Upper Limb Myofascial Pain Diagnosis - Literature Review

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

Introduction

Often a patient will present in your clinic with a complaint that does not seem to fit the average picture or 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 symptoms that can help you distinguish this dysfunction from other conditions. This page will discuss studies with symptoms to help you to get to a diagnosis more efficiently.

Chronic Non-Specific Neck Pain

Objective: To assess the prevalence of active and latent myofascial trigger points in subjects suffering from chronic non-specific neck pain.

Design: A population-based cross-sectional descriptive study was carried out from January 2012 to December 2014.

Setting: Three primary healthcare centres in Alcalá de Henares, Madrid (Spain).

Subjects: 224  participants diagnosed by their family doctor with chronic non-specific neck pain.

Methods: Physical therapist evaluation for myofascial pain syndrome, descriptions from the subjects and pain body diagrams guided the physical examination.

Results: Myofascial trigger points of the trapezius muscles in 93.75%. The most prevalent active myofascial trigger points were on the right (82.1%) and left (79%) in the nearly-horizontal fibres of the upper trapezius muscle. Active myofascial trigger points in the levator scapulae, multifidi, and splenius cervicis muscles were 82.14%, 77.68%, and 62.5%, respectively.

Chronic Tension-Type Headaches

Objective:  To investigate the characteristics and distributions of the myofascial trigger point (TrP) and pressure pain threshold (PPT) of the active TrP in individuals with chronic tension-type headache (CTTH).

Design and Setting:  Fifty-three CTTH patients and 53 age and gender-matched individuals without CTTH (CON) were recruited. The TrPs and tenderness points were first identified by manual palpation, and the PPTs of the active TrPs were determined by using a manual algometer.

Results: The active TrP, latent TrP and tenderness point totals per person in the head, neck, shoulder and upper back in CTTH were 4.3 ± 2.1, 0.6 ± 1.0 and 1.9 ± 1.8, respectively, while those in CON were 0, 0.7 ± 1.5 and 1.9 ± 1.8, respectively. The PPT levels of the active TrPs were 0.7 ± 0.2 to 1.2 ± 0.6 kg/cm2 in the muscles of the head, neck, shoulder and upper back. A larger number of active TrPs and lower PPT levels of the active TrPs were found in the head, neck and shoulder regions than in the upper back region.

Conclusion: Lower PPTs of the active TrPs in the head, neck and shoulder regions could influence individuals with CTTH.

Chronic Craniofacial/ Cervicobrachial pain

Case report: 1 treatment , 1 patient

Objective:  CFP and CBP with possible involvement of impaired Deep Cervical Fascia and to explore the short-term effect of fascia directed approach (Fascial Manipulation).

Methods: 25-year-old female college student with chronic head, temporomandibular, neck, and arm pain over the past four years with acute pain exacerbation.

Treatment: Fascial Manipulation (FM) was performed by deep manual friction. The patient-reported outcomes such as the Numerical Pain Rating Scale (NPRS), Temporomandibular disability index (TMDI), and Patient Specific Functional Scale (PSFS) were assessed.

Result: Following FM treatment, there was a reduction in pain and improved function between the baseline and follow up evaluation after one week based on all the outcomes (NPRS, PSFS, and TMDI)

Orofacial Pain of Cervical Origin

A 55-year-old male teacher with a 3-year history of pain in the right lower jaw, radiating to the ear.

The patient was unsuccessfully treated for dental pain and trigeminal neuralgia. The patient's functioning was grossly limited and the patient was unable to sleep because of severe pain. Physical examinations: no infection, malignancies, or sinusitis. Palpation: no temporomandibular disorder, tenderness or myofascial trigger points. Examination: Cervical ROM reduction in rotation to the right side.

Treatment: The patient was treated for upper cervical joint dysfunction involving mobilisation of the first three cervical vertebrae and motor control exercises. The patient had an almost complete resolution of symptoms and reported significant improvement in the Patient Specific Functional Scale (PSFS) and the Global Rating of Change (GRC) scale.

Conclusion: This case study demonstrates the importance of considering, assessing and treating the cervical spine as a possible source of orofacial pain, and the positive role of cervical mobilisation on these disorders.

