Upper Limb Myofascial Pain Evaluation and Treatment

Original Editor - Carin Hunter based on the course by Rina Pandya
Top Contributors - Carin Hunter, Jess Bell and Merinda Rodseth

Myofascial Pain Symptoms[edit | edit source]

  • Sore spots, sensitive to pressure, primarily in muscles.
  • Dull, aching, and nagging pain.
  • Deep muscle pain than joints.
  • Limbs may feel a little weak, heavy, and stiff.
  • Pain mainly occurs in a specific area with a fairly clear epicenter
  • Crave massage, but it usually provides only temporary relief.
  • Hot showers and baths are also appealing and almost always at least briefly relieving.
  • Usually feels better with activity and exercise.
  • Pain is not strongly or sharply linked to movement.
  • There is no clear mechanism of injury, but flare-ups often occur in response to extremes of position, exercise, or temperature.
  • Pain is mostly episodic, but episodes can last a long time (weeks or months).
  • Pain may move around a bit…even to the other side of your body! While uncommon, it’s a distinctive symptom of trigger points.

Myofascial Treatment Techniques[edit | edit source]

  1. Instrument assisted soft tissue mobilization (IASTM)
  2. Trigger point release
  3. Selective Functional Movement Assessment (SMFA)
  4. Kinesiotaping
  5. Dry needling
  6. Foam Rolling
  7. Exercises

1. Instrument assisted soft tissue mobilization (IASTM)[edit | edit source]

Instrument assisted soft tissue mobilization (IASTM) is a widely known and acknowledged treatment for myofascial restriction. IASTM uses specially designed instruments to provide to mobilize scar tissue and myofascial adhesions. One such example is the Graston technique ® .

A systematic review by Scott Cheatham and Matt Lee, 2016, appraised the evidence assessing the effects of IASTM.[1]

Methodology: databases: PubMed, PEDro, Science Direct, and the EBSCOhost collection. The search terms included individual or a combination of the following: instrument; assisted; augmented; soft-tissue; mobilization; Graston®; and technique.

Results: A total of 7 randomized controlled trials were appraised. Five of the studies measured an IASTM intervention versus a control or alternate intervention group for a musculoskeletal pathology. The results of the studies were insignificant (p>.05) with both groups displaying equal outcomes. Two studies measured an IASTM intervention versus a control or alternate intervention group on the effects of joint ROM. The IASTM intervention produced significant (P<.05) short term gains up to 24 hours.

IASTM uses specially designed instruments for deeper penetration and mechanical advantage to the clinician. Using instruments for soft tissue mobilization is theorized to increase vibration sense by the clinician and patient. The increased perception of vibration may facilitate the clinician’s ability to detect altered tissue properties (e.g. identify tissue adhesions) while facilitating the patient’s awareness of altered sensations within the treated tissues.[2] [3]

It is theorized that IASTM stimulates connective tissue remodelling through resorption of excessive fibrosis, along with inducing repair and regeneration of collagen secondary to fibroblast recruitment.[4](, Strung 2014) This results in the release and breakdown of scar tissue, adhesions, and fascial restrictions.[5][4]

There are various IASTM tools and companies such as Graston®, Técnica Gavilán®, Hawk Grips®, Functional and Kinetic Treatment and Rehab (FAKTR)®, Adhesion Breakers® and Fascial Abrasion Technique™ that have their own approach to treatment and instrument design (e.g. instrument materials, instrument shape).

The Graston® technique[edit | edit source]

The Graston® technique contains a protocol for treatment that contains several components: examination, warm-up, IASTM treatment (e.g. 30–60 seconds per lesion), post treatment stretching, strengthening, and ice (only when subacute inflammation is of concern). (Technique: G. Graston Technique[6])

Graston Technique® (GT) is a unique, evidence-based form of instrument-assisted soft tissue mobilization that enables clinicians to effectively and efficiently address soft tissue lesions and fascial restrictions resulting in improved patient outcomes.GT uses specially designed stainless steel instruments with unique treatment edges and angles to deliver an effective means of manual therapy. The use of GT instruments, when combined with appropriate therapeutic exercise, leads to the restoration of pain-free movement and function. The instruments also are used diagnostically to assess the kinetic chain, in an efficient manner using the principles of regional interdependence.

