Upper Limb Myofascial Pain Diagnosis - Literature Review

Original Editor - Carin Hunter based on the course by Rina Pandya
Top Contributors - Jess Bell, Carin Hunter and Wanda van Niekerk

Introduction[edit | edit source]

Often a patient will present at your clinic with a complaint that does not seem to fit the average picture or who is not responding to treatment as you would expect. It could be that the underlying cause of the condition is coming from the myofascial system. It can be difficult to initially pick up myofascial complaints, but there are certain features that can help you distinguish this dysfunction from other conditions. This page will discuss studies which explore these features to help you to reach a diagnosis more efficiently. Please note that red flags must also be ruled out.

Chronic Non-Specific Neck Pain[edit | edit source]

Cerezo-Téllez et al.[1] explored the prevalence of myofascial pain syndrome in 224 individuals diagnosed with chronic non-specific neck pain by their family doctor. This study was conducted in three primary healthcare centres in Madrid (Spain). They looked specifically for active and latent myofascial trigger points and found:[1]

  • Trapezius myofascial trigger points in 93.75 percent of participants
    • The most prevalent active myofascial trigger points were located in the nearly-horizontal fibres of the upper trapezius muscle (82.1 percent located on the right and 79 percent located on the left)
  • There were also active myofascial trigger points in levator scapulae (82.14 percent), multifidi (77.68 percent), and splenius cervicis (62.5 percent)

Chronic Tension-Type Headaches[edit | edit source]

Chatchawan et al.[2] investigated the characteristics and location of myofascial trigger points and pressure pain threshold (PPT) of active trigger points in 53 individuals who had chronic tension-type headache (CTTH). They were compared to 53 age- and gender-matched individuals without CTTH (CON). Trigger points and tenderness points were identified by manual palpation. The pressure pain threshold (PPT) was then measured with a manual algometer. The authors found:[2]

  • In the CTTH group, active trigger points per person in the head, neck, shoulder and upper back were 4.3 ± 2.1 vs 0 in the CON group
  • In the CTTH group, latent trigger points per person in these areas were 0.6 ± 1.0 vs 0.7 ± 1.5 in the CON group
  • In both the CTTH and CON groups, tenderness points in these areas were 1.9 ± 1.8
  • PPT levels of active trigger points in the head, neck, shoulders and upper back were 0.7 ± 0.2 to 1.2 ± 0.6 kg/cm2
  • There were more active trigger points and these active trigger points had lower PPT levels in the head, neck and shoulder than in the upper back

Thus, Chatchawan et al.[2] concluded that the lower PPTs of active trigger points in the head, neck and shoulder regions could have an impact on patients with CTTH.

Chronic Craniofacial / Cervicobrachial Pain[edit | edit source]

A case report by Raja et al.[3] looked at chronic craniofacial pain (CFP) and cervicobrachial pain (CBP) in a 25-year-old female college student. The student had chronic head, temporomandibular, neck and arm pain for 4 years with an acute exacerbation. This case report aimed to explore the short-term effect of a fascia directed approach (i.e. fascial manipulation) on CFP and CBP.

Deep manual friction was used to achieve fascial manipulation. The outcome measures used were the Numerical Pain Rating Scale (NPRS), Temporomandibular Disability Index (TMDI), and Patient Specific Functional Scale (PSFS).

At the follow-up (1 week post-treatment), there were improvements in all outcomes (NRPS, TMDI, PSFS) - i.e. function improved and pain reduced.[3]

Orofacial Pain of Cervical Origin[edit | edit source]

A case report by Ganesh et al.[4] looked at orofacial pain of cervical origin in a 55-year-old male teacher who had a 3-year history of right lower jaw pain, which radiated to the ear. The patient had already received treatment for dental pain and trigeminal neuralgia, but this was unsuccessful.

