eMedicine Specialties > Physical Medicine and Rehabilitation > Cervical Spine Disorders

Cervical Myofascial Pain

Beth B Froese, MD, Consulting Staff, Department of Physical Medicine and Rehabilitation, Orthopaedic Associates of DuPage Ltd

Updated: Apr 12, 2009

Introduction

Background

Descriptions of myofascial pain date back to the mid 1800s when Froriep described muskelschwiele, or muscle calluses. He described these calluses as tender areas in muscle that felt like a cord or band associated with rheumatic complaints. In the early 1900s, Gowers first used the term fibrositis to describe muscular rheumatism associated with local tenderness and regions of palpable hardness. In 1938, Kellgren described areas of referred pain associated with tender points in muscle. In the 1940s, Janet Travell, MD, began writing about myofascial trigger points. Her text, written in conjunction with David Simons, MD, continues to be viewed as the foundational literature on the subject of myofascial pain.¹ (See image below and Image 1.)

Schematic of a trigger point complex of a muscle in longitudinal section. A: The central trigger point (CTrP) in the endplate zone contains numerous electrically active loci and numerous contraction knots. A taut band of muscle fibers extends from the trigger point to the attachment at each end of the involved fibers. The sustained tension that the taut band exerts on the attachment tissues can induce a localized enthesopathy that is identified as an attachment trigger point (ATrP). B: Enlarged view of part of the CTrP shows the distribution of 5 contraction knots. The vertical lines in each muscle fiber identify the relative spacing of its striations. The space between 2 striations corresponds to the length of 1 sarcomere. The sarcomeres within one of these enlarged segments (ie, contraction knot) of a muscle fiber are markedly shorter and wider than the sarcomeres in the neighboring normal muscle fibers, which are free of contraction knots.

Pathophysiology

Pain attributed to muscle and its surrounding fascia has been termed myofascial pain. The diagnosis of this syndrome in clinical, with no confirmatory laboratory tests available. Thus, myofascial pain in any location is characterized on examination by the presence of trigger points located in skeletal muscle. In the cervical spine, the muscles most often implicated in myofascial pain are the trapezius, levator scapulae, rhomboids, supraspinatus, and infraspinatus.² A trigger point is defined as a hyperirritable area located in a palpable taut band of muscle fibers. According to Hong and Simon's review on the pathophysiology and electrophysiologic mechanisms of trigger points, the following observations help to define them further³ :

• Trigger points are known to elicit local pain and/or referred pain in a specific recognizable distribution.
• Palpation in a rapid fashion (ie, snapping palpation) may elicit a local twitch response (LTR), a brisk contraction of the muscle fibers in or around the taut band. The LTR also can be elicited by rapid insertion of a needle into the trigger point. (See images below and Images 2, 3.)
• Restricted range of motion (ROM) and increased sensitivity to stretch of muscle fibers in a taut band are noted frequently.
• The muscle with a trigger point may be weak because of pain. Usually, no atrophic change is observed.
• Patients with trigger points may have associated localized autonomic phenomena (eg, vasoconstriction, pilomotor response, ptosis, hypersecretion).
• An active myofascial trigger point is a site marked by generation of spontaneous pain or pain in response to movement. This phenomenon is in contrast to the case of latent trigger points, which may not produce pain until they are compressed.

Cross-sectional drawing shows flat palpation of a taut band and its trigger point. Left: A. Skin is pushed to one side to begin palpation. B. The fingertip slides across muscle fibers to feel the cord-line texture of the taut band rolling beneath it. C. The skin is pushed to other side at completion of movement. This same movement performed vigorously is snapping palpation. Right: A. Muscle fibers are surrounded by the thumb and fingers in a pincer grip. B. The hardness of the taut band is felt clearly as it is rolled between the digits. C. The palpable edge of the taut band is sharply defined as it escapes from between the fingertips, often with a local twitch response.

Longitudinal schematic drawing of taut bands, myofascial trigger points, and a local twitch response. A: Palpation of a taut band (straight lines) among normally slack, relaxed muscle fibers (wavy lines). B: Rolling the band quickly under the fingertip (snapping palpation) at the trigger point often produces a local twitch response that usually is seen most clearly as skin movement between the trigger point and the attachment of the muscle fibers.

