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Myofascial Trigger Point
Pain and Dysfunction
Dr. Janet G Travell’s
Approach for Examination and
Treatment
Myofascial Pain Syndromes
I. Definition, Hyperirritable spot, painful on
compression, can give rise to referred
pain, tenderness, autonomic
phenomena.
Myofascial Pain Syndromes
Active Trigger Points (TP)
Pain at Rest or Activity
Latent Trigger Points
1. May show features of active TP except pain only
when examined
2. Restriction of motion and weakness
3. Persist for years after apparent recovery
4. Predispose to acute attacks of pain
5. No clinical c/o pain
6. Difficult to reproduce pain
7. There is a local twitch response
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Myofascial Pain Syndromes
II. Incidence
1. Latent TPs afflict nearly half the population.
2. Patients with chronic pain, MPS cause of pain in
half of the patients.
3. Likelihood of developing active TPs increases
with age.
4. Laborers who exercise their muscles every day
less likely to develop active TPs than sedentary
workers who become weekend warriors.
Myofascial Pain Syndromes
III. Symptoms
1. PAIN
ONSET: Abrupt or Gradual (Chronic Overload)
CHARACTER: Steady, Deep & Aching, Rarely Burning
Referral: In Specific Patterns NOT Simple Segmental Patterns
Pain Picture: A Precise Pictorial Representation of Pain is
Needed for an Accurate Diagnosis.
Myofascial Pain Syndromes
III. Symptoms (continued)
2. LIMITED ROM AND STIFFNESS
WORSE ON ARISING IN THE MORNING AND RECURS
AFTER PERIODS OF OVERACTIVITY OR IMMOBILITY
3. WEAKNESS
4. OTHER NON-PAIN SYMPTOMS
AUTONOMIC, PROPRIOCEPTIVE, REDUCED STIMULATION THRESHOLD
AND DISTURBANCE OF MOTOR COORDINATION
5. DEPRESSION
6. SLEEP DISTURBANCE
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Myofascial Pain Syndromes
III. Symptoms (continued)
7. ACTIVATION
Direct Activation:
a) ACUTE OVERLOAD
b) OVERWORK FATIGUE
c) DIRECT TRAUMA
d) CHILLING
Myofascial Pain Syndromes
III. Symptoms (continued)
7. Activation
Indirect Activation:
a) Other TP’s
b) Visceral Disease
c) Arthritic Joints
d) Emotional Distress
Myofascial Pain Syndromes
Satellite TP’s -
occur in muscles within
the reference zone
Secondary TP’s - occur in adjacent or
synergistic muscles
weakened or shortened
by primary TP
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Myofascial Pain Syndromes
IV. PHYSICAL EXAMINATION
1. MOBILITY AND POSTURE
2. NEUROMUSCULAR EXAM
3. CUTANEOUS SIGNS
(Dermatographia, Panniculosis)
4. COMPRESSION TEST
5. DISTURBANCE OF NON-SENSORY
FUNCTION (ie autonomic, motor unit activity)
6. TRIGGER POINT EXAM
a) TAUT BAND b) LOCAL TWITCH RESPONSE
c) JUMP SIGN d) PRODUCE REFERRED PAIN
Myofascial Pain Syndromes
V. LAB FINDINGS
1. Routine Lab: No Abnormalities
2. EMG of involved muscle at rest
NO Abnormalities
3. Thermograms over active TP may show
increased skin temperature