For more information, please refer to: The Graston® technique website

Effects of the Graston® technique[edit | edit source]

Empirical and anecdotal evidence: based on patient and clinician experience and documentation

  • Separates and breaks down collagen cross-links, and splays and stretches connective tissue and muscle fibres
  • Facilitates reflex changes in the chronic muscle holding pattern (inhibition of abnormal tone/guarding leading to pain reduction via improved sensory input)
  • Alters/inhibits spinal reflex activity (facilitated segment)
  • Increases the rate and amount of blood flow to and from the area (angiogenesis vs. immediate local increases in blood flow)
  • Increases cellular activity in the region, including fibroblasts and mast cells
  • Increases histamine response secondary to mast cell activity.

Conditions treated with the Graston® technique[edit | edit source]

  • Achilles tendinitis/tendinosis (ankle pain)
  • Carpal Tunnel Syndrome (wrist pain)
  • Cervicothoracic Sprain/Strain (neck pain)
  • Fibromyalgia
  • Lateral Epicondylitis/Epicondylosis (tennis elbow)
  • Lumbosacral Sprain/Strain (back pain)
  • Medial Epicondylitis/Epicondylosis (golfer's elbow)
  • Myofascial Pain Syndromes
  • Patellofemoral Disorders (knee pain)
  • Plantar Fasciitis(foot pain)
  • Post surgeries such as joint replacements, RTC repairs (once post-surgical protocol allows for soft tissue mobilization/manual therapy)
  • Rotator Cuff Tendinitis/tendinosis (shoulder pain)
  • Scar Tissue/post-surgical scars (once completely closed)
  • Patients demonstrating central and/or peripheral sensitization (only used in light stroking/brushing mode to desensitize)
  • Shin Splints
  • Trigger Finger
  • Women's Health (post-mastectomy and Caesarean scarring)

The Graston® technique Tools[edit | edit source]

2. Trigger Point Release[edit | edit source]

  1. Primary or Central trigger points: A trigger point that causes severe pain locally at the pressure with irradiation according to referred pain map. Usually are based around the centre of a muscle belly.
  2. Secondary or Satellite trigger points: A trigger point that arises in response to existing central trigger points in surrounding muscles. They usually spontaneously withdraw when the central trigger point is healed. Can be present in the form of a cluster.
  • Active Trigger Points: Any point that causes tenderness and referral pain pattern on palpation. Almost always central trigger points are active and some satellite trigger points are also active (but not necessarily all of them). Inactive trigger points can eventually become active if there is a provocative factor.
  • Inactive or Latent Trigger Points: These can develop in anywhere and under fingertips feel like lumps, but are not painful. Can increase a stiffness of the muscles.
  • Diffuse Trigger Points: Commonly happen in case of severe postural deformity where initially primary trigger points are multiple, so secondary multiple trigger points are only a response of a mechanism, called diffuse.
  • Attachment Trigger Points: tendo-osseous junctions which become very tender. If not treated these can create degenerative processes of an adjacent joint.
  • Ligamentous Trigger Points: Pay attention to the ligament for the presence of trigger points. Presence of trigger points in the anterior longitudinal ligament of the spine can result in neck instability. Some knee pain syndromes are successfully healed when treated ligamentum patellae and fibular collateral ligament.

