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Myofascial Pain in Athletes Clinical Presentation

  • Author: Auri Bruno-Petrina, MD, PhD; Chief Editor: Sherwin SW Ho, MD  more...
 
Updated: Oct 07, 2015
 

History

See the list below:

  • Symptoms
    • Active TrPs produce a clinical complaint, usually pain, that the patient recognizes when the TrP is compressed digitally. The patient is aware of the pain caused by an active TrP, but he or she may or may not be aware of the dysfunction it causes.
    • Latent TrPs characteristically cause increased muscle tension and limit the stretch range of motion, which often escapes the patient's attention or is simply accepted. The patient becomes aware of pain originating from a latent TrP only when pressure is applied to it. Spontaneous referred pain appears with increased irritability of the TrP; then, the TrP is identified as active.
    • The patient usually presents with complaints due to the most recently activated TrP. When this TrP is successfully eliminated, the pain pattern may shift to that of an earlier key TrP that must also be inactivated. If the key TrP is inactivated first, the patient may recover without further treatment.
    • Patients with active MTrPs usually complain of poorly localized, regional, aching pain in subcutaneous tissues, including muscles and joints. They rarely complain of sharp, clearly localized cutaneous-type pain. The myofascial pain is often referred away from the TrP in a pattern that is characteristic for each muscle. Sometimes, the patient is aware of numbness or paresthesia rather than pain.
  • Dysfunction
    • In addition to the clinical symptoms produced by the sensory disturbances of referred pain, dysesthesias, and hypesthesias, patients can also have clinically important disturbances of autonomic and motor functions.
    • Disturbances of autonomic functions
      • Disturbances of autonomic functions caused by TrPs include abnormal sweating, persistent lacrimation, persistent coryza, excessive salivation, and pilomotor activities.
      • Related proprioceptive disturbances caused by TrPs include imbalance, dizziness, tinnitus, and distorted perception of the weight of lifted objects.
    • Disturbances of motor functions
      • Disturbances of motor functions caused by TrPs include spasm of other muscles, weakness of the involved muscle function, loss of coordination by the involved muscle, and decreased work tolerance of the involved muscle.
      • The weakness and loss of work tolerance are often interpreted as an indication for increased exercise, but if this is attempted without inactivating the responsible TrPs, the exercise is likely to encourage and further ingrain substitution by other muscles, with further weakening and deconditioning of the involved muscle.
      • The combination of weakness in the hands and loss of forearm muscle coordination makes the grasp unreliable. Objects sometimes slip unexpectedly from the patient's grasp. The weakness results from reflex motor inhibition and characteristically occurs without atrophy of the affected muscle. Patients are prone to intuitively substitute muscles without realizing that, for instance, they are carrying the grocery bag in the nondominant but now stronger arm.
    • The motor effects of TrPs on the muscle in which they are located are considered in detail under Surface electromyography in Other Tests.
  • Sleep disturbances
    • Disturbance of sleep can be a problem for patients with a painful TrP syndrome. Authors of a series of studies have shown that many sensory disturbances, including pain, can seriously disturb the patient's sleep.
    • This sleep disturbance can, in turn, increase pain sensitivity the next day. Active MTrPs become more painful when the muscle is held in the shortened position for long periods and if body weight compresses the TrP. Thus, for patients with active TrPs, sleep positioning can be critical to prevent unnecessary disturbances of their sleep.
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Physical

Each muscle has a characteristic elicited referred pain pattern that, for active MTrPs, is familiar to the patient. Without a laboratory test or imaging method, diagnosis of MTrPs depends entirely on history and physical examination.[4, 5] MTrP symptoms follow muscle overload, are activated acutely by sudden overload, or develop gradually with prolonged contractions or repetitive activity. The diagnostic skill required depends on considerable innate palpation ability, authoritative training, and extensive clinical experience.

Pain prevents a muscle with a MTrP from reaching its full stretch range of motion and also restricts its strength and/or endurance. Clinically, the lip is a localized spot of tenderness in a nodule within a palpable taut band of muscle fibers. Restricted stretch range of motion and a palpable increase in muscle tenseness (ie, decreased compliance) are more severe in more active MTrPs.