Frequency

United States

Myofascial pain is thought to occur commonly in the general population. As many as 21% of patients seen in general orthopedic clinics have myofascial pain. Of patients seen at specialty pain management centers, 85-93% have a myofascial pain component.

Mortality/Morbidity

Increased mortality is not associated with cervical myofascial pain.

Race

No studies clarify whether racial differences exist in frequency of cervical myofascial pain.

Sex

While fibromyalgia occurs more commonly in women than in men, cervical myofascial pain occurs in both sexes, also with a predominance among women.

Age

Myofascial pain seems to occur more frequently with increasing age until midlife. Incidence declines gradually after middle age.

Clinical

History

Typical findings reported by the patient with myofascial pain may include the following:

• The patient may present with a history of acute trauma associated with persistent muscular pain. In contrast, myofascial pain also manifests insidiously, without a clear antecedent accident or injury. It may be associated with repetitive tasks, poor posture, stress, or cold weather.
• Cervical spine ROM is often limited and painful.
• The patient may describe a lumpiness or painful bump in the trapezius or cervical paraspinal muscles.
• Massage is often helpful, as is superficial heat.
• The patient's sleep may be interrupted because of pain. The cervical rotation required for driving is difficult to achieve.
• The patient may describe pain radiating into the upper extremities, accompanied by numbness and tingling and making discrimination from radiculopathy or peripheral nerve impingement difficult.
• Dizziness or nausea may be a part of the symptomatology.
• The patient experiences typical patterns of radiating pain referred from trigger points.

Physical

Common findings noted upon physical examination may include the following:

• Patients with cervical myofascial pain often present with poor posture. They exhibit rounded shoulders and protracted scapulae.
• Trigger points frequently are noted in the trapezius, supraspinatus, infraspinatus, rhomboids, and levator scapulae muscles.
• The palpable taut band is noted in the skeletal muscle or surrounding fascia. An LTR often can be reproduced with palpation of the area.
• Cervical spine ROM is limited, with pain reproduced in positions that stretch the affected muscle.
• While the patient may complain of weakness, normal strength in the upper extremities is noted on physical examination.
• Sensation typically is normal when tested formally. No long tract signs are observed on examination.

Causes

Cervical myofascial pain is thought to occur following either overuse or trauma to the muscles that support the shoulders and neck. Common scenarios are that the patient recently was involved in a motor vehicle accident or that he or she performed repetitive upper extremity activities. Trapezial myofascial pain commonly occurs when a person with a desk job does not have appropriate armrests or must type on a keyboard that is too high. Other issues that may play a role in the clinical picture include endocrine dysfunction, chronic infections, nutritional deficiencies, poor posture, and psychological stress.

Differential Diagnoses

Cervical Disc Disease
Cervical Spondylosis
Cervical Sprain and Strain
Fibromyalgia
Rheumatoid Arthritis
Thoracic Outlet Syndrome

Other Problems to Be Considered

Myopathy

Workup

Laboratory Studies

• Myofascial pain traditionally does not produce abnormalities in the results of the patient's lab work. Travell and Simons describe a study looking at lactate dehydrogenase (LDH) isoenzymes.¹ A shift was noted in distribution of the isoenzymes, with higher levels of LDH1 and LDH2, while the total LDH remained within normal limits. In clinical practice, myofascial pain is diagnosed by way of a thorough physical examination in conjunction with an adequate medical history.
• Depending on the clinical presentation, it may be reasonable to check for indicators of inflammation, assess thyroid function, and perform a basic metabolic panel to rule out a concomitant medical illness.

Imaging Studies

• Imaging studies often reveal nonspecific change only and typically are not helpful in making the diagnosis of cervical myofascial pain; however, radiographs and a cervical spine magnetic resonance imaging (MRI) scan may be helpful in ruling out other pathology that may be present at the same time.