Indications of Trigger Point Therapy[edit | edit source]

  • Repetitive / acute micro-trauma
  • Vitamin deficiencies
  • Poor posture
  • Sleep disturbances
  • Joint problems
  • Chronic stress on muscles fibres or psychologically
  • Chronic infections
  • Radiculopathy
  • Depression
  • Hypothyroidism
  • Hyperuricemia
  • Hypoglycemia[7]

Contraindications of Trigger Point Therapy[edit | edit source]

  • Epilepsy
  • Asthma
  • Pregnancy
  • Hypertension
  • Patient pain tolerance
  • Anxiety and stress
  • Acute stage of healing or open wounds, burns
  • Medical conditions such as pneumonia, kidney, liver or respiratory failure
  • Diabetes with gangrene
  • Haemorrhagic conditions and use of blood thinners
  • Severe atherosclerosis
  • Unstable hypertension
  • Shock
  • Contagious diseases[7]

Interventions for Trigger Point Therapy[edit | edit source]

  • Modify or eliminate every day micro stressors
  • Correction and training of posture, extensive patient education on lifestyle (ergonomics)
  • Passive stretching techniques and/or Foam Roller stretching, few times a day
  • Self-massage, few times a day, and especially Deep Stroking Massage, done rhythmically and in only one direction
  • Strengthening: initially only isometric and then isotonic exercises
  • Taping Technique
  • Spray and Stretch Technique by using ethyl chloride spray
  • Manual Lymphatic Drainage (MLD), since the presence of TrPs obstacle lymphatic flow
  • Other proprioceptive neuromuscular techniques: Reciprocal Inhibition (RI), Post-Isometric Relaxation (PIR), Contract-Relax/Hold-Relax (CRHR), Contract-Relax/Antagonist Contract (CRAC)
  • Some specific techniques like Neuromuscular Technique(NMT), Muscle Energy Technique (MET) and Myotherapy (MT), Ultrasonography, Hot and Cold packs, Diathermy- Tecar therapy, Laser, Ionophoresis.(vasquez,2010)

3. Selective Functional Movement Assessment (SMFA)[edit | edit source]

Nomenclature:

  1. Functional/Painful (FP): Patient completes the movement but has pain
  2. Dysfunctional/ Non-painful (DN): Patient unable to complete movement, does not have pain
  3. Dysfunctional/ Painful (DP): Unable to complete the movement, has pain
  4. Functional/Non-painful (FN): Completes movement, no pain

SFMA patterns and assessment[edit | edit source]

  1. Cervical spine patterns
    1. Flexion: touch the chin to chest
    2. Extension: look back at the ceiling
    3. Rotation with flexion: touch the chin to each collar bone
  2. Upper extremity patterns
    1. Abduction with external rotation: Reaching the arm around the head attempting to touch the superior angle of the opposite scapula
    2. Adduction with internal rotation: Reaching the arm around the back attempting to touch the inferior angle of the scapula
  3. Multi-segmental Flexion: Reach down and touch your toes
  4. Multi-segmental Extension: Reach overhead and extend back as far as you can
  5. Multi-segmental rotation: Rotate your body as far as you can to each side, keeping the feet flat on the floor
  6. Single leg stance: Stand on one leg with the other leg to at least 90 degrees of hip flexion for at least 10seconds
  7. Overhead deep squat: Hands overhead feet about shoulder width apart and squat down as deep as you can while keeping the feet on the floor[8][9][10]

Example: Overhead squat and upper extremity patterns

  • Upper extremity patterns - Abduction/External Rotation and Adduction/Internal Rotation: Can be addressed by treating the front of the arm lines and back of the arm lines as discussed in the beginning of the lecture.
  • Back arm line: The 3rd tract of the front and back arm lines, the stabilization tract, have in integral connection into latissimus dorsi, TLFascia, sacral fascia contralaterally, gluteus max contralateral to TLF, Vastus lateralis.
  • Front arm line: Pec major , external oblique , adductor longus (opposite side of external oblique) , gracilis, pes anserine, tibial periosteum.
  • Use this as a tool in conjunction with palpation and visual observation, assess and re-assessment of the dysfunctional movement.

