Myofascial Pain Syndrome : Physiotherapy Management

Myofascial Pain Syndrome

Myofascial pain syndrome (MPS) is one of the most common causes of chronic skeletal muscle pain that results due to presence of myofascial trigger point (MTRP). As a physiotherapist, understanding MPS involves recognizing the patterns of pain, palpating for trigger points, and developing a treatment plan to alleviate symptoms.

 

Classification of Myofascial Pain Syndrome

Myofascial pain syndrome (MPS) can be classified in various ways based on its characteristics, triggers, and locations.

 

Myofascial Pain Syndrome Trigger Points Location

Myofascial trigger points can occur in various muscles throughout the body. Here are some common trigger point locations associated with myofascial pain syndrome:

 

Symptoms

• Localized Pain
• Referred Pain
• Muscle Stiffness
• Tenderness
• Muscle Knots or Nodules
• Weakness or Fatigue
• Sweating
• Sleep Disturbances
• Range of Motion Limitations
• Headaches
• Emotional Distress

 

Causes

• Repetitive movements
• Poor posture
• Scoliosis
• Muscle Imbalance – between dynamic muscles (rhomboids and gluteus
• medius) and postural muscles (scalenes and quadratus lumborum)
• Psychological and Emotional Stress
• Trauma or Accidents - Contusions, sprains and strains
• Poor Work Ergonomics
• Fibromyalgia
• Chronic fatigue syndrome
• Nutritional Deficiencies
• Sleep Disturbances
• Dehydration
• Thyroid and Estrogen Insufficiencies
• Inflammatory Conditions

 

Diagnosis and Tests

Patient History:

It includes gathering detailed information about the patient's symptoms, pain patterns, medical history, daily activities, work habits, and any previous injuries or traumas.

Physiotherapist looks for yellow flags such as  psychosocial factors that are associated with chronic pain syndrome and Red flags that are related to musculoskeletal pathologies, such as fractures, neurological deficits, malignancy and infection.

 

Physical Examination:

Physical examination includes the assessment of  muscle tenderness, trigger point presence, range of motion, and any muscle imbalances or weaknesses.

 

Palpation:

Physiotherapist can palpate muscles and soft tissues to identify trigger points and areas of increased tenderness. Palpation can be categorized into following types:

• Flat palpation: The physiotherapist uses finger bellies for an initial examination of muscle tone to identify spasm or superficial tenderness.
• Fingertip palpation: It involves muscle fiber of small superficial muscles.
• Pincer palpation: The physiotherapist use the thumb and fingers to grasp the opposite side of muscles that are easily accessible, such as sternocleidomastoid, upper trapezius, pectoralis major, latissimus dorsi and hip adductors.
• Overlying hand palpation: One hand applies pressure while the underlying hand palpates for the deep muscles, such as glutei muscles and piriformis.

 

Assessment of Pain Patterns:

Determining if the pain is localized or if it radiates to other areas, following specific patterns associated with trigger points. Physiotherapist can use tools like algometer (force gauge meter) which measure the minimum pressure that induces pain. 

 

Functional Assessment:

Evaluating how the patient's symptoms affect their daily activities, movement, and functional abilities.

Physiotherapist can look for following limitations in the movements:

• Neck Movements: Difficulty turning the head or looking up and down.
• Shoulder Movements: Restrictions in reaching overhead, lifting objects, or performing activities involving the arms.
• Spinal Movements: Reduced ability to bend, twist, or extend the spine fully.
• Hip Movements: Difficulty with activities like squatting, bending forward, or lifting the legs.

Functional Movements: MPS can impact everyday functional movements, affecting activities such as:

• Walking: Limited hip mobility or pain during movement.
• Reaching: Difficulty extending the arms fully or reaching across the body.
• Gripping: Weakness or discomfort in the hands and fingers affecting tasks like gripping objects or typing.
• Postural Changes: MPS can affect posture and lead to limitations in maintaining proper alignment and positions:
• Sitting: Difficulty sitting for prolonged periods due to discomfort or pain in the back, neck, or hips.
• Standing: Trouble maintaining an upright posture without discomfort or muscle fatigue.
• Sleeping: Discomfort or pain that disrupts sleep or limits movement during sleep.

