What is Myofascial Pain?
Your fascial system is made up of both solid parts (like muscles, bones, cartilage, and fat) and liquid parts (like blood and lymph). Inside that system, your myofascial system includes the muscles and the connective tissue. The connective tissue shapes the muscle, goes through the muscle, and directs nerve endings and blood vessels. The end of the connective tissue is thickened and forms the attaching points of muscles on bones, helping transfer movement from muscles to the bones.
The myofascial system also includes your nervous, vascular (blood vessels), and lymphatic (part of your immune system) systems. The nerves and their endings are enclosed in layers of fascia (a type of connective tissue). Different tissues work together as part of the myofascial system. The fascia connects all muscles, forming an interconnected network. We can’t treat a muscle area as if it’s separate from the rest of the system.
When the myofascial system is disturbed, it can cause pain or restrict movement, creating unclear symptoms that can be difficult for doctors to understand and treat. This article discusses myofascial pain or myofascial syndrome. Myofascial pain is identified by muscle trigger points (TP), which are hard, small knots in your muscles that can be felt and are sensitive to touch and movement. These trigger points can cause local and referred pain (pain felt in another part of the body). There are two types of trigger points: active, causing pain even without touch or movement, and latent, causing pain only when touched.
Myofascial pain syndrome is a medical condition without a standard treatment plan or monitoring protocol. It was previously called fibrositis, referring to inflammation of the connective tissue covering the muscles. Trigger points in muscles are tender to touch and movement, cause muscle weakness, and limit the range of motion. If you have multiple trigger points for more than a year, it confirms myofascial pain syndrome.
The concept of myofascial pain dates back to 1600 when it was first talked about by Guillaume de Baillou. Over the years, doctors and researchers have further expanded on what exactly makes up myofascial pain, with terms like “thickenings” and “nodular tumors”. In 1919, the term “myogeloses” was used to describe the hard texture of trigger points. In the mid-1900s, painful local areas in patients with myofascial pain were identified, which, when stimulated, produced pain. Janet Travell and Rinzler eventually coined the term “myofascial trigger points”.
What Causes Myofascial Pain?
Myofascial pain, or pain in your muscles and the soft tissues that surround them, can be complex and isn’t fully understood yet. Your muscles and tissues contain blood, lymph fluid (part of your immune system), and nerve signals; changes in any of these could be a source of pain.
The following are some theories about what might cause myofascial pain:
Constant minor injury to the muscles could exhaust the muscles’ energy supply, causing an increase in sensation of pain. This is especially true in muscles meant for maintaining posture. Certain muscles respond to substances like potassium, prostaglandins, histamine, and kinins, which may cause increased stiffness. This ongoing stimulation could potentially change the pain response of the spinal cord’s nerve cells, initially causing local and then widespread sensitivity to pain.
“Trigger points,” or sensitive spots in the muscle, might be caused by changes in the junctions between nerve and muscle fibers. An increased concentration of a chemical called acetylcholine could cause continuous muscle contraction even without any nerve signals telling it to. This non-stop contraction can deplete the muscles of energy and leads to the release of substances that cause inflammation and trigger points.
Continuous changes in the mechanical and metabolic environment of the muscle could cause changes in the connective tissue of the myofascial system. In response, the cells that produce connective tissue can transform into a different type of cell that causes the tissue to shorten and increase in tension. The sensory receptors in the tissue could turn into pain-generating receptors and become sensitive to touch or pressure (a condition known as allodynia or mechanical hyperalgesia). Any changes in the tissue structure can mess up the electrical charge of muscle fibers, causing them to contract spontaneously.
A part of the matrix outside cells, called hyaluronan (HA), may also play a role. Changes in the muscle environment causing HA to alter its properties results in a more sticky outside cell matrix. This makes the tissue have difficulty sliding between layers, making muscle contraction harder. The nerve endings in the tissue stretch in the stickiest areas and stay activated, forming a trigger point.
Changes in blood flow might also cause myofascial pain. Changes in the speed of blood flow can affect the shape and function of tiny blood vessels in the muscle, leading to a lack of blood supply during minor active movements. This activates certain nerve endings, contributing to the pain.
Risk Factors and Frequency for Myofascial Pain
Myofascial pain syndrome is a condition that affects about 9 million people in both the United States and Canada. It happens to both men and women, and is more common in people over 60 years old. There isn’t any strong evidence to suggest that this condition is related to a person’s ethnicity or where they live.