Active MTrPs are identified when patients recognize the pain induced by applying pressure to a MTrP. The taut band fibers usually respond with a MTrP when the taut band is accessible and when the TrP is stimulated by properly applied snapping palpation. The taut band fibers have a consistent twitch response when a needle penetrates the MTrP.

  • Taut band
    • By gently rubbing across the direction of the muscle fibers in a superficial muscle, the examiner can feel a nodule at the MTrP and a ropelike induration that extends from this nodule to the attachment of the taut muscle fibers at each end of the muscle.
    • The taut band can be snapped or rolled under the finger in accessible muscles. With effective inactivation of the TrP, this palpable sign becomes less tense and often (but not always) disappears, sometimes immediately. See the image below.
      Myofascial pain in athletes. Cross-sectional drawi Myofascial pain in athletes. Cross-sectional drawing shows flat palpation of a taut band and its trigger point.Left: Skin pushed to one side to begin palpation (A). The fingertip slides across muscle fibers to feel the cord-line texture of the taut band rolling beneath it (B). The skin is pushed to other side at completion of movement. This same movement performed vigorously is snapping palpation (C).Right: Muscle fibers surrounded by the thumb and fingers in a pincer grip (A). The hardness of the taut band is felt clearly as it is rolled between the digits (B). The palpable edge of the taut band is sharply defined as it escapes from between the fingertips, often with a local twitch response (C).
  • Tender nodule
    • Palpation along the taut band reveals a nodule exhibiting a highly localized and exquisitely tender spot that is characteristic of a MTrP. When the spot is tested for tenderness, displacement of the algometer by 2 cm produces a statistically significant decrement in pain threshold algometer readings. Clinically, displacement of the application of pressure by 1-2 mm at a MTrP can result in a markedly reduced pain response.
    • This strong localization of tenderness in the vicinity of a MTrP corresponds to the localized sensitivity of the experimental muscle for eliciting TrPs as demonstrated in rabbit experiments. A 5-mm displacement to either side of the trigger spot (at right angles to the taut band) results in almost total loss of response. However, the response fades out more slowly when stimulated over a range of several centimeters from the trigger spot along the taut band.
  • Recognition: Application of digital pressure on either an active or latent MTrP can elicit a referred pain pattern characteristic of that muscle. However, if the patient recognizes the elicited sensation as a familiar experience, this establishes the MTrP as being active and is one of the most important diagnostic criteria available when the palpable findings also are present. Similar recognition is observed frequently when a needle penetrates the MTrP and encounters an active locus.
  • Referred sensory signs: In addition to referring pain to the reference zone, MTrPs may refer other sensory changes such as tenderness and dysesthesias.
  • Local twitch response: Snapping palpation of the TrP frequently evokes a transient twitch response of the taut band fibers. Twitch responses can be elicited both from active and latent TrPs. Hubbard at al showed that no difference was noted in twitch responses whether elicited by snapping palpation or by needle penetration. See the image below.
    Myofascial pain in athletes. Longitudinal schemati Myofascial pain in athletes. 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.
  • Limited range of motion
    • Muscles with active MTrPs have a restricted passive (stretch) range of motion because of pain. An attempt to passively stretch the muscle beyond this limit produces increasingly severe pain because the involved muscle fibers are already under substantially increased tension at rest length.
    • The limitation of stretch due to pain is not as great with active movement as with passive lengthening of the muscle; this finding at least partly due to reciprocal inhibition. When the TrP is inactivated and the taut band is released, range of motion returns to normal.
    • The degree of limitation produced by MTrPs is much more marked in some muscles (eg, subscapularis) than in other muscles (eg, latissimus dorsi).
  • Painful contraction: When a muscle with an active TrP is strongly contracted against fixed resistance, the patient feels pain. This effect is most marked when the patient attempts to contract the muscle when it is in a shortened position.
  • Weakness
    • Although weakness is generally characteristic of a muscle with active myofascial MTrPs, the magnitude is varied from muscle to muscle and from subject to subject.
    • EMG studies indicate that, in muscles with active MTrPs, the muscle starts out fatigued, it fatigues more rapidly, and it becomes exhausted sooner than normal muscles. The weakness may reflect reflex inhibition of the muscle by the MTrPs.
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Causes

