Myofascial Pain in Athletes Treatment & Management

Rehabilitation program

Physical therapy

Effective treatment of an MPS caused by TrPs usually involves more than simply applying a procedure to TrPs. ^{[5, 11, 12]} Often, it is necessary to consider and deal with the cause that activated the TrPs, to identify and correct any perpetuating factors (which often are different than what activated the TrPs), and to help the patient restore and maintain normal muscle function. Common misconceptions about the treatment of TrPs include the following:

• Simply treating the TrP should be sufficient, especially if the stress that activated the TrP is not recurrent and if no perpetuating factors are present.

  • In this case, the TrP is likely to be reactivated by the same stress.

  • Ignoring perpetuating factors invites recurrence. After the TrPs have persisted for some time, failure to retrain the muscle to normal function or failure to reestablish its full-stretch range of motion results in a degree of persistent motor dysfunction.

• The pain cannot be as severe as the patient says and must be largely psychogenic.

  • The patients are trying to communicate their degree of pain. Believe them. The pain feels severe to them. Patients in a general medical practice rated their pain as severe as or more severe than pain from other causes such as pharyngitis, cystitis, angina, and herpes zoster.

  • An appreciable amount of the pain reported by many patients with fibromyalgia comes from their TrPs. The pain of fibromyalgia rates fully as severe as the pain of rheumatoid arthritis. It is severe enough to cause central nervous system changes characteristic of chronic pain.

  • Because of their chronic lip and fibromyalgia pain, these patients often develop pain behaviors that tend to reinforce dysfunction and further pain. Many patients experience grievous and needless degree and duration of pain, because a series of clinicians unacquainted with MTrPs erroneously (covertly if not overtly) diagnosed a psychogenic condition.

• MPSs are self-limiting and will cure themselves.

  • An acute uncomplicated TrP activated by an unusual activity or muscle overload can revert spontaneously to a latent TrP within 1 or 2 weeks, if the muscle is not overstressed (used within tolerance, which may be limited) and if no perpetuating factors are present. Otherwise, if the acute syndrome is not properly managed, it evolves needlessly into a chronic MPS.

• Relief of pain by treatment of skeletal muscles for MTrPs rules out serious visceral disease.

  • Because of the referred pain nature of visceral pain, application of vapocoolant spray or infiltration of a local anesthetic into the somatic reference zone can temporarily relieve the pain of myocardial infarction, angina, and acute abdominal disease with no effect on the visceral pathology.

Rehabilitation program: The treatment approaches include the use of simple muscle stretch, augmented muscle stretch, post-isometric relaxation, reciprocal inhibition, slow exhalation, eye movement, TrP pressure release, massage, range of motion, heat, ultrasound, high-voltage galvanic stimulation, drug treatment, biofeedback, and new injection techniques. ^[6]

Physical therapy includes simple muscle stretch, augmented muscle stretch, post-isometric relaxation, reciprocal inhibition, slow exhalation, eye movement, TrP pressure release, massage, range of motion, heat, ultrasound, and high-voltage galvanic stimulation. ^{[6, 13, 14]}

A study by Yeste-Fabregat et al showed that Tecar therapy (diathermy) can raise local temperature in the medial gastrocnemius and decrease local pain at the TrP in professional male basketball players with latent MTrPs. ^[15]

A meta-analysis by Zhou et al demonstrated that the addition of exercise rehabilitation to a single-intervention clinical treatment for MPS significantly reduced pain and improved functioning in patients with MTrPs. ^[16]

Medical issues/complications

Table 2. Myofascial Trigger Points Mistakenly Diagnosed as Other Conditions (Open Table in a new window)

Table 3. Differences in Clinical Features that Distinguish Myofascial Pain due to TrPs from Fibromyalgia (Open Table in a new window)

Complications of injections

Pneumothorax by aiming the needle at an intercostal space: The only exception is when the intercostal muscles must be injected. This should be performed with great care.

The location of the needle tip can be misjudged readily when using a long slender needle. Furthermore, the needle should be inserted straight, avoiding any side pressure that might bend it, deflecting the tip an unknown distance to one side.

It is especially important to avoid using a needle with a burr at the tip because it causes unnecessary bleeding. When the tip of a disposable needle contacts bone, the impact frequently curls the tip to produce a fishhook burr that feels scratchy and drags as the needle is drawn through tissues.

Contraindications

Contraindications to TrP injections are as follows:

• Patients on anticoagulation therapy

• If the patient has taken aspirin within 3 days of injection

• Tobacco smokers, unless they have stopped smoking and have taken at least 500 mg of timed-release vitamin C for 3 days prior to injection

• Patients who have an inordinate fear of needles

• Patients should avoid strenuous activity and sports for 10 days.

