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Introduction to Myofascial Pain

Original Editor - Carin Hunter Top Contributors - Jess Bell, Carin Hunter, Kim Jackson, Lucinda hampton, Robin Tacchetti, Tony Lowe and Ewa Jaraczewska

Introduction

The fascial system is an integrated, body-wide network of connective tissue, including fasciae and their interstitial spaces. It features a layered, multiscale structure that allows for both tensional loading and shearing movement. [1] Fascia surrounds muscles, groups of muscles, blood vessels, and nerves. It binds some structures together, while permitting others to slide smoothly over each other.

The video below provides a fascinating introduction to fascia.

[2]

Fascia Organisation

The fascial system is organized into four anatomical organs: superficial, musculoskeletal (deep), visceral, and neural fascia. These organs and their components are made up of various combinations of the four classic tissue types: epithelial, connective, muscle, and neural.[1] However, the official anatomical terminology, as set forth by the Federative International Programme for Anatomical Terminology (FIPAT) in the Terminologia Anatomica (TA), discourages the traditional and somewhat imprecise use of the terms superficial fascia and deep fascia. Instead, FIPAT recommends the use tela subcutanea describing the layer of tissue situated immediately beneath the dermis of the skin and superficial to the outermost layer of muscle fascia, and fascia musculorum, dense and organised layer of connective tissue that envelops individual muscles, muscle groups, and compartments.[3]

Structure

The overall function is derived from its two fundamental layer types: a stiff, collagenous layer for structural support, and a viscous, hyaluronic acid-rich layer that promotes fluid flow and mobility. The specific arrangement of these layers—such as unidirectional for tension or interwoven for shear mobility—reflects the localized function across the body.[1]

Alternative Definitions

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.”[4]

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"[5]

Myofascia

Myofascia is the continuous, interwoven connective tissue (fascia) surrounding and linking muscle (myo) throughout the body. It forms a three-dimensional matrix vital for structural support and movement.[6] Myofascia consists of muscle fibers and the dense fascia, which is made of collagen and elastin and a viscous ground substance allowing it to stretch and glide. Furthermore, fascia is highly innervated, functioning as a key sensory organ for proprioception and pain (nociception). [7] Maintaining the health, flexibility, and hydration of this unified functional system is essential for optimal posture, efficient movement, stability, and injury prevention, as disruptions like adhesions can lead to restricted movement and chronic pain.[7]

Myofascial Pain

"Myofascial pain is a soft tissue pain syndrome with local and referred musculoskeletal pain arising from trigger points."[8]

Myofascial pain is a common chronic musculoskeletal pain syndromes.[9] The liquid fascia (blood and lymph) can be a source of pain as changes in the following can affect surrounding tissues, leading to myofascial pain:

  • Flow velocity
  • Direction
  • Type of flow

Myofascial pain can be caused by any structure that is tangled in the myofascia:

  • Nerves
  • Muscles
  • Connective tissue

Hypotheses for Myofascial pain

  1. Trigger points:[7][8]
    1. Active: pain without movement
    2. Passive or latent: painful with palpation, vague, non-localised[10]
  2. Constant microtrauma to the muscle→ depletes ATP → alters mechano-metabolic environment → increases nociceptive impulses to the brain→ peripheral sensitisation in acute phase and central sensitisation chronically (potassium, prostaglandins, histamine, kinins) → increase in ACH at synaptic end plate→ continuous contraction→ depletes ATP → inflammation[10]
  3. Change in connective tissue due to inflammation →  fibroblasts transform to myofibroblasts → shortening of tissue and increase in tone→ nociceptive stimulus → alters polarisation of muscle fibers → muscle contraction[7]
  4. Altered mechano-metabolic environment → thickening of extracellular matrix → fascia has difficulty sliding→ harder for muscle to contract[11] →the nerve endings of the fascia in the most viscous area stretch, so that they are constantly activated, creating a trigger point[12]
  5. Alteration of blood flow (increase in systolic velocity, decrease in diastolic velocity) → alters morphology and function of capillaries→ ischaemia → activates type IV nerve endings → myofascial pain[13]

Differential Diagnosis for Myofascial Pain

Differential diagnosis of MPS should include: fibromyalgia, joint pain (TMJ), inflammation (arthritis, degenerative disk disease, radiculopathy, bursitis, and tendonitis), as well as autoimmune or infectious etiologies, metabolic and endocrine dysfunction including hypothyroidism, and psychiatric disorders including depression and anxiety.[8]

