Myofascial Pain Syndrome
Vasu Kanjana-huttakit M.D.
Orthopedic Surgery & Rehabilitation
Vibharam Hospital
Muscle pain
Muscle spasm
involuntary contraction caused by trauma,
excessive tension, organic disorder
Muscle tension
• Prolonged contraction of a muscle cause
by
• Postural tension
• Emotional tension
• Situational tension
Muscle deficiency
• Inadequate muscular fitness to meet the
requirements of activities of daily living
Trigger point
Etiology
Epidemiology
• Female > male
• Prevalence 31-50 y
• Axial, postural muscle groups
• Most common cause of chronic pain
• Latent trigger point > active
Pathophysiology
• Micro ,macro trauma
• Disruption of sarcomere
• Release of free calcium
• join ATP to stimulate actin-myosin
• Increase metb,serotonin,pg,kinin,His
• Stimulate nociceptor..pain,refer pain
• CNS stimulate muscle spasm
Pathophysiology
• Decrease blood flow, ATP ,calcium pump
• Local fibrosis
Most frequent locations
Symptoms
• Local & refer pain
• Pain w contraction
• Stiffness
• Weakness
• Paresthesia
• Propioceptive disturbance
• Autonomic dysfunction
Physical findings
• Local tenderness
• Refer pain
• Single or multiple muscle involvement
• Palpable nodules
• Firm or taut bands in muscle
• Twitch response
• Jump sign
• Weak , shortening , limit motion
Types of trigger point
• Active vs Latent
• Primary, secondary, satellite
Trigger point
Trigger point
History
• Systemic review
• Trauma
• Previous medical & surgical treatment
• Chronic debilitating disorder
• Endocrine disorder
• Dental
• Allergy
History related to MPS
• Characteristic of pain
• Onset
• Occupational activities
• Athletic activities
• Sleep problems
• Psychological
• Endocrine
Physical examination
• General
• Posture & Movement
• Muscle evaluation
ROM flexibility strength spasm tension trp
• Neurological exam
Trigger points vs Tender points
• Local tenderness,
•
•
•
•
taut-band ,twitch
,jump sign
Singular or multiple
Any muscle
Specific refer pain
Autonomic &
propioception
symptoms
•
•
•
•
Local tenderness
Multiple
Specific , symmetrical
No refer pain
Trigger point palpation
• Flat palpation
• Snapping
• Pincer or grasping
Diagnosis Criteria (Yunus)
• Major 5
1
2
3
4
5
regional pain
referred pain pattern of trigger point
taut band
hyperirritable spot in taut band
limit ROM
Diagnosis Criteria (Yunus)
• Minor
1 reproducible referred pain
2 local twitch response
3 release by stretching exercise or trigger
point injection
Diagnosis with all major and one of minor
Natural course
• Spontaneous recovery
• Persistence without
•
progression
Additional trigger
points and chronic
Classification of MPS
• Acute <2 m
• Subacute 2-6 m
• Chronic > 6 m
Poor prognosis (chronic)
• Unrecognized
• Overlook
• Improper treatment
• Inadequate treatment
Principle of MPS managemment
• Trigger point management
• Correct Perpetuating factors
Trigger point management
•
•
•
•
•
•
•
•
Injection
Stretch and Spray
Massage
Heat therapy
Acupuncture
Electrotherapy
Exercise
Drug
Perpetuating factors
• Mechanical
• Systemic
• Psychological
Trigger point injection
• Local anesthetic agent
• Steroids
• NSAIDS
• Saline
• Distilled water
• Botulinum toxin
Mechanism of injection
• Mechanical
-feedback disruption
-release of
intracellular K
-wash out effect
-focal necrosis
• Chemical
-local vasodilatation
-local anesthetic
-focal necrosis
Stage of recovery
• Local anesthetic period ½ -1 hr
• Post injection soreness 2-3 days
• Migrating pain
• Healing phase
Complications
• Internal organ injury
• Pneumothorax
• Pneumoperitoneum
• Muscle injury
• Nerve injury
• Infection
• Toxic , allergic
Contraindications
• Acute trauma
• Bleeding tendency
• Allergy
• Infection
• Pregnancy
Stretch and spray
• Inhibit pain gate
• Disruption of trigger
•
point
Restoration of normal
length
Massage
• Circulation
• Gate control
• Waste product
removal
Stroking
Stripping
Kneading
Friction
Acupressure
Precaution
• Hyperirritable trigger point
• DVT
• Infection
• CA
• Skin disease
• Personel
Heat therapy
• Superficial
-hot pack
-hydrocollator
• Deep
-ultrasound
-short wave
Thermal effect
• Gate control theory
• Endorphins
• Increase pain threshold
• Increase circulation
• Sedation
• Relaxing effect
Contraindications
• Impair sensation
• Impair circulation
• Bleeding disorder
• CA
• Acute inflammation
Acupuncture
• Acupuncture point
yin yang balance
meridian
• Trigger point
endorphins
common location
Electrotherapy
• Muscle stimulation
-AC..DC faradic
-continuous mode
-surged
-interrupted
• Nerve stimulation
-Hi (fq) TENS
gate control
-lo TENS
acupuncture like
-Burst
Muscle stimulation
Nerve stimulation
Exercise
• Stretching
• Strengthening
• Endurance
• Relaxation
Common drugs
• Simple analgesic
• Muscle relaxant
• NSAIDs
• Steroid for post injection soreness
• Water soluble vitamins
• Hormones
• Psychotropes ,,antidepressant,anxiolytic
• Balms and gels
Mechanical factor
• Internal
Poor posture
Anatomical abnormalities
Constriction of the
muscle
• External(ergonomic)
-modern office
(sedentary)
-field work
(heavy duty)
Systemic factor
• Nutritional insufficiency
•
Vitamin water soluble ;folic acid , B1 6 12 vit C
Metabolic & Endocrine
Anemia
Hypothyroid
menopause
gout
Systemic
• Infection
• Allergy
• Impair sleep
• Nerve impingement
Psychological
• Stress
• Fear
• Anxiety
• Depression
• Cognitive –behavior modification
• Social factor
Wake up!!!
Suggest reading
• Myofascial pain syndrome by
Pradit Prateepavanich
• Myofascial pain and Fibromyalgia
Edward S. Rachlin