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Richard M. Bachrach, D.O., F.A.O.A.S.M.
Center for Sports and Osteopathic MedicineMYOFASCIAL PAIN
SYNDROMES
Repetitive micro-traumata (injuries), unresolved single injury,
inflammation, poor posture or maladaptive movement habits at play or at work, stress, lack
of sleep, or any combination of the above will produce tightness or abnormal contraction
of skeletal muscles. The investing fascia becomes taut and bound down. Circulation to and
from the muscles is decreased, resulting in the accumulation of the end-products of muscle
metabolism, particularly lactic acid and potassium ions. Localized areas of muscle
tenderness called TRIGGER POINTS are formed. These are extremely sensitive and will
fire impulses (under the slightest provocation such as pressure and stretching), to
distant tissues, producing pain and consequent loss of motion at remote locations. This
causes the further accumulation of muscle toxins, more muscle and fascial tightness, more
pain, etc., perpetuating the MYOFASCIAL PAIN cycle.
This is an extremely common cause of pain anywhere in the body:
head, face, neck, shoulders, chest, arms, low back, buttocks, legs, feet, etc. To
understand more about this ubiquitous problem, a few definitions and explanations are in
order:
- Fascia is a tough connective tissue lining, covering and
investing muscles, and, indeed, all cells, tissues and organs. Fascia is three-dimensional
and is continuous throughout the body. Anything affecting fascia in one area is manifested
to some extent in all body regions.
- Pain is an abnormal, unpleasant EMOTIONAL and sensory
experience caused by actual or perceived injury. This results in the stimulation of nerve
endings called nociceptors. These impulses are transmitted to the spinal cord and then to
the brain where they register as pain.
- Trigger points (TrP) are foci of hyperirritability in muscle,
fascia or ligaments (connecting bone to bone as in joints). They are characterized by taut
fibrous bands, a twitch response when stimulated, and constant areas of referred pain. The
pain patterns thus produced are called myofascial pain syndromes. There are several
types and locations of trigger points:
- Active TrPs are always tender. They prevent full lengthening
of the muscle and weaken it. Direct compression, stretching, or other sources of
irritation such as accumulation of the toxic chemical products of muscle metabolism or
lack of oxygen will ignite the TrP. From it, localized pain is produced in a specific area
with associated autonomic changes. These may include increased or reduced skin
temperature, sweating or dryness. The area of referred pain is often distant from the TrP.
- Latent TrPs may not be painful to pressure, but result in
muscle weakness and restricted motion. There are also secondary and satellite TrPs,
the explanation of which is beyond the scope of this article.
- Ligamentous TrPs are found in lax, stretched ligaments as a
result of aging, trauma and/or poor posture, particularly those ligaments involved in the
support of the axial (vertebral column and pelvis) or appendicular skeleton.
- Periosteal TrPs are found on the surface of bone usually at
the site of ligament or tendon attachment and related to tension on that area from
stretched ligaments.
PERPETUATING FACTORS
- Alignment Or Postural Factors: Gravity in combination with
aging, long term poor posture, and/or repeated injury causes laxity of the axial (trunk
and pelvis) and appendicular skeletal ligaments. This is most relevant in the spine and
pelvis. Tightness of the psoas major muscle combined with weakness of the abdominal
muscles, particularly the pelvic attachment of the obliques and recti, combine to
perpetuate a downward tilting of the pelvis and an increase in the lumbar lordosis. Thus,
the ligaments connecting the pelvis to the vertebral column and to the lower extremities
are stretched and their nociceptors depolarized, initiating the pain cycle. The same
applies to the pelvic and low back muscles which now are tightened and ischemic.
- Other Perpetuating Factors: include leg length disparity or
pelvic tilt; hyperpronation (inward rolling of the foot); nutritional, metabolic,
endocrine, postural and emotional factors as well as bacterial or viral infections or
parasitic infestations.
- Major Myofascial Pain Syndromes: The trigger points I have
found most frequently related to pain complaints in our practice are located in the
following muscles: iliopsoas, quadratus lumborum, gluteus medius, gluteus minimus,
piriformis, hamstrings, trapezius, levator scapula, scalenus anticus.
TREATMENT
Here are a few pointers to help you in your own pain management:
- Passive stretching can be dangerous: "no pain no gain" is a
rule with strict limitations. The inadequately trained person stretching you has no
conception of your pain or tolerance. Stretch yourself or let a trained therapist help.
- The presence of a TrP in a muscle can be suspected when stretching or
attempting to strengthen a muscle group is either fruitless or results in aggravation of
pain with the pattern being repetitive. Don’t attempt to stretch or strengthen a
muscle with TrPs.
- Any discomfort while stretching should be experienced in the belly of
the muscle, NOT at the point of attachment to bone or in the tendon.
- Remember: not everybody needs to stretch and not every muscle needs
to be stretched. Older people with extremely lax ligaments may depend on hypertonic
muscles to support unstable skeletal structures and may react poorly to attempts to
stretch.
Treatment of myofascial pain syndromes consists principally of the
following measures and is part of the program available at the Center for Sports and
Osteopathic Medicine:
1. Identify and correct all possible perpetuating factors. Of
particular importance are: correction of postural imbalances with short leg lifts;
correction of faulty foot mechanics with orthotics.
2. Identify and treat all trigger points with ultra sound and low
volt electrical stimulation, dry needling, injection with a local anaesthetic,
acupuncture, spray and stretch with a topical local anaesthetic or any combination of the
above.
3. Osteopathic manipulation, massage, soft tissue mobilization.
4. Re-establish normal, restorative sleep using muscle relaxants,
L-tryptophan (if available), acupuncture or a combination of these.
5. Pain relief with medication ranging from acetominophen through
non-steroid anti-inflammatories and aspirin to short term narcotics, if necessary.
6. Careful, appropriate stretching and strengthening are essential
components of any successful treatment and rehabilitation program. Your physical therapist
and I will be your guides in such a program.
7. Aerobic exercise, instituted carefully and progressed gradually
to tolerance is vital to recovery and prevention of recurrence.
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