Other Tests

• Several research articles have attempted to identify changes on electromyograms/nerve conduction velocity studies that may be unique to patients with myofascial pain. The research has been somewhat contradictory, with some studies finding no real electromyographic activity and others finding nonspecific electrical activity. Studies by Simons and by Hobbard and Berkoff described low-amplitude action potentials recorded at the region of the myofascial trigger point. Spontaneous electrical activity apparently can be detected using high-sensitivity recordings at the site of the trigger point. The spontaneous electrical activity may be a type of endplate potential.

Treatment

Rehabilitation Program

Physical Therapy

The primary goal of physical therapy is to restore balance between muscles working as a functional unit. The physical therapist may progress toward that goal initially by attempting to diminish pain. This goal can be accomplished using a modality-based approach performed in conjunction with myofascial release techniques and massage. Cervical stretch and stabilization are integral parts of the approach as well. Postural retraining is crucial in cervical myofascial pain. An ergonomic evaluation may be indicated if overuse in the work setting is contributing to the patient's symptoms.

Medical Issues/Complications

The primary concern for patients with cervical myofascial pain is chronicity. Recurrence of myofascial pain is a common scenario. Prompt treatment prevents other muscles in the functional unit from compensating, thereby producing a more widespread and chronic problem. Migraine headaches and muscle contraction headaches are known to occur frequently in the patient with myofascial pain.⁴ Temporomandibular joint (TMJ) syndrome also may be myofascial in origin.²

Other Treatment

Several treatment options for cervical myofascial pain are discussed in the literature. Trigger point injection probably is one of the most accepted means of treating myofascial pain besides physical therapy and exercise. Injection is performed most commonly with local anesthetic, although dry needling has been shown to be equally effective.⁵

Palpate the trigger point in the taut band, and place the muscle in a slightly stretched position to prevent it from moving. Hold the trigger point between 2 fingers while injecting with the other hand. (See image below and Image 4.) Then redirect the needle in the area to assure widespread infiltration of the anesthetic. Instruct the patient to be aggressive about compliance with stretching protocols, because they increase the injection's effectiveness. Production of an LTR helps to confirm the diagnosis. Hong and Simon's article describes a fast-in/fast-out method as more successful in eliciting the local twitch response.³ This approach, therefore, generally is the most helpful technique for reducing myofascial pain.

Cross-sectional schematic drawing shows flat palpation to localize and hold the trigger point for injection. A and B show use of alternate pressure between 2 fingers to confirm the location of the palpable module of the trigger point. C shows the trigger point being positioned halfway between the fingertips to keep it from sliding to one side during the injection.

Sequence of steps to use when stretching and spraying any muscle for myofascial trigger points.

Schematic drawing showing how the jet stream of vapocoolant is applied.

Botulinum toxin injection therapy has gotten mixed reviews in the literature. Injection directly into the trigger point produces inconsistent results. The best use of botulinum toxin may be for correcting abnormal biomechanics that incite a myofascial response.^6,7

Medication

The goals of pharmacotherapy are to reduce morbidity and prevent complications.

Nonsteroidal anti-inflammatory drugs

The goal of medication for patients with cervical myofascial syndrome is to reduce pain. Nonsteroidal anti-inflammatory drugs (NSAIDs) are the drugs DOC for initial treatment of myofascial pain. Keep narcotic analgesics at a minimum if at all possible. If the clinical picture is one of more chronic pain accompanied by sleep dysfunction, consider use of a tricyclic antidepressant (TCA).

Ibuprofen (Motrin, Advil)

Inhibits inflammatory reactions and pain by decreasing prostaglandin synthesis. Used to provide relief of cervical myofascial pain.

Dosing

Adult

400-600 mg PO tid with food; 800 mg if pain is severe and patient has no history of gastric ulceration

Pediatric

Not established

Interactions

Coadministration with aspirin increases risk of inducing serious NSAID-related side effects; probenecid may increase concentrations and, possibly, toxicity of NSAIDs; may decrease effect of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; monitor PT closely (instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently

Contraindications

Documented hypersensitivity; peptic ulcer disease, recent GI bleeding or perforation, renal insufficiency, or high risk of bleeding

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Caution in congestive heart failure, hypertension, and decreased renal and hepatic function; caution in anticoagulation abnormalities or during anticoagulant therapy

Tricyclic antidepressants

TCAs are commonly used for chronic pain. They help to treat insomnia and reduce painful dysesthesia. They treat nociceptive and neuropathic pain syndromes.

