History
The diagnosis of myofascial pain is clinical, with no confirmatory laboratory tests available. The patient with cervical myofascial pain may present with a history of acute trauma associated with persistent muscular pain. However, myofascial pain can also manifest insidiously, without a clear antecedent accident or injury. It may be associated with repetitive tasks, poor posture, stress, or cold weather. Typical findings reported by patients also include the following:
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Cervical spine range of motion (ROM) is often limited and painful
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The patient may describe a lumpiness or painful bump in the trapezius or cervical paraspinal muscles
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Massage is often helpful, as is superficial heat
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The patient's sleep may be interrupted because of pain
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The cervical rotation required for driving is difficult to achieve
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The patient may describe pain radiating into the upper extremities, accompanied by numbness and tingling, making discrimination from radiculopathy or peripheral nerve impingement difficult
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Dizziness or nausea may be a part of the symptomatology
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The patient experiences typical patterns of radiating pain referred from trigger points
Physical Examination
Common findings noted upon physical examination include the following:
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Patients with cervical myofascial pain often present with poor posture; they exhibit rounded shoulders and protracted scapulae
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Trigger points frequently are noted in the trapezius, supraspinatus, infraspinatus, rhomboids, and levator scapulae muscles
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The palpable, taut band is noted in the skeletal muscle or surrounding fascia; a local twitch response often can be reproduced with palpation of the area
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ROM of the cervical spine is limited, with pain reproduced in positions that stretch the affected muscle
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While the patient may complain of weakness, normal strength in the upper extremities is noted on physical examination
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Sensation typically is normal when tested formally; no long tract signs are observed on examination
Myofascial pain in any location is characterized on examination by the presence of trigger points located in skeletal muscle. 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 further [10] :
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Trigger points are known to elicit local pain and/or referred pain in a specific, recognizable distribution
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Palpation in a rapid fashion (ie, snapping palpation) may elicit a local twitch response, a brisk contraction of the muscle fibers in or around the taut band; the local twitch response also can be elicited by rapid insertion of a needle into the trigger point (see the images below)
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Restricted ROM and increased sensitivity to stretch of muscle fibers in a taut band are noted frequently
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The muscle with a trigger point may be weak because of pain; usually, no atrophic change is observed
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Patients with trigger points may have associated localized autonomic phenomena (eg, vasoconstriction, pilomotor response, ptosis, hypersecretion)
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An active myofascial trigger point is a site marked by generation of spontaneous pain or pain in response to movement; in contrast, latent trigger points may not produce pain until they are compressed
Cross-sectional drawing shows flat palpation of a taut band and its trigger point. Left: A. The 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 the other side at completion of the movement. This same movement performed vigorously is called 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, which usually is seen most clearly as skin movement between the trigger point and the attachment of the muscle fibers.
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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.
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Cross-sectional drawing shows flat palpation of a taut band and its trigger point. Left: A. The 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 the other side at completion of the movement. This same movement performed vigorously is called 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.
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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, which usually is seen most clearly as skin movement between the trigger point and the attachment of the muscle fibers.
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Cross-sectional schematic drawing shows flat palpation to localize and hold the trigger point for injection. A and B show the 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.
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Sequence of steps to use when stretching and spraying any muscle for myofascial trigger points.
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Schematic drawing showing how the jet stream of vapocoolant is applied.