His function was significantly affected and he was unable to sleep due to severe pain. He was cleared for other conditions (infection, malignancies, sinusitis, temporomandibular disorder, tenderness and myofascial trigger points). On examination, he had a reduction in cervical rotation to the right.[4]

In this report, the patient was treated for upper cervical joint dysfunction (i.e. mobilisation of the upper three cervical vertebrae and motor control exercises). Post-treatment, the patient's symptoms almost completely resolved and he had significant improvements on his Patient Specific Functional Scale (PSFS) and Global Rating of Change (GRC) scale.[4]

The authors[4] of this study concluded that it is essential to consider the cervical spine as a potential cause of orofacial pain and that cervical mobilisation can be beneficial.

Comorbid Myofascial Pain[edit | edit source]

Comorbid myofascial pain has been observed in a wide variety of medical conditions, including malignant tumours, osteoarthritis, neurological conditions, and mental health conditions.

  1. Oncological diseases
  2. Osteoarthritis
  3. Neurological diseases
  4. Chronic Regional Pain Syndrome
  5. Headaches
  6. Inflammatory and infectious diseases
  7. Syndromes of the upper extremity

The following section discusses these areas in detail, using information from the qualitative review from Vulsfons and Minerbi.[5] The full text of this article is available here:

1. Myofascial Pain Syndrome and Oncological Diseases[edit | edit source]

A number of studies have found that myofascial pain syndrome (MPS) contributes to cancer pain (particularly breast cancer, head and neck tumours, and advanced cancer). The following studies are discussed in Vulsfons and Minerbi's qualitative review:[5]

  • Cardoso et al.[6] assessed 167 patients for MPS after treatment for head or neck cancer. All patients had been disease-free for at least a 1-year interval:
    • The authors found that 1 in 9 participants had MPS. Their quality of life was found to be lower than those who did not have MPS.[6]
  • Torres Lacomba et al.[7] found that of 116 women who had breast cancer with axillary lymph node resection, 44.8 percent developed MPS:[5]
  • Ko et al.[8] conducted a retrospective study of 52 breast cancer patients who were treated with surgery and chemotherapy and who were experiencing upper limb sensory disturbance that developed after chemotherapy. The authors found that:[5][8]
    • More than 20 percent of participants had MPS
    • 13.5 percent had isolated MPS
    • 7.5 percent had combined MPS and chemotherapy-induced neuropathic pain
    • A longer duration of chemotherapy treatment and hormone treatment resulted in an increased risk of MPS
    • Shoulder and chest muscles were most often affected
  • Fernández-Lao et al.[9] examined the differences in widespread pressure pain hypersensitivity in breast cancer patients after mastectomy, lumpectomy or no surgery. While there was widespread pressure pain hyperalgesia in patients after surgery, which suggests central spreading sensitisation, there were no significant differences between patients who had a lumpectomy and those who had a mastectomy.[9] Myofascial trigger points were, however, more common after surgery compared to no surgery.[5]

2. Myofascial Pain Syndrome and Osteoarthritis[edit | edit source]

As discussed by Vulsfons and Minerbi:[5]

  • Bajaj et al.[10] compared 14 patients with osteoarthritis (OA) of the hip, knee, or both with a matched control group.  Patients with OA had significantly more trigger points compared to the control group. There was also a positive correlation between the number of trigger points and OA radiological scores.[10]
  • Henry et al.[11] looked at the prevalence of MPS in 25 patients with knee OA who were waiting for total knee arthroplasty. It was found that each patient had MPS in the muscles around the knee. Gastrocnemius was most frequently involved.[11]
  • A case-control study by Albuquerque-García et al.[12] compared 18 female knee OA patients with 18 matched controls. The authors compared the number of active trigger points in both groups' knee muscles. They found that the OA group had more myofascial trigger points (which was associated with a higher pain intensity and lower functional ability).[12]
  • Sánchez-Romero et al.[13] conducted a cross-sectional study, which included 114 patients with knee OA. Participants were assessed for myofascial trigger points. 75% of participants had active myofascial trigger points in their vastus medialis muscles. 65% had them in their vastus lateralis muscles.[13]
  • Mayoral et al.'s[14] randomised controlled trial found that dry needling of the hip and calf muscles under anaesthesia reduced post-operative use of analgesia in patients having total knee replacements. Patients who received dry needling also had reduced pain one month post-surgery compared to participants who received a sham needling treatment.[5] [14]