Amitriptyline (Elavil)

Inhibits reuptake of serotonin and/or norepinephrine at presynaptic neuronal membrane, which increases concentration in CNS. May increase or prolong neuronal activity since reuptake of these biogenic amines is important physiologically in terminating transmitting activity.

Dosing

Adult

30-100 mg PO qhs

Pediatric

Children: 0.1 mg/kg PO qhs; increase, as tolerated, over 2-3 wk to 0.5-2 mg/d qhs
Adolescents: 25-50 mg/d PO initially; increase gradually to 100 mg/d in divided doses

Interactions

Phenobarbital may decrease effects; coadministration with CYP2D6 enzyme system inhibitors (eg, cimetidine, quinidine) may increase levels; inhibits hypotensive effects of guanethidine; may interact with thyroid medications, alcohol, CNS depressants, barbiturates, and disulfiram

Contraindications

Documented hypersensitivity; use of MAOIs within 14 d of initiating therapy; history of seizures, cardiac arrhythmias, glaucoma, or urinary retention

Precautions

Pregnancy

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Caution in cardiac conduction disturbances and history of hyperthyroidism, renal or hepatic impairment; avoid using in the elderly

Muscle relaxants

Muscle relaxants are commonly used to treat muscle pain, but they must be used cautiously because of sedation and because of the addictive potential of some of the medications in this category of drugs (benzodiazepines).

Cyclobenzaprine (Flexeril)

Acts centrally and reduces motor activity of tonic somatic origins, influencing both alpha and gamma motor neurons. Structurally related to TCAs.
Skeletal muscle relaxants have modest short-term benefit as adjunctive therapy for nociceptive pain associated with muscle strains and, used intermittently, for diffuse and certain regional chronic pain syndromes. Long-term improvement over placebo has not been established.
Often produces a "hangover" effect, which can be minimized by taking the nighttime dose 2-3 h before going to sleep.

Dosing

Adult

10 mg PO tid with a range of 20-40 mg/d in divided doses; not to exceed 60 mg/d

Pediatric

Not established

Interactions

Coadministration with MAOIs and TCAs may increase toxicity; cyclobenzaprine may have additive effect when used concurrently with anticholinergics; effects of alcohol, CNS depressants, and barbiturates may be enhanced with cyclobenzaprine

Contraindications

Documented hypersensitivity; MAOIs within last 14 d

Precautions

Pregnancy

B - Usually safe but benefits must outweigh the risks.

Precautions

Caution in angle closure glaucoma, and urinary hesitance

Tizanidine (Zanaflex)

Centrally acting muscle relaxant metabolized in liver and excreted in urine and feces.

Dosing

Adult

4-8 mg PO q8h prn; not to exceed 36 mg/d

Pediatric

Not established

Interactions

May interact with alcohol (increase somnolence, stupor) and oral contraceptives (which decrease its clearance), and can cause increased hypotensive effects when administered concurrently with diuretics

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

C - Safety for use during pregnancy has not been established.

Precautions

Caution in renal impairment

Non-narcotic analgesics

Tramadol is a weak opioid and an inhibitor of serotonin and norepinephrine reuptake in the dorsal horn. Studies have shown efficacy when treating fibromyalgia, although no formal studies have been performed for myofascial pain. Tramadol is known to help with chronic low back pain and osteoarthritis pain, both of which are commonly associated with myofascial pain.

Tramadol (Ultram)

Analgesic probably acting over monoaminergic and opioid mechanisms. Monoaminergic effect shared with TCAs. Tolerance and dependence appear to be uncommon.