Signs and Symptoms of Myofascial Pain
Myofascial pain syndrome is a condition that can involve both short-term and long-term pain. The pain may be a dull, poorly pinpointed ache that is hard to distinguish from other types of body and organ pain. Some people experience unusual feelings in their skin, such as numbness or prickling, and the pain might be felt somewhere other than where the issue actually lies. These symptoms might stick around for months or perhaps even years after the original cause is resolved. Tight bands in the muscle tissue could potentially trap nerves and lead to more pain and hindrance.
This condition is diagnosed by checking for what are known as myofascial trigger points, which cause the associated pain. These trigger points are found by examining the areas that are tender or painful. These points are characterized by tight bands that can be felt within the muscle. These bands can be readily felt in all types of muscles, whether on the surface or deeper down. Muscles with these trigger points sometimes have inconsistent soft, firm, or hard areas rather than a uniform feel. Trigger points tend to give off a sharp, localized pain when flexed during daily activities. Sometimes, these bands are not painful to the touch, but they can affect the normal operation of the muscle. The best way to examine these trigger points is by feeling the muscle perpendicular to the direction that the muscle fibers are running.
In 2017, a study suggested at least two of the following criteria must be met for a diagnosis of a trigger point: a tight band present, a hypersensitive spot, and pain referred elsewhere. The pain that is felt elsewhere due to a trigger point can include pain radiating to a remote area, deep pain, dull aching, a tingling or a burning sensation.
Testing for Myofascial Pain
Several diagnostic tools can help medical professionals identify the presence of knot-like areas in your muscles, also known as “trigger points”. Each tool has its benefits.
Ultrasound imaging is often used to examine the thickness and texture of these muscle knots and the movement of the different tissue layers around them. Some studies have used a kind of ultrasound technique called elastography and a handheld device that causes vibrations. With this method, trigger points show up as focal and hypoechoic nodules, meaning they look darker and have lower vibration amplitudes than the surrounding tissue. This suggests an increase in stiffness and changes in blood supply compared to normal tissue.
Micro-dialysis is another method that measures substances that can cause inflammation in trigger points, like bradykinin, substance P, tumor necrosis factor-alpha, CGRP, interleukin 1 beta, serotonin, interleukin 6 and 8, and norepinephrine.
Electromyography evaluates the electrical activity of active and latent trigger points, both when the muscle is at rest and when it is moving. In most cases, trigger points show more electrical activity when the muscles are contracted, compared to normal muscles.
Infrared thermography is a tool used to measure the skin temperature in areas where trigger points are present. However, because of varying results, this tool is currently used more as a supporting test rather than a primary one.
Magnetic resonance elastography is also a diagnostic tool used to assess the presence of trigger points. However, there hasn’t been a consensus on the reliability of its results due to the fact that it can sometimes miss detecting the presence of trigger points.
Treatment Options for Myofascial Pain
Non-steroidal anti-inflammatory drugs, or NSAIDs, are often used to alleviate pain in patients suffering from myofascial pain (pain originating in the muscles and surrounding tissues). These drugs come in both oral and topical forms, though there is so far no concrete scientific proof backing their effectiveness.
Muscle relaxants like cyclobenzaprine and tizanidine are used to lessen the stimulation of pain in the brain. However, scientific evidence supporting their use specifically for the treatment of myofascial pain points, or TPs, remains lacking.
Benzodiazepines such as clonazepam and diazepam have been studied for their potential in treating TPs. However, their long-term use is not considered feasible due to their side effects, which may include unsteadiness, mental decline, and depression.
Antidepressants are sometimes used to manage myofascial pain, particularly when the patient also has a mood disorder. Medications such as amitriptyline and nortriptyline have shown promise in some studies, though the evidence is not definitive.
Lidocaine patches, applied directly to the skin, can also be used to manage TP pain. They are generally considered to have fewer unwanted effects than needle-based treatments. Some research suggests that these patches can reduce pain at TPs, although larger-scale studies are needed.
Botulinum toxin, or Botox, works by blocking the release of a chemical in our nerves, which can reduce muscle spasms at TPs. Research on the effectiveness of Botox in reducing myofascial pain remains mixed.