 

Provocative Testing:

Performing specific maneuvers or applying pressure to trigger points to reproduce the patient's pain or symptoms, aiding in confirming the presence of trigger points.

 

Differential Diagnosis

• Fibromyalgia
• Muscle Strain or Injury
• Herniated discs
• Nerve compression syndromes
• Osteoarthritis
• Rheumatoid arthritis
• Cervical or Lumbar spondylosis
• Spinal Stenosis
• Degenerative Disc Disease
• Visceral Pain Referral: Some internal organ conditions like gallbladder disease, kidney stones, or visceral pathology can cause referred pain that might be mistaken for MPS.
• Myositis
• Lyme disease
• Peripheral Neuropathy
• Tension-Type Headaches or Migraines
• Psychological Factors like depression or anxiety

 

Physiotherapy Treatment for Myofascial Pain Syndrome

Modalities:

• Heat and Cryotherapy: Application of heat or cold can help reduce pain and inflammation.
• Ultrasound or Electrical Stimulation: These modalities can help with pain relief and promote healing.

 

Neuromuscular Relaxation Techniques

• Muscle relaxation by exhalation.
• Muscle relaxation by eye movement, inferiorly and in the direction in which relaxation is desired.
• Muscle relaxation following isometric contraction, by autogenic inhibition.
• Muscle relaxation following minimal activation of the antagonist muscle, by reciprocal inhibition.

 

Stretching and Strengthening Exercises:

Stretching: Targeted stretching exercises help improve flexibility and reduce muscle tension. Some examples include:

• Neck Stretch
• Upper Trapezius Stretch
• Hamstring Stretch
• Quadriceps Stretch:
• Piriformis Stretch
• Child's Pose
• Cat-Cow Stretch

 

Strengthening Exercises: Specific exercises can help strengthen muscles to support the affected area and prevent further discomfort.

• Shoulder Blade Squeezes
• Bent-Over Rows
• Wall Push-up
• Squats
• Planks
• Bridges

 

Kinesio Taping

Kinesio Taping helps in reducing  pain intensity and improving range of motion for patients with myofascial pain syndrome. It is often used as part of a comprehensive treatment plan that may include exercises, manual therapy, and other modalities.

Important Considerations:

• Application: Kinesiology tape should be applied by a trained professional who understands the specific needs and goals of the individual with MPS.
• Duration: The duration of tape application can vary based on the individual's response and the intended therapeutic goals.

Manual Therapy:

• Trigger Point Release: Physiotherapist apply pressure to specific trigger points to release tension and alleviate pain.
• Soft Tissue Massage: Techniques like myofascial release or deep tissue massage can help relax muscles and improve blood flow.

Dry Needling

Dry Needling is done to mechanically break the trigger points. The needle is targeted at the point of maximum tenderness. The muscle may manifest a local twitch response. It relieves pain through pain modulation pathway by release of endorphins. Contraindications include bleeding diatheses, anticoagulation, local or systemic infection and inability to rest the treated region after the procedure.

Two types of needles are commonly used which includes hypodermic and acupuncture needles.

1. Hypodermic needles allows the infiltration of local anaesthetic during the procedure. The local anesthetic helps to relieve postneedling soreness. Gauge 25 and 27 hypodermic needles are usually used.
2. Acupuncture needles are stainless steel filiform needles with a diameter range of 0.25 to 0.35 mm.

 

Frequently Asked Questions

What is difference between Myofascial Pain Syndrome and Fibromyalgia?

Fibromyalgia is diffuse, widespread and symmetrical muscle pain with specific tender points location as defined by the American College of Rheumatology. While MFP is prevalent in patients with regional musculoskeletal pain with frequent complain of back and neck pain.

Which vitamins deficiency cause Myofascial Pain Syndrome?

• Zinc
• magnesium
• Iron 
• Vitamin D 
• Vitamin C 
• vitamin B12

 

How does a patient practice Myofascial Pain Syndrome self-care?

Patient can do certain things in self care like using ice pack to reduce inflammation or using a heating pad to induce muscle relaxation. He can change his dietary habits and include important vitamins like C, D, B12 etc. He can practice relaxation techniques  like yoga (to stretch and relax muscles and decrease stress), breathing exercises and meditation.