Dosing

Adult

100-400 mg PO qd shown to be effective in diabetic neuropathic pain

Pediatric

Not established

Interactions

Decreases carbamazepine effects significantly; cimetidine increases toxicity, risk of serotonin syndrome with coadministration of antidepressants

Contraindications

Documented hypersensitivity; opioid-dependent patients; concurrent use of MAOI or within 14 d; use of SSRIs, TCAs, opioids, acute alcohol intoxication

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Can cause dizziness, nausea, constipation, sweating, pruritus; additive sedation with alcohol and TCAs; abrupt discontinuation can precipitate opioid withdrawal symptoms; adjust dose in liver disease, myxedema, hypothyroidism, hypoadrenalism; pregnancy, breast-feeding; seizure; development of tolerance or dependency with extended use

Anticonvulsants

Anticonvulsants used as neuropathic analgesics may be helpful, because myofascial pain may at its core be a spinal-mediated disorder affected by neuropathic dysfunction. Gabapentin has been shown to be effective in treating myofascial and neuropathic pain.

Gabapentin (Neurontin)

Membrane stabilizer, a structural analogue of inhibitory neurotransmitter GABA, which paradoxically is thought to not exert effect on GABA receptors. Appears to exert action via the alpha(2)delta1 and alpha(2)delta2 auxiliary subunits of voltage-gaited calcium channels.
Used to manage pain and provide sedation in neuropathic pain.
Titration to effect occurs over several days (300 mg on day 1, 300 mg bid on day 2, and 300 mg tid on day 3).

Dosing

Adult

Day 1: 100 mg PO tid or 300 mg hs
Day 2: 400 mg PO tid for 3 d and titrate prn; not to exceed 1200 mg PO tid

Pediatric

<12 years: Not established
>12 years: Administer as in adults

Interactions

Antacids may significantly reduce bioavailability (administer at least 2 h following antacids); may increase norethindrone levels significantly

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Caution in severe renal disease

Follow-up

Deterrence/Prevention

• Cervical myofascial pain may be prevented if overuse is avoided. Appropriate ergonomic considerations for jobs that require repetitive use of the arm or shoulders are always important. Any activity that requires sustained muscle contraction without rest puts the patient at risk. Appropriate posture also makes a significant difference in reduction of cervical myofascial pain. Because stress may play a role, relaxation techniques in conjunction with other stress relievers are integral to any treatment program for the patient prone to development of cervical myofascial pain. Advise the patient that reasonable nutrition and rest help to avoid pain from trigger points.

Complications

• Chronic pain and disability² - A Turkish study attempted to establish which factors related to chronic cervical myofascial pain effect patient disability. The report's assessment was based on data collected from 103 female patients with the chronic disorder and from 30 healthy female participants, using the Neck Pain and Disability Scale, the Beck Depression Inventory, and a visual analog scale, as well as pain pressure threshold measurements from common cervical myofascial pain trigger points. The investigators found that patient disability was most strongly linked to the duration of pain.
• Migraine and/or muscle contraction headaches⁴
• TMJ syndrome

Prognosis

• When the patient with cervical myofascial pain undergoes appropriate treatment(s) (eg, physical therapy, massage therapy, stretch and spray, trigger point injections), the prognosis is generally good. Recurrence can be a common scenario. Outcomes seem to be better when treatment is initiated early in order to prevent compensation patterns that exacerbate pain.

Patient Education

• Patients with cervical myofascial pain need to be educated on the factors or underlying problems that may contribute to their pain and loss of mobility. The physical therapist can educate the patient on proper exercise habits and instruct them in a home exercise program for stretching and reconditioning. The patient also may benefit from specific exercises and strategies to improve posture awareness and body mechanics with activities of daily living. If poor workplace ergonomics contribute to the patient's condition, offer instruction in proper ways to modify and revamp the workstation. Cervical myofascial pain is a treatable condition if the patient is educated on the condition and takes an active role in the recovery process.
• For excellent patient education resources, visit eMedicine's Back, Ribs, Neck, and Head Center and Muscle Disorders Center. Also, see eMedicine's patient education articles Temporomandibular Joint (TMJ) Syndrome, Fibromyalgia, and Chronic Pain.