Myofascial Pain Syndromes
VI. TREATMENT
SPRAY AND STRETCH
1. PATIENT POSITIONED COMFORTABLY
2. STABILIZATION: ANCHOR ONE END OF MS
3. SPRAY SKIN OVER THE MS
A) PARALLEL SWEEPS IN ONE DIRECTION
B) 18 INCHES ABOVE THE SKIN
C) 4 INCHES PER SECOND
D) SPRAY ALONG REFERENCE ZONE
E) HOLD BOTTLE AT A 30 DEGREE ANGLE
4. STRETCH MUSCLE PASSIVELY
“STRETCH IS THE ACTION,
SPRAY IS THE DISTRACTION”
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Myofascial Pain Syndromes
SPRAY AND STRETCH CONTINUED
5. REPEAT WITH PARALLEL AFTER REWARMING
6. MOVE MS THRU 3 CYCLES OF FULL ROM
7. RECOMMEND HOT BATH TO PATIENT AND HOME
STRETCHING PROGRAM
REASONS FOR FAILURE
1. PERPETUATING FACTORS
2. INADEQUATE SPRAYING OF ALL TP AREAS
3. PATIENT NOT FULLY RELAXED
4. INCORRECT SPRAYING TECHNIQUE
5. INADEQUATE STRETCHING TECHNIQUE
6. INCOMPLETE STRETCH
7. INCREASED MS SORENESS IF MUSCLE NOT REWARMED
8. RECURRENCE IF PATIENT FAILS TO ACTIVELY
MOVE THRU FULL ROM
9. INCOMPLETE SPRAY AND STRETCH
10. NON COMPLIANCE WITH HOME EXERCISE PROGRAM
Myofascial Pain Syndromes
VII. ETHYL CHLORIDE VS FLUORI METHANE
ETHYL CHLORIDE
FLAMMABLE
TOXIC
GEN. ANESTHETIC
EXPLOSIVE
LOCAL CHILLING
FLUORI METHANE
NON-FLAMMABLE
NON-TOXIC
NON-ANESTHETIC
NON-EXPLOSIVE
NON-CHILLING
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Myofascial Pain Syndromes
VIII. PERPETUATING FACTORS
A) MECHANICAL
1. ANATOMIC VARIATIONS; SHORT LEG,
SHORT HEMIPELVIS, SHORT UPPER
ARMS AND LONG SECOND METATARSAL
(MORTON’S FOOT)
2. POSTURAL STRESS
3. CONSTRICTION OF MUSCLES
(ie HEAVY PURSE, NARROW BRA STRAPS,
TIGHT COLLAR,TIGHT TIE, TIGHT BELT, EDGE OF SEAT)
Myofascial Pain Syndromes
VIII. PERPETUATING FACTORS
B) SYSTEMIC PERPETUATING FACTORS
1. NUTRITIONAL INADEQUACIES / ENZYME DYSFUNCTION
a) THIAMINE B1
b) PYRIDOXINE B6
c) FOLATE AND COBALAMINS B9 AND B12
d) ASCORBIC ACID, VITAMIN C
e) DIETARY MINERALS AND TRACE ELEMENTS
Ca, K, Fe, Mg
Myofascial Pain Syndromes
VIII. PERPETUATING FACTORS
B) SYSTEMIC PERPETUATING FACTORS
2.
METABOLIC AND ENDOCRINE DYSFUNCTION
a) HYPOMETABOLISM (ie LOW THYROID)
b) HYPOGLYCEMIA
c) HYPERURICEMIA AND GOUT
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Myofascial Pain Syndromes
VIII. PERPETUATING FACTORS
B) SYSTEMIC PERPETUATING FACTORS
3. CHRONIC INFECTION
a) VIRAL DISEASE
b) BACTERIAL INFECTIONS
c) INFESTATIONS
d) ALLERGIC RHINITIS
4. PSYCHOLOGICAL FACTORS
Myofascial Pain Syndromes
IX MYOFASCIAL PAIN vs FIBROMYALGIA
1. FM may initially be isolated to a few well-defined
locations prior to spreading. Therefore, FM may
represent a generalized form of MPS.
2 MPS which have become chronic may resemble FM
involving multiple sites and causing systemic
symptoms.
Myofascial Pain Syndromes
IX MYOFASCIAL PAIN vs FIBROMYALGIA
3. Simons feels its necessary to distinguish these 2
conditions. Etiology of FM is usually systemic whereas
MPS is related to focal dysfunction of the muscle.