4. Kinesiotaping[edit | edit source]

Evidence for kinesiotaping in management of myofascial pain syndrome: a systematic review and meta-analysis, 2019.[11]

Objective: To evaluate the effectiveness of kinesiotaping for managing myofascial pain syndrome in terms of pain intensity, pressure pain threshold, range of motion, muscle strength and disability.

Data sources: PubMed, EBSCO, ScienceDirect, Web of Science, Cochrane Library and Physiotherapy Evidence Databases were searched from database inception to November 2018.

Data synthesis: Meta-analyses of 20 RCTs involving 959 patients showed that kinesiotaping was more effective than other treatments in reducing pain intensity at post-intervention. Kinesiotaping was also superior to other non-invasive techniques in relieving pain intensity at follow-up. However, there was no detectable effect on disability or function.

Conclusion: Statistical evidence showed that kinesiotaping could be recommended to relieve pain intensity and range of motion for patients with myofascial pain syndrome at post-intervention.[11]

5. Dry needling[edit | edit source]

Charles et al: A systematic review of manual therapy techniques, dry cupping and dry needling in the reduction of myofascial pain and myofascial trigger points, 2019[12]

Methods: Search engines included Google Scholar, EBSCO Host, and PubMed. Searches were performed for each modality using the keywords myofascial pain syndrome and myofascial trigger points. ; a diagnosis of myofascial pain syndrome or trigger points; manual therapy, dry needling, or dry cupping treatments; retrospective studies or prospective methodology; and inclusion of outcome measures.

Results: Eight studies on manual therapy, twenty-three studies on dry needling, and two studies on dry cupping met the inclusion criteria. The Physiotherapy Evidence Database (PEDro) was utilized to assess the quality of all articles.

Discussion: While there was a moderate number of randomized controlled trials supporting the use of manual therapy, the evidence for dry needling ranged from very low to moderate compared to control groups, sham interventions, or other treatments and there was a paucity of data on dry cupping.[12]

6. Foam Rolling[edit | edit source]

Kalichman and Chen David, published a narrative review titles” Effect of self-myofascial release on myofascial pain, muscle flexibility and strength: A Narrative review.[13]

Objective: To review the current methods of SMFR, their mechanisms, and efficacy in treating myofascial pain, improving muscle flexibility and strength.

Methods: PubMed, Google Scholar, and PEDro databases were searched without search limitations from inception until July 2016 for terms relating to SMFR.

Results and conclusions: During the past decade, therapists and fitness professionals have implemented SMFR mainly via foam rolling as a recovery or maintenance tool. Researchers observed a significant increase in the joint range of motion after using the SMFR technique and no decrease in muscle force or changes in performance after treatment with SMFR. SMFR has been widely used by health-care professionals in treating myofascial pain. However, we found no clinical trials which evaluated the influence of SMFR on myofascial pain. There is an acute need for these trials to evaluate the efficacy and effectiveness of SMFR in the treatment of the myofascial syndrome.”[13]

Garrett and Ramer in 2019, conducted a systematic review of literature for the purpose of determining duration of Myofascial rolling for optimal recovery , range of motion and performance.[14]

Method: A systematic search was conducted using PubMed, EMBASE, EBSCOHost and PEDro (July 2018). Twenty-two studies met the inclusion criteria and were appraised using the PEDro scale. Studies were grouped by outcome measure, with a total number of subjects of n = 328 for pain/soreness, n = 398 for ROM, and n = 241 for performance.

Results: The most evidence-based benefit of MR is the alleviation of muscle soreness; seven of eight studies assessing pain/soreness resulted in a short-term reduction, and a minimum dose of 90 seconds per muscle appeared beneficial. While ten of 17 studies involving ROM showed acute improvements, the results were inconsistent and highly variable. No significant effects on performance were detected.