3. Myofascial Pain Syndrome and Neurological Diseases[edit | edit source]

A cross-sectional study by Villafañe et al.[15] looked at the prevalence of myofascial trigger points in 50 post-stroke patients who had shoulder pain. The authors also explored the relationship between trigger points and pain / function in participants. They found that 50% of patients had active myofascial trigger points in their infraspinatus muscles. Supraspinatus (34%), teres minor (12%), and upper trapezius (20%) were less often affected.

As is stated by Vulsfons and Minerbi,[5] post-stroke shoulder pain is also associated with weakness, rigidity, and adhesive capsulitis and this pain often occurs alongside MPS of the subscapularis and shoulder girdle muscles. De Oliveira et al.[16] found that 27 of 40 patients with central post-stroke pain had MPS (i.e. 67.5%).

Treating the myofascial elements of post-stroke pain has been found to:[5]

  • Reduce pain levels
  • Improve range of motion
  • Have a positive impact on balance and function

4. Myofascial Pain Syndrome and Chronic Regional Pain Syndrome[edit | edit source]

Allen et al.[17] explored the relationship between the myofascial system and chronic regional pain syndrome (CRPS). They found that the myofascial system was implicated in the pain of 56% of participants.[5] Similarly, Rashik and Galer[18] note that 61% of patients with CRPS had myofascial dysfunction in their affected limb. This occurred more frequently in the upper limb (70%) than the lower limb (47%).[5]

In a case-control study, Dor et al.[19] examined thoracic paraspinal myofascial trigger points in 20 individuals with upper limb CRPS and 20 healthy controls. 15 to 35% of participants with CRPS had active myofascial trigger points compared to 0% in the control group.[5]

People with the following conditions also had a high prevalence of MPS:[5]

5. Myofascial Pain Syndrome and Headaches[edit | edit source]

Fricton at al.[20] found that 164 of 296 patients (i.e. 55.4%) with head and neck pain had trigger points associated with their pain. Pain was reported to refer to a range of areas, including the supraorbital, forehead, temple, post-auricular, vertex, occipital, and retro-orbital areas.[5] Sjaastad et al.[21] also reported that the prevalence of MPS was increased on the affected side of patients with cervicogenic headache. Treating myofascial dysfunction in patients with a history of chronic headache (associated with MPS) can have a positive effect.[5][22]

Tfelt-Hansen et al.[23] found that 48 out of 50 individuals with migraine had tenderness in their head and neck muscles. 73% of these patients had referred pain. Moreover, injections of 1 mL lidocaine 1.5% or 1 mL saline into tender points eliminated pain in 54% of cases.[5] Fernández-de-Las-Peñas et al.[24] also looked at trigger points in individuals with migraine. They reported that migraine patients had significantly more active trigger points than healthy controls. The muscles most often affected were on the same side as the migraine.[5]

Individuals with episodic and chronic tension-type headaches also have an increased incidence of trigger points in their neck muscles. Studies by Verma et al.[25] and Castejón et al.[26] have found that the referred pain generated by active neck and shoulder trigger points replicates headache pain patterns in individuals with tension-type headaches.[5]

6. Myofascial Pain Syndrome and Inflammatory / Infectious Disease[edit | edit source]

Localised inflammation and infections have been shown to cause muscle irritation (resulting in contraction, stiffness and pain) in a number of conditions, such as:[5]

  • Meningitis (nuchal rigidity)
  • Head and neck infections (torticollis)
  • Intra-abdominal pathologies (abdominal rigidity and guarding)
  • Lund and Cohen[27] discussed five cases of trismus and MPS:[5]
    • Two were found to be secondary to infection
    • Three were secondary to cancer
  • Niraj and Kamel [28] investigated 54 patients who had abdominal pain caused by chronic pancreatitis:[5]
    • 38% of participants had MPS of the abdominal wall, which almost always responded positively to a transversus abdominis plane block

