Myofascial Pain in Athletes

Myofascial Pain in Athletes

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Voluntary, or skeletal, muscle is the largest single organ of the human body and accounts for nearly 50% of the body’s weight. The number of muscles in the body depends on the degree of subdivision that is considered and on the number of variable muscles that are included. Not counting heads, bellies, and other divisions of muscles, the Nomina Anatomica reported by the International Anatomical Nomenclature Committee under the Berne Convention lists 200 paired muscles, or a total of 400 muscles. Any one of these muscles can develop myofascial trigger points (MTrPs). [1] MTrPs are hyperirritable tender spots in palpable tense bands of skeletal muscle that refer pain and motor dysfunction, often to another location. [2, 3]

The myofascial pain syndromes (MPS) owe their ever-widening acceptance to the pioneering work of Travell and her later collaboration with Simons. [2, 3] In 1983, they combined their clinical experience in a detailed description of the multiple pain syndromes attributed to this disorder. In doing so, they further defined the major clinical components that are characteristic of myofascial pain, the most important being the TrP, the taut band, and the local twitch response. See the image below.

United States

MTrPs are extremely common and become a painful part of nearly everyone’s life at one time or another. Latent TrPs, which often cause motor dysfunction (eg, stiffness, restricted range of motion) without pain, are far more common than active TrPs that cause pain.

Active TrPs are commonly found in postural muscles of the neck, shoulder, and pelvic girdles and in the masticatory muscles. In addition, the upper trapezius, scalene, sternocleidomastoid, levator scapulae, and quadratus lumborum muscles are commonly involved.

Reports of the prevalence of MTrPs in specific patient populations are available. The data indicate a high prevalence of this condition among individuals with a regional pain complaint, as shown in Table 1.

Table 1. Prevalence of Myofascial Pain (Open Table in a new window)

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

The wide range in the prevalences of myofascial pain caused by TrPs is likely due to differences in the patient populations examined and in the degree of chronicity, at least in part. Probably even more important are differences in the criteria used to diagnose MTrPs and, most important, differences in the training and skill of the examiners.

Some isolated large round muscle fibers and some groups of these darkly staining, enlarged, round muscle fibers appear in cross-sections. In longitudinal sections, the corresponding feature is a number of contraction knots. An individual knot appears as a segment of muscle fiber with extremely contracted sarcomeres. This contractured segment has a corresponding increase in diameter of the muscle fiber.

The structural features of contraction knots presents a likely explanation for the palpable nodules and the taut bands associated with TrPs. Three single contraction knots can be seen scattered among normal muscle fibers. Beyond the thickened segment of the contractured muscle fiber at the contraction knot, the muscle fiber becomes markedly thinned and consists of stretched sarcomeres to compensate for the contractured ones in the knot segment. In addition, a pair of contraction knots separated by empty sarcolemma may represent one of the first irreversible complications that result from the continued presence of the contraction knot.

The activation of a TrP is usually associated with some degree of mechanical abuse of the muscle in the form of muscle overload, which may be acute, sustained, and/or repetitive. In addition, leaving the muscle in a shortened position can convert a latent TrP to an active TrP; this process is greatly aggravated if the muscle is contracted while in the shortened position.

In paraspinal muscles (and likely other muscles, too), a degree of nerve compression that causes identifiable neuropathic electromyographic (EMG) changes is associated with an increase in the numbers of active TrPs. These TrPs may be activated by disturbed microtubular communication between the neuron and the endplate because the motor endplate is involved in the pathophysiologic process of the peripheral core TrP.

The histopathologic complications that could contribute to the chronicity of the condition and make treatment more difficult include the following:

Distortion of the striations (sarcomere arrangement) in adjacent muscle fibers for some distance beyond the contraction knot (see the image below). This produces unnatural shear forces between fibers that could seriously and chronically stress the sarcolemma of the adjacent muscle fibers. If the membrane were stressed to the point at which it became pervious to the relatively high concentration of calcium in the extracellular space, it could induce massive contracture that could compound the shear forces.

The occasional finding of a segment of an empty sarcolemmal tube between 2 contractions knots may represent an additional irreversible complication of a contraction knot.

Latent TrPs can produce other effects characteristic of a TrP, including increased muscle tension and muscle shortening; but these do not produce spontaneous pain. Both active and latent TrPs can cause significant motor dysfunction. The same factors that are responsible for the development of an active TrP can, to a lesser extent, cause a latent TrP. An active key TrP in one muscle can induce an active satellite TrP in another. Inactivation of the key TrP often inactivates its satellite TrP without treatment of the satellite TrP itself.

The intensity and extent of the pattern of referred pain depends on the degree of irritability in the TrP, not on the size of the muscle. MTrPs in small, obscure, or variable muscles can be as troublesome to the patient as TrPs in large familiar muscles.

TrPs are activated directly by acute overload, overwork fatigue, direct impact trauma, and radiculopathy. TrPs can be activated indirectly by other existing TrPs, visceral disease, arthritic joints, joint dysfunctions, and emotional distress. Satellite TrPs are prone to develop in muscles that lie within the pain reference zone of key MTrPs or within the zone of pain referred from a diseased viscus, such as the pain due to myocardial infarction, gastric ulcer, cholelithiasis, or renal colic. A perpetuating factor increases the likelihood of overload stress that can convert a latent TrP to an active TrP.

With adequate rest and in the absence of perpetuating factors, an active TrP may spontaneously revert to a latent state. Pain symptoms disappear; however, occasional reactivation of the TrP by exceeding that muscle’s stress tolerance can account for a history of recurrent episodes of the same pain over a period of years.

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

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

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:

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.

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

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].

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

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

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

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.

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].

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].

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

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

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

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].

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].

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.

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

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].

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].

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].

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.

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].

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

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

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

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].

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

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

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

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

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.

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

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].

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

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

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

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

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.

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.

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.

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.

Myofascial Pain in Athletes

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