Introduction to Myofascial Pain

Introduction[edit | edit source]

Fascia is a structure of connective tissue that surrounds muscles, groups of muscles, blood vessels, and nerves, binding some structures together, while permitting others to slide smoothly over each other. Various kinds of fascia may be distinguished.  [1]
Like ligaments, aponeuroses, and tendons, fasciae are dense regular connective tissues, containing closely packed bundles of collagen fibres oriented in a wavy pattern parallel to the direction of pull. Fasciae are consequently flexible structures able to resist great unidirectional tension forces until the wavy pattern of fibres has been straightened out by the pulling force. These collagen fibres are produced by the fibroblasts located within the fascia. [1]
Fasciae are similar to ligaments and tendons as they are all made of collagen except that ligaments join one bone to another bone, tendons join muscle to bone and fasciae surround muscles or other structures. [1]

The video below gives a fascinating introduction to fascia.


Structure[edit | edit source]

Fascia: Consists of solid and liquid components.

  • Solid components : muscle, bone , cartilage and adipose tissue.
  • Liquid components include: blood and lymph.

Myofascia: includes contractile muscle and connective tissues. End thickenings make origins and insertions of the muscles on the bones. Thus able to guide the skeletal system with muscular contractions.(1) The nerve, vascular and lymphatic system are enclosed in multiple layers of fascia. Thus different tissues are linked together by the fascia.

  • The fascia creates different interdependent layers with several depths, from the skin to the bone
  • The fascia creates different interdependent layers with several depths, from the skin to the periosteum, forming a three-dimensional mechano-metabolic structure .
  • The liquid fascia (blood and lymph) can be a source of myofascial pain
    • Flow velocity,
    • Direction
    • Type of flow
  • Myofascial pain, can be due to any of the structure tangled in the myofacia :
    • Nerves
    • Muscles
    • Connective tissue

Alternative definitions:[edit | edit source]

Fascia Nomenclature Committee (2014)

“The fascial system consists of the three-dimensional continuum of soft, collagen containing, loose and dense fibrous connective tissues that permeate the body. It incorporates elements such as adipose tissue, adventitia and neurovascular sheaths, aponeuroses, deep and superficial fasciae, epineurium, joint capsules, ligaments, membranes, meninges, myofascial expansions, periosteum, retinacula, septa, tendons, visceral fasciae, and all the intramuscular and intermuscular connective tissues including endo-/peri-/epimysium. The fascial system interpenetrates and surrounds all organs, muscles, bones and nerve fibers, endowing the body with a functional structure, and providing an environment that enables all body systems to operate in an integrated manner.”[3]

FORCE (2013) - Foundation of Osteopathic Research and Clinical Endorsement.

“The fascia is any tissue that contains features capable of responding to mechanical stimuli. The fascial continuum is the result of the evolution of the perfect synergy among different tissues, liquids and solids, capable of supporting, dividing, penetrating, feeding and connecting all the regions of the body, from the epidermis to the bone, involving all its functions and organic structures. This continuum constantly transmits and receives mechanometabolic information that can influence the shape and function of the entire body. These afferent/efferent impulses come from the fascia and the tissues that are not considered as part of the fascia in a biunivocal mode. In this definition, these tissues include: epidermis, dermis, fat, blood, lymph, blood and lymphatic vessels, tissue covering the nervous filaments (endoneurium, perineurium, epineurium), voluntary striated muscle fibers and the tissue covering and permeating it (epimysium, perimysium, endomysium), ligaments, tendons, aponeurosis, cartilage, bones, meninges, and tongue"[4][5]

Hypotheses for Myofascial pain[edit | edit source]

  1. Trigger points :
    1. Active: Pain without movement
    2. Passive or Latent: Painful with palpation, vague, non localised[6]
  2. Constant microtrauma to the muscle→ depletes ATP → alters mechano-metabolic environment → increases nociceptive impulses to the brain→ peripheral sensitization in acute phase and central sensitization chronically (2).  (potassium, prostaglandins, histamine, kinins, ) Increase in Ach at synaptic end plate→ continuous contraction→ depletes ATP → inflammation.[6]
  3. Change in connective tissue due to inflammation →  fibroblasts transform to myofibroblasts → shortening of tissue and increase in tone→ nociceptive stimulus → alters polarization of muscle fibers → muscle contraction.[7]
  4. Altered mechanometabolic environment → thickening of extracellular matrix → fascia difficulty sliding→ harder for muscle to contract[8] → The nerve endings of the fascia in the most viscous area stretches, becoming constantly activated, creating a trigger point.[9]
  5. Alteration of blood flow ( increase in systolic velocity, decrease in diastolic velocity) → alters morphology and function of capillaries→ ischemia → activate type IV nerve endings → myofascial pain.[10]