Miscellaneous

Medicolegal Pitfalls

• Remember that cervical myofascial pain can be present at the same time as other more serious medical conditions. The term myofascial pain tends to imply that the patient does not have a serious illness. If the patient's symptoms are resistant to traditional treatment for cervical myofascial pain, further workup is indicated. If a history of trauma exists, order cervical flexion/extension films to rule out the possibility of instability. MRI also may be helpful to rule out any significant abnormality within the structure of the cervical vertebrae or spinal canal. The cervical discs also may be evaluated. If the pain is in the shoulders or chest wall, be aware that visceral pain may refer to these areas and even produce some myofascial findings on examination. Be open-minded to the possibility that another problem also may be present.

Multimedia

Media file 1: Schematic of a trigger point complex of a muscle in longitudinal section. A: The central trigger point (CTrP) in the endplate zone contains numerous electrically active loci and numerous contraction knots. A taut band of muscle fibers extends from the trigger point to the attachment at each end of the involved fibers. The sustained tension that the taut band exerts on the attachment tissues can induce a localized enthesopathy that is identified as an attachment trigger point (ATrP). B: Enlarged view of part of the CTrP shows the distribution of 5 contraction knots. The vertical lines in each muscle fiber identify the relative spacing of its striations. The space between 2 striations corresponds to the length of 1 sarcomere. The sarcomeres within one of these enlarged segments (ie, contraction knot) of a muscle fiber are markedly shorter and wider than the sarcomeres in the neighboring normal muscle fibers, which are free of contraction knots.

Media file 2: Cross-sectional drawing shows flat palpation of a taut band and its trigger point. Left: A. Skin is pushed to one side to begin palpation. B. The fingertip slides across muscle fibers to feel the cord-line texture of the taut band rolling beneath it. C. The skin is pushed to other side at completion of movement. This same movement performed vigorously is snapping palpation. Right: A. Muscle fibers are surrounded by the thumb and fingers in a pincer grip. B. The hardness of the taut band is felt clearly as it is rolled between the digits. C. The palpable edge of the taut band is sharply defined as it escapes from between the fingertips, often with a local twitch response.

Media file 3: Longitudinal schematic drawing of taut bands, myofascial trigger points, and a local twitch response. A: Palpation of a taut band (straight lines) among normally slack, relaxed muscle fibers (wavy lines). B: Rolling the band quickly under the fingertip (snapping palpation) at the trigger point often produces a local twitch response that usually is seen most clearly as skin movement between the trigger point and the attachment of the muscle fibers.

Media file 4: Cross-sectional schematic drawing shows flat palpation to localize and hold the trigger point for injection. A and B show use of alternate pressure between 2 fingers to confirm the location of the palpable module of the trigger point. C shows the trigger point being positioned halfway between the fingertips to keep it from sliding to one side during the injection.

Media file 5: Sequence of steps to use when stretching and spraying any muscle for myofascial trigger points.

Media file 6: Schematic drawing showing how the jet stream of vapocoolant is applied.

References

1. Travell JG, Simons DG. Myofascial Pain and Dysfunction. vol 2. Baltimore, Md: Lippincott Williams & Wilkins; 1992.

2. Duyur Cakit B, Genc H, Altuntas V, et al. Disability and related factors in patients with chronic cervical myofascial pain. Clin Rheumatol. Feb 18 2009;[Medline].

3. Hong CZ, Simons DG. Pathophysiologic and electrophysiologic mechanisms of myofascial trigger points. Arch Phys Med Rehabil. Jul 1998;79(7):863-72. [Medline].

4. Harden RN, Cottrill J, Gagnon CM, et al. Botulinum toxin A in the treatment of chronic tension-type headache With cervical myofascial trigger points: a randomized, double-blind, placebo-controlled pilot study. Headache. Oct 10 2008;[Medline].

5. Lee SH, Chen CC, Lee CS, et al. Effects of needle electrical intramuscular stimulation on shoulder and cervical myofascial pain syndrome and microcirculation. J Chin Med Assoc. Apr 2008;71(4):200-6. [Medline].

6. Jabbari B. Botulinum neurotoxins in the treatment of refractory pain. Nat Clin Pract Neurol. Dec 2008;4(12):676-85. [Medline].

7. Jeynes LC, Gauci CA. Evidence for the use of botulinum toxin in the chronic pain setting--a review of the literature. Pain Pract. Jul-Aug 2008;8(4):269-76. [Medline].

