significant improvement in ROM was observed only
in the MTrPs group (Yentür et al., 2003).
A study by Gomaa and Zaky, (2015) investigated the effect of ITB
myofascial release on hip adduction angle, patellar malalignment,
and pain pressure threshold (PPT) of MTrPs in patients with knee
OA. Thirty-six females with knee OA were recruited and divided
into two groups: a control group furnished with an exercise pro-
gram and an intervention group who in addition to the exercise
program were given an ITB MTrPs release compromising ischemic
compression and neuromuscular techniques (longitudinal strokes).
The duration of the exercise session ranged between 20 and
30 min every other day for four weeks (12 sessions). The myofascial
release was added to the session between 5 and 20 min depending
on the targeted number of MTrPs. The results of the study were as
follows: ITB flexibility-no significant difference between groups in
the post-treatment adduction angle values (F ¼ 3.711, p ¼ 0.062).
The control group improved in adduction angle values by 25.69%
following treatment (statistically not significant) (F ¼ 0.813;
p ¼ 0.373). The intervention group, following treatment, showed a
highly significant improvement in adduction angle values by
45.35% (F ¼ 8.356; p ¼ 0.000). As to patellar malalignment,
comparing the median values of patellar malalignment values be-
tween the two groups post-treatment, showed a significant
improvement (Mann-Whitney U ¼ 58; p ¼ 0.000) in favor of the
intervention group. As to PPT, comparing the median values of PPT
between the two groups post-treatment, showed a significant
improvement (Mann-Whitney U ¼ 35; p ¼ 0.000) in favor of the
intervention group. In conclusion, an exercise program in combi-
nation with ITB myofascial release techniques significantly im-
proves ITB flexibility, patellar alignment, and PPT in patients with
knee OA (Gomaa and Zaky, 2015).
Please cite this article in press as: Dor, A., Kalichman, L., A myofascial component of pain in knee osteoarthritis, Journal of Bodywork &
Movement Therapies (2017), http://dx.doi.org/10.1016/j.jbmt.2017.03.025
5
4. Discussion
The current review included two observational studies evalu-
ating the prevalence of MTrPs in OA patients and six intervention
studies evaluating the efficacy of treatment, focusing on the myo-
fascial component. Two of the intervention studies (Henry et al.,
2012; Itoh et al., 2008) also evaluated the prevalence of MTrPs in
OA patients.
All studies found a high prevalence of myofascial pain in knee
OA patients (Alburquerque-García et al., 2015; Bajaj et al., 2001;
Henry et al., 2012; Itoh et al., 2008). A recent case-control study
(Alburquerque-García et al., 2015) found significantly more active
MTrPs in patients with knee OA than in healthy matching subjects
(Alburquerque-García et al., 2015). On the other hand, there is
some dispute as to the affected muscles. Bajaj et al., (2001) found
that unilateral knee joint OA patients had a greater number of
MTrPs in muscles surrounding the knee joint compared to the
unilateral hip joint OA patients. The knee muscles with the
highest prevalence of MTrPs, compared to the healthy controls,
were the rectus femoris (prevalence of 64.3%) and the gastroc-
nemius (prevalence of 57.1%) (Bajaj et al., 2001). Henry et al.,
(2012) found that more than 60% of the subjects had MTrPs only
in the medial muscles (medial head of the gastrocnemius muscle
and the vastus medialis); none had MTrPs in the lateral muscles;
approximately 40% of the subjects had pain in both medial and
lateral muscles (Henry et al., 2012). Itoh et al., (2008) reported that
the highest prevalence of MTrPs was found in the quadriceps,
followed by the iliopsoas, adductors and hamstrings muscles (Itoh
et al., 2008).
As indicated by the aforementioned studies, we can cautiously
state that MTrPs can be considered a partial factor in creating pain
in knee OA patients. Because MTrPs also cause muscle weakness
and decreased ROM (Rahbar et al., 2013; Simons et al., 1999),
symptoms found to be associated with knee OA (Harish and
Kashif, 2013; Pollard et al., 2008; Alburquerque-García et al.,
2015), it is possible that MTrPs are also an element of knee OA
etiology. Further studies with a larger sample size are warranted
in order to confirm the association between the prevalence of
MTrPs and OA pain in the knees and other sites (hips, facet joints,
etc.). More precise data on involved muscles is needed. It is also
potentially important to explore the role of MTrPs in the etiology
of OA.