7. Myofascial Pain Syndrome and the Upper Extremity[edit | edit source]

As Gerwin[29] notes, MPS in the upper limb is a common cause of pain (either following trauma or due to acute / chronic musculoskeletal dysfunction). Myofascial trigger points are present and can be identified via palpation. Individuals with upper limb MPS will have local and referred pain, but pain patterns may present like other conditions such as radiculopathy or nerve entrapment. Treatment focuses on:[29]

  • Inactivating trigger points
  • Correcting underlying causes
  • Restoring normal relationships between muscles

Diagnosis and Treatment of Myofascial Pain[edit | edit source]

Myofascial pain is often overlooked as a diagnosis because it:[30]

  • Is often is associated with other signs and symptoms
  • May occur in conjunction with other conditions
  • May be accompanied by other psychosocial / behavioural problems.[30]

When assessing individuals, it is important to consider any contributing factors, as well as to locate the trigger points and muscles involved.[30]

Management includes:

  • Palliative care
  • Splint therapy
  • Muscle exercises
  • Trigger point therapy
  • Behavioural therapy

As Fricton and Steenks[30] note, short-term goals should focus on restoring muscle length, addressing postural dysfunction, and achieving full joint range of motion with exercises and trigger point therapy.

The long-term goals should focus on reducing symptoms and limiting their negative effects, and achieving normal function without the need for additional health care.[30]

"Failure to address the entire problem through a team approach if needed, may lead to failure to resolve the pain and perpetuation of a chronic pain syndrome."[30]

Myofascial Pain Syndrome, Forward Head Posture and Episodic Tension-Type Headache[edit | edit source]

The following section provides a summary of Fernández‐de‐las‐Peñas et al.'s[24] research article: Myofascial Trigger Points, Neck Mobility, and Forward Head Posture in Episodic Tension-Type Headache

Figure 1. Forward head posture.

Objective of the study: To evaluate the relationship between trigger points, forward head posture (FHP) (see Figure 1), neck mobility, and other clinical variables related to headache intensity and temporal profile.[24]

Method: 15 individuals with episodic tension-type headache (ETTH) and 15 matched controls were assessed. Trigger points in upper trapezius, sternocleidomastoids, and temporalis muscles were identified on both sides using the Simons and Gerwin diagnostic criteria. FHP was evaluated by measuring the craniovertebral angle using side-view (profile) pictures. Cervical range of motion was measured using a goniometer. Participants were asked to keep a 4-week headache diary, noting headache intensity, frequency, and duration.[24]

Results:[24]

  • The authors found that patients in the ETTH group had more trigger points in the right upper trapezius muscles, the left sternocleidomastoid, and both temporalis muscles than the control group
  • Headache intensity, frequency and duration did not differ depending on trigger point activity (i.e. whether trigger points were latent or active) in the ETTH group
  • The ETTH demonstrated greater FHP (i.e. a smaller craniovertebral angle) than the control group
  • The ETTH group had reduced neck mobility compared to the control group in terms of total range of motion, as well as half-cycles (except for extension). However, the authors concluded that neck mobility did not seem to impact headache parameters[24]

Trigger Points: Diagnosis and Management[edit | edit source]

Alvarez and Rockwell[31] provide a summary of trigger points and their management here:

They note that:[31]

Interventions discussed by Alvarez and Rockwell[31] include:

  • Spray and Stretch technique (i.e. passively stretching the relevant muscle while at the same time topically applying dichlorodifluoromethane-trichloromonofluoromethane (Fluori-Methane) or ethyl chloride spray[31])
  • Ultrasound
  • Manual therapy, massage
  • Heat / ice
  • Injection (has been found to be one of the most effective interventions to inactivate trigger points and rapidly reduce pain)[31]

[32]

References[edit | edit source]