Causes of myofascial pain include or are related to the following:

  • The lack of motor unit action potentials due to the endogenous contracture of the contractile elements, rather than a nerve-initiated contraction of the muscle fibers
  • The frequency with which muscle overload activates TrPs, which may reflect the marked mechanical vulnerability of the synaptic cleft region of an endplate
  • The release of substances that could sensitize nociceptors in the region of the dysfunctional endplate of the TrP as a result of tissue distress caused by the energy crisis
  • The effectiveness of essentially any technique that elongates the TrP portion of the muscle to its full stretch length even briefly, which could break the cycle that includes energy-consuming contractile activity
  • Laborers who exercise their muscles heavily every day are less likely to develop active TrPs than sedentary workers who are prone to intermittent episodes of vigorous physical activity. This author's clinical experience supports this observation.
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Contributor Information and Disclosures
Author

Auri Bruno-Petrina, MD, PhD Physiatrist

Auri Bruno-Petrina, MD, PhD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, Canadian Association of Physical Medicine and Rehabilitation, International Society of Physical and Rehabilitation Medicine

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.

Russell D White, MD Clinical Professor of Medicine, Clinical Professor of Orthopedic Surgery, Department of Community and Family Medicine, University of Missouri-Kansas City School of Medicine, Truman Medical Center-Lakewood

Russell D White, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Family Physicians, American Association of Clinical Endocrinologists, American College of Sports Medicine, American Diabetes Association, American Medical Society for Sports Medicine

Disclosure: Nothing to disclose.

Chief Editor

Sherwin SW Ho, MD Associate Professor, Department of Surgery, Section of Orthopedic Surgery and Rehabilitation Medicine, University of Chicago Division of the Biological Sciences, The Pritzker School of Medicine

Sherwin SW Ho, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, Arthroscopy Association of North America, Herodicus Society, American Orthopaedic Society for Sports Medicine

Disclosure: Received consulting fee from Biomet, Inc. for speaking and teaching; Received grant/research funds from Smith and Nephew for fellowship funding; Received grant/research funds from DJ Ortho for course funding; Received grant/research funds from Athletico Physical Therapy for course, research funding; Received royalty from Biomet, Inc. for consulting.

Additional Contributors

Anthony J Saglimbeni, MD President, South Bay Sports and Preventive Medicine Associates; Private Practice; Team Internist, San Francisco Giants; Team Internist, West Valley College; Team Physician, Bellarmine College Prep; Team Physician, Presentation High School; Team Physician, Santa Clara University; Consultant, University of San Francisco, Academy of Art University, Skyline College, Foothill College, De Anza College

Anthony J Saglimbeni, MD is a member of the following medical societies: California Medical Association, Santa Clara County Medical Association, Monterey County Medical Society

Disclosure: Received ownership interest from South Bay Sports and Preventive Medicine Associates, Inc for board membership.