Comorbid Myofascial Pain

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. Syndrome of the upper extremity

1. Myofascial Pain Syndrome and Oncological Diseases

• The contribution of myofascial pain syndrome to cancer pain has been observed in several studies, most often in the context of breast cancer, head and neck tumours, and advanced cancer.
• Myofascial pain syndrome in patients with head and neck cancer, 40 patients, completed therapy. Pain in 57% with 13% experiencing myofascial pain syndrome. 167 pts /57% pain, 11.9 % MPS of upper traps; 30/30 TP only in patient group.
• 116 women with breast cancer with axillary lymph node resection, 44.8% in pain, MPS was approximately six months post-surgery in latissimus dorsi, serratus anterior, pectoralis major, and infraspinatus.
• Ko et al. conducted a retrospective study in 52 patients with breast cancer, who had surgery and chemotherapy. MPS  exceeded 20%, 13.5% isolated MPS, 7.5% combined MPS and chemotherapy-induced neuropathic pain. The risk of developing MPS was increased with a longer duration of chemotherapy treatment and with hormone treatment. Shoulder and chest muscles were affected the most.
• Fernández-Lao et al. compared the frequency of shoulder and neck pain among breast cancer patients undergoing either lumpectomy, mastectomy, or no surgery. Myofascial trigger points were more common after surgery, but no significant differences were observed between patients undergoing a lumpectomy and those undergoing mastectomy.

2. Myofascial Pain Syndrome and Osteoarthritis

• Bajaj et al. investigated 14 patients with OA of the hip, knee, or both as compared to that of a matched group of healthy controls  A significantly higher number of trigger points was identified in patients as compared to controls, and a positive correlation was observed between the number of recognized trigger points and OA radiological scores.
• Henry et al. explored the prevalence of MPS in a cohort of 25 patients on a waitlist for total knee arthroplasty due to OA of the knee. All patients were found to have MPS of the muscles surrounding the knee, with the gastrocnemius being most commonly involved.
• Case-control study, Albuquerque-García et al. compared the number of active trigger points in the muscles surrounding the knees of 18 women with bilateral painful knee OA to those of 18 matched controls. A higher number of myofascial trigger points was detected in OA patients, correlating with a higher intensity of pain and lower functional capacity.
• In a cross-sectional study by Sánchez-Romero et al., 114 patients with OA of the knee were evaluated for myofascial trigger points. Active myofascial trigger points were detected in 75% of participants’ vastus medialis muscles and in 65% of their vastus lateralis muscles.
• In a randomized controlled trial including 40 patients undergoing total knee replacement, dry needling of the hip and calf muscles under anaesthesia resulted in decreased post-surgical analgesic consumption, as well as decreased pain intensity one month post-surgery, when compared to sham needling.

3. Myofascial Pain Syndrome and Neurological Diseases

In a cross-sectional study of 50 post-stroke individuals with shoulder pain, active myofascial trigger points were documented in up to 50% of the examined infraspinatus muscles, while other muscles were less often affected by MPS (supraspinatus (34%), teres minor (12%), and upper trapezius (20%)). Weakness, rigidity, and adhesive capsulitis have all been implicated in the development of post-stroke shoulder pain, often accompanied by MPS of the subscapularis and other shoulder girdle muscles.

In another observational study, de Oliveira et al. examined 40 patients with central post-stroke pain, observing MPS in 67.5% of them.

Several studies explored the clinical efficacy of treating the myofascial component of post-stroke pain, demonstrating reduced pain intensity and improved range of motion  as well as improved balance and function.

4. Myofascial Pain Syndrome and Chronic Regional Pain Syndrome

Allen et al. conducted a cross-sectional study of 134 individuals with CRPS, reporting that 56% of them had a myofascial component to their pain

In a retrospective chart review of 41 CRPS patients, Rashik et al. found myofascial dysfunction of the involved limb in 61% of the patients, more often in upper extremity CRPS (70%) than in lower (47%)

Dor et al. compared the presence of thoracic paraspinal myofascial trigger points in a case-control study involving 20 individuals with upper extremity CRPS and 20 healthy controls. The prevalence of active myofascial trigger points in the different muscles which were evaluated was 15–35% in CRPS patients, as opposed to 0% in the control group.

A high prevalence of MPS was observed in individuals with spinal cord injury, brachial plexus injury, trigeminal neuralgia, diabetic peripheral neuropathy, and post-thoracotomy pain syndrome.

5. Myofascial Pain Syndrome and Headaches

Fricton, in a study of 296 patients evaluated for head and neck pain, 164 (55.4%) exhibited trigger points attributable to their pain. The patients complained of a wide variety of pain sites, including supraorbital, forehead, temple, post-auricular, vertex, occipital, and retro-orbital.

Sjaastad et al. reported that cervicogenic headaches, increased the prevalence of MPS on the affected side. Successfully treated for MPS, biomechanical factors involving neck musculature and posture have been attributed to the aetiology and maintenance of chronic headache in patients suffering from this condition.