8. Borg-Stein J, Simons DG. Focused review: myofascial pain. Arch Phys Med Rehabil. Mar 2002;83(3 Suppl 1):S40-7, S48-9. [Medline].

9. De Andres J, Cerda-Olmedo G, Valia JC, et al. Use of botulinum toxin in the treatment of chronic myofascial pain. Clin J Pain. Jul-Aug 2003;19(4):269-75. [Medline].

10. Gnatz SM. Referred pain syndromes of the head and neck. In: Physical Medicine and Rehabilitation: State of the Art Reviews. Vol 5. 1991:585-596.

11. Hou CR, Tsai LC, Cheng KF, et al. Immediate effects of various physical therapeutic modalities on cervical myofascial pain and trigger-point sensitivity. Arch Phys Med Rehabil. Oct 2002;83(10):1406-14. [Medline].

12. Jacob AT. Myofascial pain. In: Physical Medicine and Rehabilitation: State of the Art Reviews. Vol 5. 1991:573-583.

13. Rosen NB. Myofascial pain: the great mimicker and potentiator of other diseases in the performing artist. Md Med J. Mar 1993;42(3):261-6. [Medline].

14. Wheeler AH. Myofascial pain disorders: theory to therapy. Drugs. 2004;64(1):45-62. [Medline].

Keywords

cervical myofascial pain, neck pain, fascia, myofascial, cervical spine, trigger point, myalgia, myofascial pain, neck and shoulder pain, trigger point therapy, trigger points, trigger point injections, TMJ, TMJ pain, temporomandibular joint, trigger point injection, myofasciitis, interstitial myofibrositis, fibrositis, nonarticular rheumatism affecting the cervical spine, tension myalgia

Contributor Information and Disclosures

Author

Beth B Froese, MD, Consulting Staff, Department of Physical Medicine and Rehabilitation, Orthopaedic Associates of DuPage Ltd
Beth B Froese, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, American Medical Association, and Illinois State Medical Society
Disclosure: Nothing to disclose.

Medical Editor

Martin K Childers, DO, PhD, Associate Professor, Department of Neurology, Wake Forest University Health Services
Martin K Childers, DO, PhD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, American Congress of Rehabilitation Medicine, American Osteopathic Association, Christian Medical & Dental Society, and Federation of American Societies for Experimental Biology
Disclosure: Allergan pharma Consulting fee Consulting

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Patrick M Foye, MD, FAAPMR, FAAEM, Associate Professor of Physical Medicine and Rehabilitation, Co-Director of Musculoskeletal Fellowship, Co-Director of Back Pain Clinic, Director of Coccyx Pain Service (Tailbone Pain Service: www.TailboneDoctor.com), University of Medicine and Dentistry of New Jersey, New Jersey Medical School
Patrick M Foye, MD, FAAPMR, FAAEM is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, American Association of Neuromuscular and Electrodiagnostic Medicine, Association of Academic Physiatrists, and International Spine Intervention Society
Disclosure: Nothing to disclose.

CME Editor

Kelly L Allen, MD, Regional Medical Director, IMX-Medical Management Services
Disclosure: Nothing to disclose.

Chief Editor

Consuelo T Lorenzo, MD, Consulting Staff, Department of Physical Medicine and Rehabilitation, Alegent Health Care, Immanuel Rehabilitation Center
Consuelo T Lorenzo, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation
Disclosure: Nothing to disclose.

Related eMedicine topics:
Back Pain, Mechanical
Cervical Spine Sprain/Strain Injuries
Cervical Sprain and Strain
Cervical Strain
Mechanical Low Back Pain
Myofascial Pain
Myofascial Pain in Athletes
Therapeutic Injections for Pain Management

Guidelines:
ACR Appropriateness Criteria Chronic Neck Pain
Assessment and Management of Chronic Pain

Clinical studies:
The Natural History of Upper Trapezius Myofascial Trigger Points: Comparison of Local and Remote Tissue Milieu in Normal Muscle, Latent and Active Myofascial Trigger Points Over Time

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