Several intervention studies circumferentially support the
assumption of myofascial involvement in knee OA pain. Henry et al.,
(2012), in a nonrandomized, nonblinded quasi-experimental study
found that MTrPs injections significantly reduced pain intensity
and pain interference and improve mobility in knee OA patients.
Itoh et al., (2008) in a blinded, sham-controlled RCT compared
MTrPs dry needling to standard Chinese acupuncture and sham
needling in patients with knee OA, suggesting that MTrPs dry
needling may be more effective in treating knee OA than standard
acupuncture and was superior to non-penetrating sham needling
in a small group of elderly patients.
Harish and Kashif (Harish and Kashif, 2013) compared the
Maitland mobilization and the myofascial release technique in
reducing pain level and increasing the ROM in knee OA patients.
They observed a significant improvement in the patients’ ROM and
pain level after the treatments, but no significant difference be-
tween treatment options. Unfortunately, the treatment protocol
was not described in the article preventing the possibility of
analyzing the results. Rahbar et al., (2013) investigated the impact
of MTrPs treatment in patients with knee OA in a single-blinded
RCT. The spray and stretching technique, followed by a hot pack
and friction massage were used to treat the MTrPs. This treatment
was added to the conventional physical therapy received by the
6 A. Dor, L. Kalichman / Journal of Bodywork & Movement Therapies xxx (2017) 1e6
control group. The intervention group showed statistically better
results in the WOMAC index and in the Timed Up and Go test, but
not in the knee ROM. It is possible that the intervention group had a
better outcome since their treatment lasted longer due to the
additional time required for the spray and stretching technique, the
hot pack and friction massage, which was applied on all MTrPs
surrounding the knee.
Yentür et al., (2003) found that by adding MTrPs injections with
lidocaine to the regular treatment of intra-articular hyaluronic acid
injections to patients with knee OA was more effective in increasing
ROM, reducing pain and improving daily activities than treatment
with only a hyaluronic acid injection. Gomaa and Zaky, (2015)
found that adding the ITB myofascial release technique to an ex-
ercise program improved ITB flexibility, patellar alignment, and PPT
in patients suffering from knee OA. In this study, it is also possible
that the intervention group had better outcomes since their treat-
ment lasted longer. It also should be taken into account that their
treatment affected only the ITB and that no other muscles
impacting the knee were examined.
The aforementioned studies provide initial evidence of the ef-
ficacy of myofascial pain treatments in patients with knee OA.
Treatment by MTrPs injections reduced pain intensity and
improved mobility; the myofascial release technique improved
ROM and reduced pain level significantly; MTrPs dry needling
improved patients' pain scores and function; the spray and
stretching technique for MTrPs improved pain ratings, joint stiff-
ness, function, and ROM; MTrPs lidocaine injections improved
ROM, reduced pain and increased patients’ function; and the ITB
myofascial release technique improved ITB flexibility, patellar
alignment, and PPT.
Considering the small sample size of the above studies and the
heterogeneity in treatment types and outcome measures, addi-
tional high-quality studies are essential to explore the treatment
options of MTrPs to alleviate pain and restore function in OA
patients.
5. Conclusions
The reviewed studies provided initial evidence that myofascial
pain and prevalence of MTrPs may be an element of OA etiology.
Additional studies are warranted to reach a definite conclusion as to
whether myofascial pain in OA co-exists and enhances the pain and
disability of these patients or causes it. We believe that the evalu-
ation of myofascial pain should be included in a routine clinical
examination of OA.
According to the interventional studies included in this review,
treatment focusing on myofascial components appears to be
effective in reducing pain and improving function in patients with
OA. However, additional large and high-quality RCTs are essential in
order to formulate a concrete treatment plan.
Please cite this article in press as: Dor, A., Kalichman, L., A myofascial component of pain in knee osteoarthritis, Journal of Bodywork &
Movement Therapies (2017), http://dx.doi.org/10.1016/j.jbmt.2017.03.025
Conflict of interest
None.
Role of funding source
This review did not receive any specific grant from funding
agencies in the public, commercial, or not-for-profit sectors.
Acknowledgements
The authors thank Mrs. Phyllis Curchack Kornspan for her
editorial services.
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