Physical Medicine and Rehabilitation for Myofascial Pain Clinical Presentation

  • Author: Jennifer E Finley, MD, FAAPMR; Chief Editor: Consuelo T Lorenzo, MD  more...
Updated: Mar 17, 2015


Patients with myofascial pain usually report regionalized aching and poorly localized pain in the muscles and joints. They also may report sensory disturbances, such as numbness in a characteristic of distribution. The type of pain felt is characteristic of the muscle involved. An acute onset may occur after a specific event or trauma (eg, moving quickly in an awkward position), while chronic pain may result from poor posture or overuse.[6] Patients may note disturbed sleep. Persons with cervical and periscapular myofascial pain may have difficulty finding a comfortable sleeping position. They may or may not be aware of muscle weakness in the affected muscles and may have a tendency to drop things.



A skilled examiner can provide accurate diagnosis of myofascial pain (MP). Unfortunately, most medical school and residency training programs do not adequately cover this common condition.[7] Locating trigger points (TrPs) is the most important part of the physical examination. TrPs tend to occur in characteristic locations in individual muscles. The book Travell and Simons' Myofascial Pain and Dysfunction: The Trigger Point Manual is considered the criterion standard reference on locating and treating TrPs.[2, 8, 9]

When the TrP is located, the patient typically has a positive jump sign when local pressure is applied over the area; the jump sign should not be confused with an LTR. The jump sign simply means that the patient jumps from pain or discomfort in the area that has been palpated. Apply a consistent amount of pressure to the area, because applying too much pressure can elicit pain in nearly all individuals. A pressure algometer (ie, pressure threshold meter) or palpatometer can be used to standardize the amount of pressure applied.[10]

A taut band is found in the muscle, either by palpation or by needle penetration. It can be distinguished by palpating or by dragging the fingers perpendicular to the muscle fibers. A localized knot or a tight, ropy area is noted. Patients report that the area is extremely tender when palpated. A localized flinching in the area of the muscle being palpated or an LTR may be noted in active TrPs, as well as in latent ones. Palpation or insertion of a needle into the TrP causes reproduction of the patient's pain and, frequently, sensory complaints. Palpation of either an active or a latent TrP causes referred pain in a characteristic area for each muscle, a phenomenon described in the above-mentioned TrP manual. Sensory disturbance (eg, paresthesias, dysesthesias, localized skin tenderness) may be noted in the same area where pain may be referred. Autonomic phenomena also may be elicited (eg, sweating, piloerection, temperature changes).

Essential criteria for identifying an active or latent TrP include the following:

  • Palpable taut band if the muscle is accessible
  • Exquisite spot tenderness of a nodule in a taut band
  • Patient's recognition of current pain complaint by pressure on the tender nodule
  • Painful limit to full ROM stretch of the involved muscle

Confirmatory observations include the following:

  • Visual or tactile identification of an LTR
  • Imaging of an LTR induced by needle penetration of a tender nodule
  • Pain or altered sensation on compression of a tender nodule, in the distribution expected from a TrP in that muscle
  • Electromyographic demonstration of spontaneous electrical activity (SEA) that is characteristic of active loci in the tender nodule of a taut band
  • Lowered skin resistance to electrical current - This has been found over active TrPs when compared with surrounding tissue and may be useful in localizing TrPs. Skin resistance normalizes after the treatment of TrPs.


Many factors may contribute to the development of myofascial pain (MP). Abnormal stresses on the muscles from sudden stress on shortened muscles, leg-length discrepancies, or skeletal asymmetry are thought to be common causes of MP. Poor posture also may cause MP.

Assumption of a static position for a prolonged period or conversely, performing repetitive movements, has been implicated in the condition, particularly in a cold environment.

Anemia and low levels of calcium, potassium, iron, and vitamins C, B-1, B-6, and B-12 are believed to play a role.

Chronic infections and sleep deprivation have been cited as causative factors, as have radiculopathy, visceral diseases, and depression. Hypothyroidism, hyperuricemia, and hypoglycemia also have been implicated in MP.

The pathogenesis likely has a central mechanism, with peripheral clinical manifestations.

Contributor Information and Disclosures

Jennifer E Finley, MD, FAAPMR Consulting Physiatrist and Sports Medicine Physician

Jennifer E Finley, MD, FAAPMR is a member of the following medical societies: American Academy of Medical Acupuncture, American College of Sports Medicine, American Academy of Physical Medicine and Rehabilitation

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Patrick M Foye, MD Director of Coccyx Pain Center, Professor and Interim Chair of Physical Medicine and Rehabilitation, Rutgers New Jersey Medical School; Co-Director of Musculoskeletal Fellowship, Co-Director of Back Pain Clinic, University Hospital

Patrick M Foye, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, International Spine Intervention Society, American Association of Neuromuscular and Electrodiagnostic Medicine, Association of Academic Physiatrists

Disclosure: Nothing to disclose.

Chief Editor

Consuelo T Lorenzo, MD Medical Director, Senior Products, Central North Region, Humana, Inc

Consuelo T Lorenzo, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation

Disclosure: Nothing to disclose.