Regular physical activity and maintaining correct posture can also help in treating myofascial pain. It enhances flexibility, mood, and pain tolerance. One commonly prescribed exercise involves stretching, which can prevent the formation of new tender areas. Improving your posture can decrease the risk of muscle injuries and microscopic tissue damage, known to trigger myofascial pain. Relaxation techniques, like yoga and meditation, can also help reduce the body’s overall tension and increase pain tolerance.
Ultrasound therapy may be used to manage TP pain. This treatment applies energy to the underlying tissues, which can improve blood flow and elasticity. Some studies suggest that ultrasound can reduce TP pain, although the effects are usually temporary.
Dry needling is a technique where a needle is directly inserted into the TP to relieve pain. This treatment is one of the quickest ways to alleviate TP pain and has shown promise in some studies; however, extensive scientific evidence is yet to be gathered.
Lastly, a technique called manipulative therapy has shown potential in the management of TP pain. However, so far there’s not enough evidence to prove its effectiveness.
What else can Myofascial Pain be?
When examining fibromyalgia, doctors might consider other conditions that could have similar symptoms. Myofascial pain, for example, might present similarly, as both conditions involve changes in connective tissue that could cause inflammation and pain. In fibromyalgia, pain is typically widespread, which can help differentiate it from other conditions.
Chronic pelvic pain is another condition that could appear similar to myofascial syndrome. Chronic pelvic pain persists for at least 6 months and its presence isn’t necessarily linked to movement or menstruation (for women). Ultrasound examinations can help determine whether this pain is due to physical abnormalities or it is solely muscular.
Myofascial pain could also present in the temporomandibular joint, however, it could also be a sign of referred pain. If the pain in this joint doesn’t improve with manual treatment or medications, it might indicate a symptom of heart ischemia.
Eagle’s Syndrome might also be mistaken for conditions like fibromyalgia, particularly when it presents as one-sided throat or neck pain. If the pain doesn’t improve with treatment, doctors might need to explore other causes.
Tendon inflammation or inflammation of connective tissues, could be another source of myofascial pain. These conditions often affect specific anatomical areas and can be identified by palpation.
Myofascial pain could be caused or perpetuated by a variety of factors, including:
- Mechanical factors (such as scoliosis, joint hypermobility, or repetitive microtraumas)
- Systemic or metabolic factors (like hypothyroidism or vitamin deficiencies)
- Psychosocial factors (such as stress or anxiety)
- Other factors (such as infectious diseases, drug use, or rheumatic polymyalgia)
These potential causes or contributors should be carefully evaluated when diagnosing myofascial pain.
What to expect with Myofascial Pain
Myofascial pain syndrome, a condition causing pain in the body’s connective tissues, can usually get better with ongoing treatment and regular check-ups. Despite this, many people dealing with this condition continue to experience symptoms for many years.
Long-term complications are generally reduced when a professional team, made up of experienced doctors, nurses, and physiotherapists, works together to care for a patient. They use a variety of treatments and frequently track how the patient responds to these in order to tailor the best care plan possible.
Possible Complications When Diagnosed with Myofascial Pain
Myofascial pain syndrome can lead to a decrease in quality of life. Constant pain generally goes hand in hand with mental health issues like depression and anxiety. This pain can also reduce a person’s ability to move around or take part in daily activities, which can make the condition even worse.
Taking medication incorrectly can lead to unwanted side effects. Similarly, if someone doesn’t follow specific guidelines for physical activity, as recommended by a trained professional, they could end up with muscle injuries.
Common Issues:
- Decreased quality of life
- Mental health issues like depression and anxiety
- Reduced mobility and daily activity
- Unwanted side effects from medication
- Possible muscle injuries if not exercising correctly
Preventing Myofascial Pain
When doctors find out that myofascial pain, or chronic pain that affects the muscles and the layer of tissue that covers them, is causing your discomfort, they will explain how this condition occurs and share ideas to help you feel better. For instance, if you’re feeling anxious at work or during your daily routine, you might benefit from learning relaxation techniques such as deep breathing. Occasionally, a psychologist might be consulted to help teach these relaxation methods.
If your pain arises from an unbalanced diet, your doctor will help you understand the benefits of more nutritious food choices. If repetitive movements, like doing the same action over and over again, are causing your pain, you’ll be advised to stay active and do stretching exercises to alleviate discomfort.
Also, remember that difficulties with sleep can increase muscle tension, contributing to this painful condition. Thus, it’s vital to follow strategies to enhance your sleep quality. In a nutshell, addressing the root causes can significantly improve your quality of life.
