Myofascial Pain in Athletes Follow-up

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

Return to Play

The athlete should avoid strenuous activity during sports, and they should always use stretching techniques prior to competitions or practice.



The single muscle MPSs usually are acute and follow an episode of muscle overload. In some cases, the pain persists and spreads to other, usually synergistic, muscles. This is referred to as a chronic regional myofascial syndrome.

Many perpetuating factors encourage transformation to a more widespread muscle pain problem. Mechanical factors include postural stress, muscle imbalances, and skeletal asymmetries. These can put additional stress on surrounding muscles, leading to spread of dysfunction and pain. Systemic perpetuating factors purportedly include anything jeopardizing the energy supply to muscle (ie, anemia, endocrine imbalances, low thyroid function, vitamin deficiencies).

Chronic regional myofascial syndromes are conceptually close to the malignant, metastasizing fibromyalgia referred to by Bennett.



Patients should avoid the mechanical and systemic factors mentioned in Complications.



The ultimate goal is to educate patients and (1) to provide them with the means to manage their own muscle pain disorder, (2) to eliminate their dependence on healthcare providers, (3) to eliminate contributing factors, providing prolonged stretch of the affected muscle, and aerobic exercises.[5]

On performing a task, the patient must learn to keep the muscles mobilized, and not held fixed in a contracted position. Muscle fibers need to alternately contract and relax to provide blood flow and replenish their energy supply.

For excellent patient education resources, see eMedicineHealth's patient education article Chronic Pain.

Contributor Information and Disclosures

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.

  1. Simons DG, Mense S. [Diagnosis and therapy of myofascial trigger points]. Schmerz. 2003 Dec. 17(6):419-24.

  2. Travell JG, Simons DG. Myofascial Pain and Dysfunction: The Trigger Point Manual. Baltimore, Md: Lippincott Williams & Wilkins; 1983.

  3. Travell JG, Simons DG. Myofascial Pain and Dysfunction: The Trigger Point Manual. Upper half of Body. 2nd ed. Baltimore, Md: Lippincott Williams & Wilkins; 1999. Vol 1:

  4. Fisher AA. Diagnosis and management of chronic pain in physical medicine and rehabilitation. Ruskin AP, ed. Current Therapy in Physiatry. Philadelphia, Pa: WB Saunders Co; 1984. 123-154.

  5. Thompson JM. The diagnosis and treatment of muscle pain syndromes. Braddom RL, ed. Physical Medicine and Rehabilitation. Philadelphia, Pa: WB Saunders Co; 1996.

  6. Ballyns JJ, Shah JP, Hammond J, Gebreab T, Gerber LH, Sikdar S. Objective sonographic measures for characterizing myofascial trigger points associated with cervical pain. J Ultrasound Med. 2011 Oct. 30(10):1331-40. [Medline].

  7. Gerwin RD. Diagnosis of myofascial pain syndrome. Phys Med Rehabil Clin N Am. 2014 May. 25 (2):341-55. [Medline].

  8. Hubbard DR, Berkoff GM. Myofascial trigger points show spontaneous needle EMG activity. Spine. 1993 Oct 1. 18(13):1803-7. [Medline].

  9. Hong CZ. Treatment of myofascial pain syndrome. Curr Pain Headache Rep. Oct/2006. 5:345-9.

  10. Walsh NE, Dimitru D, Schoenfeld LS, Ramamurthy S. Treatment of the patient with chronic pain. DeLisa JA, ed. Rehabilitation Medicine: Principles and Practice. 3rd ed. Philadelphia, Pa: Lippincott-Raven; 1998.

  11. Sarrafzadeh J, Ahmadi A, Yassin M. The Effects of Pressure Release, Phonophoresis of Hydrocortisone, and Ultrasound on Upper Trapezius Latent Myofascial Trigger Point. Arch Phys Med Rehabil. 2011 Oct 7. [Medline].

  12. 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].

  13. Acquadro MA, Borodic GE. Treatment of myofascial pain with botulinum A toxin. Anesthesiology. 1994 Mar. 80(3):705-6. [Medline].

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

  15. Scott AB. Forward. Jankovic J, Hallet M, eds. Therapy with Botulinum Toxin. New York, NY: Marcel Dekker Inc; 1994. vii-ix.

  16. Nicol AL, Wu II, Ferrante FM. Botulinum toxin type a injections for cervical and shoulder girdle myofascial pain using an enriched protocol design. Anesth Analg. 2014 Jun. 118 (6):1326-35. [Medline]. [Full Text].

  17. Zhou JY, Wang D. An update on botulinum toxin A injections of trigger points for myofascial pain. Curr Pain Headache Rep. 2014 Jan. 18 (1):386. [Medline].

  18. Coffield JA, Considine RV, Simpson LL. The site and mechanism of action of botulinum neurotoxin. Jankovic J, Hallet M, eds. Therapy with Botulinum Toxin. New York, NY: Marcel Dekker Inc; 1994. 3-13.

  19. Travell JG. Ethylchloride spray for painful muscle spasm. Arch Phys Med Rehabil. 1952. 33:291-8.

  20. Huang YT, Lin SY, Neoh CA, Wang KY, Jean YH, Shi HY. Dry needling for myofascial pain: prognostic factors. J Altern Complement Med. 2011 Aug. 17(8):755-62. [Medline].