Tfelt-Hansen et al. described 50 migraine sufferers, of whom all but two had tenderness in the head and neck muscles. Of these, 73% also demonstrated referred pain characteristics (Injections of 1 mL lidocaine 1.5% or 1 mL saline into these tender points).

Fernández-de-Las-Peñas et al. found that migraine subjects showed a significantly greater number of active, but not latent, trigger points when compared to healthy controls. Involved muscles were mostly located ipsilateral to the migraine headaches.

Patients suffering from tension-type headaches (TTH), both episodic and chronic, have increased incidence of myofascial trigger points in their neck musculature In these studies, the referred pain elicited by active trigger points in the neck and shoulder muscles reproduced the headache pattern in patients with frequent episodic and chronic TTH.

6. Myofascial Pain Syndrome and Inflammatory and Infectious Disease

The potential of localized inflammatory and infectious processes to cause muscle irritation, leading to contraction, stiffness, and pain, has been widely documented in multiple clinical syndromes, such as nuchal rigidity accompanying meningitis, torticollis accompanying head and neck infections and abdominal rigidity and guarding associated with intra-abdominal pathologies.

Cohen et al. reported on five cases of trismus and MPS, two of which proved to be secondary to infection and three secondary to cancer.

Niraj et al. followed 54 patients with abdominal pain due to chronic pancreatitis. Twenty-one (38%) patients had abdominal wall MPS which, in almost all cases, responded to a transversus abdominis plane block.

7. Myofascial Pain Syndrome and the Upper Extremity

Myofascial pain syndromes of the upper extremity are common causes of pain that may follow trauma and are associated with acute or chronic musculoskeletal stress. The syndromes are characterized by the presence of the myofascial trigger point, a physical finding that is reliably identified by palpation. Local and referred pain are hallmarks of the syndrome, and the referred pain patterns may mimic such conditions as radiculopathy and nerve entrapment syndromes. Treatment is directed toward inactivating the myofascial trigger point, correcting underlying perpetuating factors, and restoring the normal relationships between the muscles of the affected functional motor units.

Diagnosis and Treatment of Myofascial Pain

Myofascial pain (MFP) is frequently overlooked as a diagnosis because it is often accompanied by signs and symptoms in addition to pain, coincidental pathology conditions, and behavioural and psychosocial problems.

Evaluation:  Locating the trigger points and muscles involved as well as recognition of these contributing factors.

Management:  Palliative care, splint therapy, muscle exercises, therapy to the trigger points, and behavioural therapy that depends on the complexity of the case. The short term goals are to restore the muscle to normal length, posture, and full joint range of motion with exercises and trigger point therapy. The long term goals include reducing the symptoms and their negative effects while helping the patient return to normal function without the need for further health care.

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.

Myofascial Pain Syndrome, Forward Head Posture (FHP) and Episodic Tension-Type Headache (ETTH)

Objective: To assess the relationship between the muscle TrPs, FHP ( Forward Head Posture), neck mobility, and several clinical variables concerning the intensity and the temporal profile of headache.

Method: Fifteen Episodic tension-type headache (ETTH) subjects and 15 matched controls. TrPs in both upper trapezius, both sternocleidomastoids, and both temporalis muscles. Side-view pictures to assess FHP by measuring the craniovertebral angle. A cervical goniometer to measure neck mobility. Blinded assessor. Patients maintained a 4 -week headache diary documenting intensity, frequency, and duration.

Results: More TP in ETTH than the control group in the right upper trapezius muscles, the left sternocleidomastoid, and both temporalis muscles. Within the ETTH group, headache intensity, frequency, and duration outcomes did not differ depending on TrP activity, whether the TrP was active or latent but the craniovertebral angle was smaller, i.e., there was a greater FHP which contributed to the pain.

ETTH patients also showed lesser neck mobility than healthy controls in the total range of motion as well as in half-cycles (except for cervical extension), although neck mobility did not seem to influence the headache parameter.

Regional, persistent pain results in a decreased range of motion in the affected postural muscles such as those in the neck, shoulders, and pelvic girdle area.

Trigger points may also manifest as tension headache, tinnitus, temporomandibular joint pain, decreased range of motion in the legs, and low back pain.

Various modalities, such as the Spray and Stretch technique, ultrasonography, manipulative therapy and injection, are used to inactivate trigger points. Trigger-point injection has been shown to be one of the most effective treatment modalities to inactivate trigger points and provide prompt relief of symptoms.

Treatment is directed toward inactivating the myofascial trigger point, correcting underlying perpetuating factors, and restoring the normal relationships between the muscles of the affected functional motor units.