Martin K Childers, DO, PhD Professor, Department of Neurology, Wake Forest University School of Medicine; Professor, Rehabilitation Program, Institute for Regenerative Medicine, Wake Forest Baptist Medical Center

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

  1. Dorsher PT. Myofascial referred-pain data provide physiologic evidence of acupuncture meridians. J Pain. 2009 Jul. 10(7):723-31. [Medline].

  2. McPartland JM. Travell trigger points--molecular and osteopathic perspectives. J Am Osteopath Assoc. 2004 Jun. 104(6):244-9. [Medline]. [Full Text].

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

  4. Alonso-Blanco C, Fernández-de-Las-Peñas C, Morales-Cabezas M, Zarco-Moreno P, Ge HY, Florez-García M. Multiple active myofascial trigger points reproduce the overall spontaneous pain pattern in women with fibromyalgia and are related to widespread mechanical hypersensitivity. Clin J Pain. 2011 Jun. 27(5):405-13. [Medline].

  5. Shah JP, Danoff JV, Desai MJ, et al. Biochemicals associated with pain and inflammation are elevated in sites near to and remote from active myofascial trigger points. Arch Phys Med Rehabil. 2008 Jan. 89(1):16-23. [Medline].

  6. Gerwin RD. A review of myofascial pain and fibromyalgia--factors that promote their persistence. Acupunct Med. 2005 Sep. 23(3):121-34. [Medline].

  7. Graff-Radford SB. Myofascial pain: diagnosis and management. Curr Pain Headache Rep. 2004 Dec. 8(6):463-7. [Medline].

  8. Simons DG, Travell JG, Simons LS. Travell and Simons' Myofascial Pain and Dysfunction: The Trigger Point Manual. 2nd ed. Baltimore, Md: Williams & Wilkins; 1999.

  9. Gerwin RD, Dommerholt J, Shah JP. An expansion of Simons' integrated hypothesis of trigger point formation. Curr Pain Headache Rep. 2004 Dec. 8(6):468-75. [Medline].

  10. Myburgh C, Larsen AH, Hartvigsen J. A systematic, critical review of manual palpation for identifying myofascial trigger points: evidence and clinical significance. Arch Phys Med Rehabil. 2008 Jun. 89(6):1169-76. [Medline].

  11. Hameroff SR, Crago BR, Blitt CD, et al. Comparison of bupivacaine, etidocaine, and saline for trigger-point therapy. Anesth Analg. 1981 Oct. 60(10):752-5. [Medline].

  12. Hong CZ. Lidocaine injection versus dry needling to myofascial trigger point. The importance of the local twitch response. Am J Phys Med Rehabil. 1994 Jul-Aug. 73(4):256-63. [Medline].

  13. Venâncio Rde A, Alencar FG, Zamperini C. Different substances and dry-needling injections in patients with myofascial pain and headaches. Cranio. 2008 Apr. 26(2):96-103. [Medline].

  14. Wreje U, Brorsson B. A multicenter randomized controlled trial of injections of sterile water and saline for chronic myofascial pain syndromes. Pain. 1995 Jun. 61(3):441-4. [Medline].

  15. Diraçoglu D, Vural M, Karan A, Aksoy C. Effectiveness of dry needling for the treatment of temporomandibular myofascial pain: a double-blind, randomized, placebo controlled study. J Back Musculoskelet Rehabil. 2012 Jan 1. 25(4):285-90. [Medline].

  16. Tekin L, Akarsu S, Durmus O, Cakar E, Dinçer U, Kiralp MZ. The effect of dry needling in the treatment of myofascial pain syndrome: a randomized double-blinded placebo-controlled trial. Clin Rheumatol. 2013 Mar. 32(3):309-15. [Medline].

  17. Rha DW, Shin JC, Kim YK, Jung JH, Kim YU, Lee SC. Detecting local twitch responses of myofascial trigger points in the lower-back muscles using ultrasonography. Arch Phys Med Rehabil. 2011 Oct. 92(10):1576-1580.e1. [Medline].

  18. Aoki KR. Evidence for antinociceptive activity of botulinum toxin type A in pain management. Headache. 2003 Jul-Aug. 43 Suppl 1:S9-15. [Medline].

  19. Lang AM. Botulinum toxin therapy for myofascial pain disorders. Curr Pain Headache Rep. 2002 Oct. 6(5):355-60. [Medline].

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

  21. Cheshire WP, Abashian SW, Mann JD. Botulinum toxin in the treatment of myofascial pain syndrome. Pain. 1994 Oct. 59(1):65-9. [Medline].

  22. Avendano-Coy J, Gomez-Soriano J, Valencia M, et al. Botulinum toxin type A and myofascial pain syndrome: a retrospective study of 301 patients. J Back Musculoskelet Rehabil. 2014. 27(4):485-92. [Medline].

  23. Affaitati G, Fabrizio A, Savini A, et al. A randomized, controlled study comparing a lidocaine patch, a placebo patch, and anesthetic injection for treatment of trigger points in patients with myofascial pain syndrome: evaluation of pain and somatic pain thresholds. Clin Ther. 2009 Apr. 31(4):705-20. [Medline].