  21. Annaswamy TM, De Luigi AJ, O'Neill BJ, Keole N, Berbrayer D. Emerging Concepts in the Treatment of Myofascial Pain: A Review of Medications, Modalities, and Needle-based Interventions. PM R. 2011 Oct. 3(10):940-61. [Medline].

  22. Schneider MJ. Tender points/fibromyalgia vs. trigger points/myofascial pain syndrome: a need for clarity in terminology and differential diagnosis. J Manipulative Physiol Ther. 1995 Jul-Aug. 18(6):398-406. [Medline].

  23. Simons AG. Muscular pain syndromes. Fricton JR, Awad FA, eds. Advances in Pain Research and Therapy. Myofascial Pain and Fibromyalgia. New York, NY: Raven Press; 1990. Vol 17: 18.

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

  25. Lambert CM. Hand and upper limb problems of instrumental musicians. Br J Rheumatol. 1992 Apr. 31(4):265-71. [Medline].

  26. Charness ME, Parry GJ, Markison RE, et al. Entrapment neuropathies in musicians. Neurology. 1985. 35(suppl 1):74.

  27. Lederman RJ. Nerve entrapment syndromes in instrumental musicians. Med Probl Perform Art. 1986. 1:45-8.

  28. Maffulli N, Maffulli F. Transient entrapment neuropathy of the posterior interosseous nerve in violin players. J Neurol Neurosurg Psychiatry. 1991 Jan. 54(1):65-7. [Medline].

  29. Gregory PL, Biswas AC, Batt ME. Musculoskeletal problems of the chest wall in athletes. Sports Med. 2002. 4:235-50.

  30. Gregory PL, Biswas AC, Batt ME. Musculoskeletal problems of the chest wall in athletes. Sports Med. 2002. 32(4):235-50.

  31. Fredericson M, Weir A. Practical management of iliotibial band friction syndrome in runners. Clin J Sport Med. 2006 May. 3:261-8.

  32. Fredericson M, Weir A. Practical management of iliotibial band friction syndrome in runners. Clin J Sport Med. 2006 May. 16(3):261-8.

  33. Hatheway CL, Dang C. Immunogenicity of the neurotoxins of Clostridium botulinum. Jankovic J, Hallet M, eds. Therapy with Botulinum Toxin. New York, NY: Marcel Dekker; 1994. 93-107.

  34. Hong CZ. Treatment of myofascial pain syndrome. Curr Pain Headache Rep. 2006 Oct. 10(5):345-9.

  35. Reiter RC, Gambone JC. Nongynecologic somatic pathology in women with chronic pelvic pain and negative laparoscopy. J Reprod Med. 1991 Apr. 36(4):253-9. [Medline].

  36. Wainapel SF, Cole IL. The not so magic flute: two cases of distal ullnar nerve entrapment. Med Probl Perform Art. 1988. 3:63-5.

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
RegionPracticeNumber StudiedPrevalence of Myofascial Pain, %
GeneralPain medical center9693
GeneralComprehensive pain center28385
CraniofacialHead and neck pain clinic16455
LumboglutealOrthopedic clinic9721
Table 2. Myofascial Trigger Points Mistakenly Diagnosed as Other Conditions
Initial DiagnosisTrPs
Angina pectoris, atypicalPectoralis major
AppendicitisLower rectus abdominis
Atypical facial neuralgiaMasseter, temporalis, sternal division of the sternocleidomastoid, upper trapezius
Atypical migraineSternocleidomastoid, temporalis, posterior cervical
Back pain, middleUpper rectus abdominis, thoracic paraspinals
Back pain, lowLower rectus abdominis, thoracolumbar paraspinals
Bicipital tendinitisLong head of the biceps brachii
Chronic abdominal wall painAbdominal muscles
DysmenorrheaLower rectus abdominis
Earache, enigmaticDeep masseter
EpicondylitisWrist extensors, supinator, triceps brachii
Frozen shoulderSubscapularis
Myofascial pain dysfunctionMasticatory muscles
Occipital headachePosterior cervicals
Post-therapeutic neuralgiaSerratus anterior, intercostals
Radiculopathy, C6Pectoralis minor, scalenes
Scapulocostal syndromeScalenes, middle trapezius, levator scapulae
Subacromial bursitisMiddle deltoid
Temporomandibular joint disorderMasseter, lateral pterygoid
Tennis elbowFinger extensors, supinator
Tension headacheSternocleidomastoid, masticatory, posterior cervicals, suboccipital, upper trapezius
Thoracic outlet syndromeScalenes, subscapularis, pectoralis minor and major, latissimus dorsi, teres major
Table 3. Differences in Clinical Features that Distinguish Myofascial Pain due to TrPs from Fibromyalgia
FeatureMyofascial Pain (TrPs)Fibromyalgia
Female-to-male ratio1:14-9:1
PainLocal or regionalWidespread, general
MuscleFeels tense (taut bands)Feels soft and doughy
MotionRestricted range of motionHypermobility
ExaminationExamine for TrPsExamine for tender points
Medscape Consult