  1. 1.0 1.1 Cerezo-Téllez E, Torres-Lacomba M, Mayoral-del Moral O, Sánchez-Sánchez B, Dommerholt J, Gutiérrez-Ortega C. Prevalence of myofascial pain syndrome in chronic non-specific neck pain: a population-based cross-sectional descriptive study. Pain medicine. 2016 Dec 1;17(12):2369-77.
  2. 2.0 2.1 2.2 Chatchawan U, Thongbuang S, Yamauchi J. Characteristics and distributions of myofascial trigger points in individuals with chronic tension-type headaches. Journal of physical therapy science. 2019;31(4):306-9.
  3. 3.0 3.1 Raja G P, Fernandes S, Cruz AM, Prabhu A. The plausible role of Deep Cervical Fascia and its continuum in chronic craniofacial and Cervicobrachial Pain: A case report. Heliyon. 2020 Jul 1;6(7):e04560.
  4. 4.0 4.1 4.2 4.3 Ganesh GS, Sahu MM, Tigga P. Orofacial pain of cervical origin: A case report. Journal of bodywork and movement therapies. 2018 Apr 1;22(2):276-80.
  5. 5.00 5.01 5.02 5.03 5.04 5.05 5.06 5.07 5.08 5.09 5.10 5.11 5.12 5.13 5.14 5.15 5.16 5.17 5.18 5.19 5.20 Vulfsons S, Minerbi A. The Case for Comorbid Myofascial Pain—A Qualitative Review. International Journal of Environmental Research and Public Health. 2020 Jan;17(14):5188.
  6. 6.0 6.1 Cardoso LR, Rizzo CC, De Oliveira CZ, Dos Santos CR, Carvalho AL. Myofascial pain syndrome after head and neck cancer treatment: prevalence, risk factors, and influence on quality of life. Head & neck. 2015 Dec;37(12):1733-7.
  7. Torres Lacomba M, Mayoral del Moral O, Coperias Zazo JL, Gerwin RD, Goñí AZ. Incidence of myofascial pain syndrome in breast cancer surgery: a prospective study. Clin J Pain. 2010;26(4):320-5.
  8. 8.0 8.1 Ko EJ, Jeon JY, Kim W, Hong JY, Yi YG. Referred symptom from myofascial pain syndrome: One of the most important causes of sensory disturbance in breast cancer patients using taxanes. Eur J Cancer Care (Engl). 2017;26(6).
  9. 9.0 9.1 Fernández-Lao C, Cantarero-Villanueva I, Fernández-de-las-Peñas C, Del-Moral-Ávila R, Menjón-Beltrán S, Arroyo-Morales M. Widespread mechanical pain hypersensitivity as a sign of central sensitization after breast cancer surgery: comparison between mastectomy and lumpectomy. Pain medicine. 2011 Jan 1;12(1):72-8.
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  11. 11.0 11.1 Henry R, Cahill CM, Wood G, Hroch J, Wilson R, Cupido T, VanDenKerkhof E. Myofascial pain in patients waitlisted for total knee arthroplasty. Pain Research and Management. 2012;17(5):321-7.
  12. 12.0 12.1 Alburquerque-García A, Rodrigues-de-Souza DP, Fernández-de-las-Peñas C, Alburquerque-Sendín F. Association between muscle trigger points, ongoing pain, function, and sleep quality in elderly women with bilateral painful knee osteoarthritis. J Manipulative Physiol Ther. 2015;38(4):262-8.
  13. 13.0 13.1 Sánchez-Romero EA, Pecos-Martín D, Calvo-Lobo C, García-Jiménez D, Ochoa-Sáez V, Burgos-Caballero V, Fernández-Carnero J. Clinical features and myofascial pain syndrome in older adults with knee osteoarthritis by sex and age distribution: A cross-sectional study. The Knee. 2019 Jan 1;26(1):165-73.
  14. 14.0 14.1 Mayoral O, Salvat I, Martín MT, Martín S, Santiago J, Cotarelo J et al. Efficacy of myofascial trigger point dry needling in the prevention of pain after total knee arthroplasty: a randomized, double-blinded, placebo-controlled trial. Evid Based Complement Alternat Med. 2013;2013:694941.