  24. Fleckenstein J, Zaps D, Ruger LJ, et al. Discrepancy between prevalence and perceived effectiveness of treatment methods in myofascial pain syndrome: results of a cross-sectional, nationwide survey. BMC Musculoskelet Disord. 2010 Feb 11. 11:32. [Medline]. [Full Text].

  25. Ay S, Dogan SK, Evcik D, Baser OC. Comparison the efficacy of phonophoresis and ultrasound therapy in myofascial pain syndrome. Rheumatol Int. 2011 Sep. 31(9):1203-8. [Medline].

  26. Gam AN, Warming S, Larsen LH, et al. Treatment of myofascial trigger-points with ultrasound combined with massage and exercise--a randomised controlled trial. Pain. 1998 Jul. 77(1):73-9. [Medline].

  27. 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. 2008 Apr. 71(4):200-6. [Medline].

  28. Srbely JZ, Dickey JP, Lowerison M, et al. Stimulation of myofascial trigger points with ultrasound induces segmental antinociceptive effects: a randomized controlled study. Pain. 2008 May 26. [Medline].

  29. Ay S, Dogan SK, Evcik D, et al. Comparison the efficacy of phonophoresis and ultrasound therapy in myofascial pain syndrome. Rheumatol Int. 2010 Mar 31. [Medline].

  30. Flor H, Birbaumer N. Comparison of the efficacy of electromyographic biofeedback, cognitive- behavioral therapy, and conservative medical interventions in the treatment of chronic musculoskeletal pain. J Consult Clin Psychol. 1993 Aug. 61(4):653-8. [Medline].

  31. Rayegani S, Bahrami M, Samadi B, Sedighipour L, Mokhtarirad M, Eliaspoor D. Comparison of the effects of low energy laser and ultrasound in treatment of shoulder myofascial pain syndrome: a randomized single-blinded clinical trial. Eur J Phys Rehabil Med. 2011 Sep. 47(3):381-9. [Medline].

  32. Chan YC, Wang TJ, Chang CC, et al. Short-term effects of self-massage combined with home exercise on pain, daily activity, and autonomic function in patients with myofascial pain dysfunction syndrome. J Phys Ther Sci. 2015 Jan. 27(1):217-21. [Medline]. [Full Text].

  33. Birch S, Jamison RN. Controlled trial of Japanese acupuncture for chronic myofascial neck pain: assessment of specific and nonspecific effects of treatment. Clin J Pain. 1998 Sep. 14(3):248-55. [Medline].

  34. Ma C, Wu S, Li G, et al. Comparison of miniscalpel-needle release, acupuncture needling, and stretching exercise to trigger point in myofascial pain syndrome. Clin J Pain. 2010 Mar-Apr. 26(3):251-7. [Medline].

  35. Chou LW, Hsieh YL, Chen HS, Hong CZ, Kao MJ, Han TI. Remote therapeutic effectiveness of acupuncture in treating myofascial trigger point of the upper trapezius muscle. Am J Phys Med Rehabil. 2011 Dec. 90(12):1036-49. [Medline].

  36. Leite FM, Atallah AN, El Dib R, et al. Cyclobenzaprine for the treatment of myofascial pain in adults. Cochrane Database Syst Rev. 2009 Jul 8. CD006830. [Medline].

  37. Lin YC, Kuan TS, Hsieh PC, Yen WJ, Chang WC, Chen SM. Therapeutic effects of lidocaine patch on myofascial pain syndrome of the upper trapezius: a randomized, double-blind, placebo-controlled study. Am J Phys Med Rehabil. 2012 Oct. 91(10):871-82. [Medline].

  38. Bendtsen L, Jensen R, Olesen J. Qualitatively altered nociception in chronic myofascial pain. Pain. 1996 May-Jun. 65(2-3):259-64. [Medline].

  39. Danto JB. Review of integrated neuromusculoskeletal release and the novel application of a segmental anterior/posterior approach in the thoracic, lumbar, and sacral regions. J Am Osteopath Assoc. 2003 Dec. 103(12):583-96. [Medline]. [Full Text].

  40. Facco E, Ceccherelli F. Myofascial pain mimicking radicular syndromes. Acta Neurochir Suppl. 2005. 92:147-50. [Medline].

  41. Hsueh TC, Cheng PT, Kuan TS, et al. The immediate effectiveness of electrical nerve stimulation and electrical muscle stimulation on myofascial trigger points. Am J Phys Med Rehabil. 1997 Nov-Dec. 76(6):471-6. [Medline].

  42. Saggini R, Giamberardino MA, Gatteschi L, et al. Myofascial pain syndrome of the peroneus longus: biomechanical approach. Clin J Pain. 1996 Mar. 12(1):30-7. [Medline].

  43. Simons DG. Review of enigmatic MTrPs as a common cause of enigmatic musculoskeletal pain and dysfunction. J Electromyogr Kinesiol. 2004 Feb. 14(1):95-107. [Medline].

Medscape Consult
All material on this website is protected by copyright, Copyright © 1994-2016 by WebMD LLC. This website also contains material copyrighted by 3rd parties.