Conclusion: Available data indicate that MR for 90 seconds per muscle group may be the minimal duration to achieve a short-term reduction in pain/soreness, with no upper limit found. Results do not support increases in chronic ROM or performance, and data are insufficient to provide a conclusive recommendation for impacting acute ROM. The heterogeneity of the literature highlights the need for additional research to determine optimal dose of MR.[14]

Stretching examples

  1. Sit on a rolling chair. Face palms down on the table in front of you. Slide hips back until elbows are almost straight. Keeping the feet on the floor, pull forward using your mid back and the core .
    1. Progression: Rest on the  medial side of the palm.
    2. Further progression: Place palms on the tennis balls and pull forwards.
  2. Desk or Wall stretch: Place palm down, roll the hip away, keeping the feet flat on the floor, rotate to the opposite direction. Turn the neck in the same direction as the trunk.
    1. Progression: above + palm facing up
    2. Further progression: above + extension of the wrist and fingers
  3. Fingers turned towards the back, keeping elbows soft, rise up with arms assisted with  the legs. Gently lean back to intensify the stretch.
    1. Progression: With thoracic extension and ER of the shoulder.

References[edit | edit source]

  1. Cheatham SW, Lee M, Cain M, Baker R. The efficacy of instrument assisted soft tissue mobilization: a systematic review. The Journal of the Canadian Chiropractic Association. 2016 Sep;60(3):200.
  2. Baker RT, Nasypany A, Seegmiller JG, Baker JG. Instrument-assisted soft tissue mobilization treatment for tissue extensibility dysfunction. International Journal of Athletic Therapy and Training. 2013 Sep 1;18(5):16-21.
  3. Lee JJ, Lee JJ, Kim DH, You SJ. Inhibitory effects of instrument-assisted neuromobilization on hyperactive gastrocnemius in a hemiparetic stroke patient. Bio-medical materials and engineering. 2014 Jan 1;24(6):2389-94.
  4. 4.0 4.1 Howitt S, Jung S, Hammonds N. Conservative treatment of a tibialis posterior strain in a novice triathlete: a case report. The Journal of the Canadian Chiropractic Association. 2009 Mar;53(1):23.
  5. Papa JA. Conservative management of Achilles Tendinopathy: a case report. The Journal of the Canadian Chiropractic Association. 2012 Sep;56(3):216.
  6. http://www.grastontechnique.com/FAQs.html
  7. 7.0 7.1 https://www.practicalpainmanagement.com/pain/myofascial/diagnosis-management-myofascial-pain-syndrome
  8. The Tai Chi Effect
  9. Wilke J, Krause F, Vogt L, Banzer W. What is evidence-based about myofascial chains: a systematic review. Archives of physical medicine and rehabilitation. 2016 Mar 1;97(3):454-61.
  10. SFMA and Anatomy Trains: Concepts For Assessment and Treatment
  11. 11.0 11.1 Zhang XF, Liu L, Wang BB, Liu X, Li P. Evidence for kinesio taping in management of myofascial pain syndrome: a systematic review and meta-analysis. Clinical rehabilitation. 2019 May;33(5):865-74.
  12. 12.0 12.1 Charles D, Hudgins T, MacNaughton J, Newman E, Tan J, Wigger M. A systematic review of manual therapy techniques, dry cupping and dry needling in the reduction of myofascial pain and myofascial trigger points. Journal of bodywork and movement therapies. 2019 Jul 1;23(3):539-46.
  13. 13.0 13.1 Kalichman L, David CB. Effect of self-myofascial release on myofascial pain, muscle flexibility, and strength: a narrative review. Journal of bodywork and movement therapies. 2017 Apr 1;21(2):446-51.
  14. 14.0 14.1 Hughes GA, Ramer LM. Duration of myofascial rolling for optimal recovery, range of motion, and performance: a systematic review of the literature. International journal of sports physical therapy. 2019 Dec;14(6):845.