Differential Diagnosis for Myofascial pain

  • Fibromyalgia: some studies highlight an alteration of the connective tissue with the stem cells that produce adipose tissue. The myofascial pain could cause an inflammatory environment and local pain. Fibromyalgia is not localized.[11]
  • The chronic pelvic pain: Condition that must be present from 6 months onwards, and not necessarily influenced by movements or the presence of menstruation (in women). Ultrasound examinations to determine muscular processes v/s organic dysfunctions.[12]
  • The Temporomandibular Joint: could be involved in myofascial pain but could also be involved in a referred pain pattern. If there are trigger points that do not improve after a manual or pharmacological approach, it could be a symptom of cardiac ischemia[13]
  • Eagle's Syndrome: Throat or neck pain, if unilateral, could be caused by Eagle's Syndrome. Pain should improve with tissue treatment; if this does not happen, the causes must be investigated.[14]
  • Inflammation: Inflammation of tendons or of purely connective formations (fasciitis, tendinopathies, and more) have a very specific anatomical area. A tendon will have a specific area with an aetiology, with the special tests, symptomology and palpation that correlates. If the pain is more a global pain, start to look outside the box of the diagnosis.

History Taking[edit | edit source]

Table showing aspects that need to be considered during the history taking.

Mechanical Psychological Systemic/ metabolic Other
Scoliosis Stress Hypothyroidism Infectious disease
Limb length discrepency Anxiety Iron deficiency Parasitic disease
Muscle hypertrophy Vitamin D deficiency Rheumatic disease
Repetitive microtrauma Vitamin c deficiency Hyperalgesia
Vitamin B12 deficiency Statins

References[edit | edit source]

  1. 1.0 1.1 1.2 Fascia. Wikipedia, the free encyclopedia. (last accessed 13 Oct 2013).
  2. Scishow Fascia Available from: (last accessed 24.5.2019)
  3. Adstrum S, Hedley G, Schleip R, Stecco C, Yucesoy CA. Defining the fascial system. Journal of bodywork and movement therapies. 2017 Jan 1;21(1):173-7.
  4. Bordoni B, Simonelli M, Morabito B. The other side of the fascia: the smooth muscle part 1. Cureus. 2019 May;11(5).
  5. Bordoni B, Simonelli M, Morabito B. The other side of the fascia: visceral fascia, part 2. Cureus. 2019 May;11(5).
  6. 6.0 6.1 Fricton J. Myofascial pain: mechanisms to management. Oral and Maxillofacial Surgery Clinics. 2016 Aug 1;28(3):289-311.
  7. Bordoni B, Marelli F, Morabito B, Castagna R. Chest pain in patients with COPD: the fascia’s subtle silence. International journal of chronic obstructive pulmonary disease. 2018;13:1157.
  8. Stecco A, Gesi M, Stecco C, Stern R. Fascial components of the myofascial pain syndrome. Current pain and headache reports. 2013 Aug 1;17(8):352.
  9. Stecco C, Stern R, Porzionato A, Macchi V, Masiero S, Stecco A, De Caro R. Hyaluronan within fascia in the etiology of myofascial pain. Surgical and radiologic anatomy. 2011 Dec 1;33(10):891-6.
  10. Bron C, Dommerholt JD. Etiology of myofascial trigger points. Current pain and headache reports. 2012 Oct;16(5):439-44.
  11. Bordoni B, Marelli F, Morabito B, Cavallaro F, Lintonbon D. Fascial preadipocytes: another missing piece of the puzzle to understand fibromyalgia?. Open access rheumatology: research and reviews. 2018;10:27.
  12. Montenegro ML, Gomide LB, Mateus-Vasconcelos EL, Rosa-e-Silva JC, Candido-dos-Reis FJ, Nogueira AA, Poli-Neto OB. Abdominal myofascial pain syndrome must be considered in the differential diagnosis of chronic pelvic pain. European Journal of Obstetrics & Gynecology and Reproductive Biology. 2009 Nov 1;147(1):21-4.
  13. Bordoni B, Sugumar K, Varacallo M. Myofascial Pain.
  14. Saccomanno S, Greco F, De Corso E, Lucidi D, Deli R, D’addona A, Paludetti G. Eagle’s Syndrome, from clinical presentation to diagnosis and surgical treatment: a case report. Acta Otorhinolaryngologica Italica. 2018 Apr;38(2):166.