Consultations

The clinical importance of MTrPs to practitioners has been described in the literature for acupuncturists, anesthesiologists, chronic pain managers, dentists, family practitioners, gynecologists, neurologists, nurses, orthopedic surgeons, pediatricians, physical therapists, physiatrists, rheumatologists, and veterinarians.

Other treatments and techniques

Botulinum A toxin injection

The clinical effectiveness of botulinum A toxin injection for the treatment of MTrPs helps to substantiate dysfunctional endplates as an essential part of the pathophysiology of TrPs (see the images below). ^{[17, 18, 19, 20, 21, 22]} This toxin specifically acts only on the neuromuscular junction, effectively denervating that muscle cell. ^[23]

Myofascial pain in athletes. Mechanism of botulinum toxin type A.

View Media Gallery

Myofascial pain in athletes. Binding of neuromuscular transmission with botulinum toxin type A, which binds the motor nerve terminal.

View Media Gallery

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.

View Media Gallery

Myofascial pain in athletes. Botulinum toxin type A blocks acetylcholine by cleaving a cytoplasmic protein on the cell membrane.

View Media Gallery

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.

View Media Gallery

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.

View Media Gallery

Stretch and spray

Infants have been observed with point tenderness of the rectus abdominis muscle and colic, both of which were relieved by sweeping a stream of vapocoolant spray over the muscle, which helps to inactivate MTrPs.

The sequence of steps when stretching and spraying any muscle for MTrPs is shown in the image below. ^[24]

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

View Media Gallery

The sequence of steps to use when stretching and spraying any muscle is as follows:

• The patient is supported in a comfortable relaxed position.

• One end of the muscle is anchored.

• Skin is sprayed with repeated parallel sweeps of the Vapo coolant over the length of the muscle in the direction of pain pattern.

• After the first sweep of spray, pressure is applied to take up the slack in the muscle and is continued as additional sweeps of spray are applied.

• Sweeps of the spray are extended to cover the referred pain pattern.

• Steps 3, 4, and 5 may be repeated 2 or 3 times until the skin becomes cold to the touch or when the range of motion reaches maximum.

Technique of spray and stretch

• For example, treatment for right levator scapulae TrPs; the direction and pattern of the Vapo coolant spray follows the muscle fibers (see the image below).

  Myofascial pain in athletes. Schematic drawing showing how the jet stream of Vapo coolant is applied.

  View Media Gallery

• During the distraction of the spray, the operator presses the patient's head forward and to the opposite side, while using the elbow to press the patient's shoulder down and back. Similar techniques are applied to most other TrPs. The key ingredient is the prolonged stretch of the affected muscle.

• Unidirectional sweeps cover, first, parallel lines of skin over those muscle fibers that are stretched the tightest, then over the rest of the muscle and its pain pattern. Sequential sweeps of spray should follow the direction of the muscle fibers and progress toward the referred pain zone.

TrP injection technique

• To prevent bleeding, the fingers of the palpating hand should be spread apart, maintaining tension on the skin to reduce the likelihood of subcutaneous bleeding where the needle has penetrated (see the image below). Also, during the injection, the fingers exert pressure around the needle tip to provide homeostasis in deeper tissues. When the angle of the needle is changed, the direction of pressure changes.

  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).

  View Media Gallery

• The physician should avoid inserting the needle to the hub where the needle is most likely to break off. Some additional depth of penetration can be obtained safely by indenting the skin and subcutaneous tissues with a finger beside the needle as illustrated in the image below.

  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.

  View Media Gallery

• The importance of distinguishing between central TrPs, ie, in the central portion of the muscle belly and attachment TrPs when injecting, is illustrated in the image below.

  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).

  View Media Gallery

• The increased capillary fragility characteristic of a low serum vitamin C level can cause excessive bleeding in muscles injected for TrPs. Capillary hemorrhage augments postinjection soreness and leads to unsightly ecchymoses. A frequent source of increased bleeding due to low vitamin C is tobacco. Mega-dose vitamin C therapy daily for 1 week should correct this deficiency. At least 500 mg of timed-release vitamin C 3 times daily is recommended for a minimum of 3 days prior to injection of TrPs. A daily dose of aspirin increases the susceptibility to bleeding. The patient should take no aspirin for 3 days before TrP injection or needling. ^[25]

Eftekharsadat et al found corticosteroid TrP injection provided greater short-term control of pain and disability than extracorporeal shock wave therapy (ESWT) did in patients with MPS of the quadratus lumborum muscle. However, after 4 weeks, ESWT was more effective than corticosteroid TrP injection in improving quality of life and reducing disability. ^[26]

Benito-de-Pedro et al compared a single session of deep dry needling with ischemic compression in a latent MTrP of the shortened triceps surae in 34 triathletes. The researchers assessed ankle dorsiflexion range of motion and dynamic and static plantar pressures before and after treatment and found no statistically significant differences between the two treatment groups. ^[27]