  • Fibromyalgia: a chronic pain condition of uncertain aetiology.[14] Individuals with fibromyalgia experience a number of changes in their myofascial system, including pain and fatigue. It has been found that the fascia may be involved in stimulating inflammation and fat cell production.[14] However, while myofascial pain can cause an inflammatory environment and local pain, fibromyalgia is not localised.
  • Chronic pelvic pain: pain must be present for at least 6 months to be classified as chronic pelvic pain. Pain may be continuous or intermittent.[15] It is not necessarily influenced by menstruation / intercourse (in women).[15] Ultrasound examinations are used to determine if an individual's pain is due to muscular processes or organic dysfunction. While menstruation pain can be linked to specific times, days, hormones etc, myofascial pain is not dependent on these factors.[7]
  • Temporomandibular Joint (TMJ): TMJ pain can be associated with myofascial pain, but other structures can also refer pain to the TMJ. If pain does not improve after manual techniques (i.e. trigger point release) or medication, this pain could be a sign of cardiac ischaemia.[16]
  • Eagle's Syndrome: characterised by abnormality of the styloid process. [17] Patients present with recurrent throat or neck pain, which radiates to the ear. They may also have dysphagia.[18] Myofascial pain should improve with tissue treatment. If it does not, then the cause must be investigated further.[7]
  • Inflammation: Inflammation of tendons or other connective tissue formations (i.e. fasciitis, tendinopathies etc) tend to affect a very specific anatomical area. There is often a clear aetiology and the subjective and objective assessments point to a specific diagnosis. If the pain is more global, it is beneficial to consider the myofascia.

History Taking

A patient's history can provide clues that the myofascia could be implicated in his / her pain. The following table lists aspects that need to be considered during the assessment process.[7]

Table 1. Factors that should be considered in a patient's history.
Mechanical Psychological Systemic/ metabolic Other
Mechanical forces (e.g. prolonged standing) Stress Hypothyroidism Infectious disease
Scoliosis (leads to imbalanced, unequal forces) Anxiety Iron deficiency Parasitic disease
Limb length discrepancy (leads to unequal forces) Vitamin D deficiency Rheumatic disease
Muscle hypertrophy (overactivity in some muscles) Vitamin C deficiency Hyperalgesia
Repetitive microtrauma Vitamin B12 deficiency Statins

References

  1. ↑ 1.0 1.1 1.2 Stecco C, Pratt R, Nemetz LD, Schleip R, Stecco A, Theise ND. Towards a comprehensive definition of the human fascial system. Journal of Anatomy. 2025 Jun;246(6):1084-98.
  2. ↑ Scishow Fascia Available from: https://www.youtube.com/watch?v=T-UsSmD7miI (last accessed 24.5.2019)
  3. ↑ Hammer CM, Hotfiel T. Fascia–The academic apple of discord. Sports Orthopaedics and Traumatology. 2025 Feb 8.
  4. ↑ 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.
  5. ↑ Bordoni B, Simonelli M, Morabito B. The other side of the fascia: the smooth muscle part 1. Cureus. 2019 May;11(5).
  6. ↑ Yıldızgören MT, Dede BT. The Role of Fascia in Myofascial Pain Syndrome: A Look at Cinderella Tissue. Cam ve Sakura Medical Journal. 2024 Jan 1;4(1).
  7. ↑ 7.0 7.1 7.2 7.3 7.4 7.5 7.6 Pandya R. Introduction to Myofascial Pain Course. Plus , 2021.
  8. ↑ 8.0 8.1 8.2 Lam C, Francio VT, Gustafson K, Carroll M, York A, Chadwick AL. Myofascial pain–A major player in musculoskeletal pain. Best Practice & Research Clinical Rheumatology. 2024 Mar 1;38(1):101944.
  9. ↑ Fernandez-de-Las-Penas C, Nijs J. Trigger point dry needling for the treatment of myofascial pain syndrome: current perspectives within a pain neuroscience paradigm. Journal of pain research. 2019;12:1899.
  10. ↑ 10.0 10.1 Fricton J. Myofascial pain: mechanisms to management. Oral and Maxillofacial Surgery Clinics. 2016 Aug 1;28(3):289-311.
  11. ↑ 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.
  12. ↑ 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.
  13. ↑ Bron C, Dommerholt JD. Etiology of myofascial trigger points. Current pain and headache reports. 2012 Oct;16(5):439-44.
  14. ↑ 14.0 14.1 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.
  15. ↑ 15.0 15.1 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.
  16. ↑ Bordoni B, Sugumar K, Varacallo M. Myofascial Pain. [Updated 2021 Aug 7]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK535344/
  17. ↑ Hassani M, Grønlund EW, Albrechtsen SS, Kondziella D. Neurological phenotypes and treatment outcomes in Eagle syndrome: systematic review and meta-analysis. PeerJ. 2024 Jun 26;12:e17423.
  18. ↑ 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.
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