  15. Villafañe JH, Lopez-Royo MP, Herrero P, Valdes K, Cantero-Téllez R, Pedersini P et al. Prevalence of myofascial trigger points in poststroke patients with painful shoulders: a cross-sectional study. Journal of Injury, Function and Rehabilitation. 2019;11:1077-82.
  16. de Oliveira RA, de Andrade DC, Machado AG, Teixeira MJ. Central poststroke pain: somatosensory abnormalities and the presence of associated myofascial pain syndrome. BMC neurology. 2012;12(1):1-9.
  17. Allen G, Galer BS, Schwartz L. Epidemiology of complex regional pain syndrome: a retrospective chart review of 134 patients. Pain. 1999 Apr;80(3):539-44.
  18. Rashiq S, Galer B. Proximal myofascial dysfunction in complex regional pain syndrome: a retrospective prevalence study. The Clinical Journal of Pain. 1999;15(2):151-3.
  19. Dor A, Vatine JJ, Kalichman L. Proximal myofascial pain in patients with distal complex regional pain syndrome of the upper limb. Journal of bodywork and movement therapies. 2019 Jul 1;23(3):547-54.
  20. Fricton JR, Kroening R, Haley D, Siegert R. Myofascial pain syndrome of the head and neck: a review of clinical characteristics of 164 patients. Oral Surgery, Oral Medicine, Oral Pathology. 1985;60(6):615-23.
  21. Sjaastad O, Fredriksen TA, Pfaffenrath V. Cervicogenic headache: diagnostic criteria. Headache: The Journal of Head and Face Pain. 1990 Nov;30(11):725-6.
  22. Roth JK, Roth RS, Weintraub JR, Simons DG. Cervicogenic headache caused by myofascial trigger points in the sternocleidomastoid: a case report. Cephalalgia. 2007;27(4):375-80.
  23. Tfelt‐Hansen P, Lous I, Olesen J. Prevalence and significance of muscle tenderness during common migraine attacks. Headache: The Journal of Head and Face Pain. 1981 Mar;21(2):49-54.
  24. 24.0 24.1 24.2 24.3 24.4 24.5 Fernández‐de‐las‐Peñas C, Cuadrado ML, Pareja JA. Myofascial trigger points, neck mobility, and forward head posture in episodic tension‐type headache. Headache: The Journal of Head and Face Pain. 2007 May;47(5):662-72.
  25. Verma S, Tripathi M, Chandra PS. Cervicogenic Headache: Current Perspectives. Neurology India. 2021 Mar 1;69(7):194.
  26. Castejón OJ, Gonzalez C, Lastre-Amell G, Leal J, Galindez P, Castejon Salones M, Sierra Carrero LL. Clinical study of cervicogenic headache.
  27. Lund TW, Cohen JI. Trismus appliances and indications for their use. Quintessence International. 1993 Apr 1;24(4).
  28. Niraj G, Kamel Y. Ultrasound-guided subcostal TAP block with depot steroids in the management of chronic abdominal pain secondary to chronic pancreatitis: a three-year prospective audit in 54 patients. Pain Medicine. 2020 Jan 1;21(1):118-24.
  29. 29.0 29.1 Gerwin RD. Myofascial pain syndromes in the upper extremity. Journal of Hand Therapy. 1997 Apr 1;10(2):130-6.
  30. 30.0 30.1 30.2 30.3 30.4 30.5 Fricton JR, Steenks MH. Diagnosis and treatment of myofascial pain. Nederlands tijdschrift voor tandheelkunde. 1996 Jul 1;103(7):249-53.
  31. 31.0 31.1 31.2 31.3 31.4 Alvarez DJ, Rockwell PG. Trigger points: diagnosis and management. American family physician. 2002 Feb 15;65(4):653.
  32. Alila Medical Media. Myofascial Pain Syndrome and Trigger Points Treatments, Animation. Available from https://www.youtube.com/watch?v=QY9ePL690Dk (last accessed 5 October 2021)