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Myofascial pain in athletes. 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 one 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.
Myofascial pain in athletes. Cross-sectional drawing shows flat palpation of a taut band and its trigger point.Left: Skin pushed to one side to begin palpation (A). The fingertip slides across muscle fibers to feel the cord-line texture of the taut band rolling beneath it (B). The skin is pushed to other side at completion of movement. This same movement performed vigorously is snapping palpation (C).Right: Muscle fibers surrounded by the thumb and fingers in a pincer grip (A). The hardness of the taut band is felt clearly as it is rolled between the digits (B). The palpable edge of the taut band is sharply defined as it escapes from between the fingertips, often with a local twitch response (C).
Myofascial pain in athletes. 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.
Myofascial pain in athletes. Sequence of steps to use when stretching and spraying any muscle for myofascial trigger points.
Myofascial pain in athletes. Schematic drawing showing how the jet stream of Vapo coolant is applied.
Myofascial pain in athletes. 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 positioning the trigger point half way between the fingertips to keep it from sliding to one side during the injection.
Myofascial pain in athletes. Schematic top view of 2 approaches to the flat injection of a trigger point area in a palpable taut band. Injection away from the fingers (A) and injection toward the fingers (B).
Myofascial pain in athletes. C. Z. Hong's technique. Finger pressure beside the needle is used to indent the skin, subcutaneous, and fat tissues so that the needle can reach the trigger point in a muscle that would be inaccessible otherwise.
Myofascial pain in athletes. Diagrammatic representation of pre-injection sites (open circles) and injection sites (solid circles) of local anesthetic to the trigger point. The enclosed stippled area represents the taut band. This diagram distinguishes the central trigger point within the large broken circle from the attachment trigger points located at the myotendinous junction and at the attachment of the tendon to the bone. Each of these 3 trigger point regions can be identified by their individual spot tenderness and anatomical locations. No rationale is apparent for injecting the part of the taut band that lies between the central trigger point and the attachment trigger point (solid circles numbers 7-10).
Myofascial pain in athletes. Mechanism of botulinum toxin type A.
Myofascial pain in athletes. Binding of neuromuscular transmission with botulinum toxin type A, which binds the motor nerve terminal.
Myofascial pain in athletes. After botulinum toxin type A is internalized, the light chain of the toxin molecule is released into the cytoplasm of the nerve terminal.
Myofascial pain in athletes. Botulinum toxin type A blocks acetylcholine by cleaving a cytoplasmic protein on the cell membrane.
Myofascial pain in athletes. After the botulinum toxin type A exerts its clinical toxic effect, a nerve sprout eventually establishes a new neuromuscular junction, and muscle activity gradually returns. However, new research findings suggest that this new nerve sprout retracts and the original junction returns to functionality.
Myofascial pain in athletes. After the clinical toxic effect of botulinum toxin type A occurs, axon sprouting and muscle fiber reinnervation terminate the clinical effect of the toxin, which results in the reestablishment of neuromuscular transmission.
Table 1. Prevalence of Myofascial Pain
Region Practice Number Studied Prevalence of Myofascial Pain, %
General Medical 172 30
General Pain medical center 96 93
General Comprehensive pain center 283 85
Craniofacial Head and neck pain clinic 164 55
Lumbogluteal Orthopedic clinic 97 21
Table 2. Myofascial Trigger Points Mistakenly Diagnosed as Other Conditions
Initial Diagnosis TrPs
Angina pectoris, atypical Pectoralis major
Appendicitis Lower rectus abdominis
Atypical facial neuralgia Masseter, temporalis, sternal division of the sternocleidomastoid, upper trapezius
Atypical migraine Sternocleidomastoid, temporalis, posterior cervical
Back pain, middle Upper rectus abdominis, thoracic paraspinals
Back pain, low Lower rectus abdominis, thoracolumbar paraspinals
Bicipital tendinitis Long head of the biceps brachii
Chronic abdominal wall pain Abdominal muscles
Dysmenorrhea Lower rectus abdominis
Earache, enigmatic Deep masseter
Epicondylitis Wrist extensors, supinator, triceps brachii
Frozen shoulder Subscapularis
Myofascial pain dysfunction Masticatory muscles
Occipital headache Posterior cervicals
Post-therapeutic neuralgia Serratus anterior, intercostals
Radiculopathy, C6 Pectoralis minor, scalenes
Scapulocostal syndrome Scalenes, middle trapezius, levator scapulae
Subacromial bursitis Middle deltoid
Temporomandibular joint disorder Masseter, lateral pterygoid
Tennis elbow Finger extensors, supinator
Tension headache Sternocleidomastoid, masticatory, posterior cervicals, suboccipital, upper trapezius
Thoracic outlet syndrome Scalenes, subscapularis, pectoralis minor and major, latissimus dorsi, teres major
Table 3. Differences in Clinical Features that Distinguish Myofascial Pain due to TrPs from Fibromyalgia
Feature Myofascial Pain (TrPs) Fibromyalgia
Female-to-male ratio 1:1 4-9:1
Pain Local or regional Widespread, general
Tenderness Focal Widespread
Muscle Feels tense (taut bands) Feels soft and doughy
Motion Restricted range of motion Hypermobility
Examination Examine for TrPs Examine for tender points
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