4. Mayo Clinic uses term Tension Myalgia for Fibrositis,
FM and MPS. They use 3 broad categories
a) Generalized Tension Myalgia- Corresponds to FM
b) Localized Tension Myalgia- Corresponds to MPS
c) Regional Tension Myalgia pts with symptoms
between
the other two categories
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TRIGGER POINTS
INCREASED BY
1. Strenuous use especially in shortened position.
2. Passive quick stretch of a muscle
3. Direct pressure
4. Involved ms in short position for prolonged period
5. Sustained or repeated contraction
6. Cold damp weather, viral infection, tension
7. Exposure to cold draft (ie: air conditioner)
8. Cold packs applied to TP area continuously
TRIGGER POINTS
DECREASED BY
1. Short period of rest
2. Slow steady passive stretch ( hot shower or bath)
3. Moist heat applications
4. Short periods of light activity
5. Specific Myofascial Therapy
Alternative Treatment
Techniques for
Myofascial
Trigger Points
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ISCHEMIC COMPRESSION
* Noninvasive, Effective but Painful
* Pressure applied to most tender spot
* Pain eases, pressure increased
* TP no longer painful release pressure,
and perform AROM
* Procedure causes ischemia, followed
by reactive hyperemia
* Advise patient pain will increase during Tx.
Post –Isometric Relaxation
* Stretch muscle to onset of resistance
* Patient contracts against fixed resistance
- 25% of maximal effort 6-10 seconds
* Maintain the position passively the patient
“ Let’s go”
* Cycle is repeated 3-5 times
Deep Muscle Massage
1. Deep Friction- Purpose to move superficial
tissue over underlying structures.
2. Cyriax Deep Friction – Across the muscle
long axis.
3. Stripping- Digital Pressure starts at distal end,
fingers slide across muscle length, gradually increase
pressure, continue motion over and beyond the TP
4. Strumming- Painful deep release technique, performed with
fingers in rigid extension, scrubbing motion parallel to muscle
fibers, follow with interferential, TENS, VMS and ice
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Modalities
Ice Massage Two Techniques
1. Intermittent use instead of spray
2. Non-specific application of cold, principle
similar to TENS
Cold plus stretch gives more
sustained relief than cold alone
Excessive cold decreases muscle
resting length
Modalities
Ultrasound - May be used by itself
or in combination with electrical
stimulation (Medco-sonlator)
Can be helpful Diagnostically
and therapeutically
Modalities
Heat - Moist heat relaxes muscles
and diminishes tension on
the TP’s
Patient’s home exercises are more
effective if done immediately after heating
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Modalities
Biofeedback- Not a direct myofascial
technique, addresses the fact that
patient’s express anxiety through
increased muscle tension
TENS- Non specific pain relief may
help regain mobility
Modalities
Dry Needling
Ø This is a general term for a therapeutic
procedure that involves multiple advances
of a filament needle into a muscle in the
area of the body which produces pain and
typically a trigger point. There is no
injectable solution and typically the needle
that is used is very thin.
Modalities
States that do not support PT’s using Dry
Needling are as follows: via KinetaCore
PT education services
California, Connecticut??, Delaware ??,
Florida, Hawaii, Idaho, Utah, Indiana ??,
Kansas, Maine ??, Michigan??,MN?, MO??
NY,PA, SD, TN,WA?
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Contraindications to
Stretching
1.
2.
3.
4.
When bony block limits joint movement
After recent fracture
Presence of acute inflammation or infection
Sharp or acute pain with joint movement
or muscle elongation
5. Hematoma or other tissue trauma
6. When contractures / shortened soft tissue is
providing increased joint stability
7. When contractures / shortened soft tissue
is a basis for increased functional abilities
(ie SCI or CVA patient’s –Tenodesis)
Rehabilitation Exercises
Manual Stretching
Home Exercise and Self Stretching
Aerobic Exercise
Strengthening Exercise
Eccentric lengthening reactions to increase
function and restore muscle to its normal
resting length
JOINT PLAY
“Voluntary movements cannot be achieved unless certain
well defined movements of joint play are present.
Movements of joint play are independent of the action of
the voluntary muscles….Their integrity, not their range,
is the basis of their importance. It is the summation of
the movements of joint play and the movements of the
voluntary range that make up the movements of the
living anatomy”
Mennell
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THANK
YOU!
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THANK
YOU!
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