*Sorry for inconvenience cause as I left out the part of: -how to differentiate from other structure involved.

1. MYOFASCIAL PAIN SYNDROME
ASNAWI BIN JOHARI
01BF-200904-00108

2. Myofascial Pain Syndrome (MPS)
• Is a chronic muscular pain disorder in one muscle or groups of
muscles presenting with vague complaints of poorly localized
muscle pain and stiffness.
• It is characterized by hyperirritable and tender spots within
taut bands of skeletal muscle called “trigger points.”
• The pathophysiology is unknown. Trigger points do not have
any abnormal histological findings, and electromyograms of
muscle affected by myofascial pain are normal.
Lyn D.Weiss,Physical Medicine and Rehabilitation p.172-4

3. Additional impairments from the trigger points include:
• decreased ROM when the muscle is being stretched,
• decreased strength in the muscle,
• increased pain with muscle stretching.
The trigger points may be active (producing a classic pain
pattern) or latent (asymptomatic unless palpated).
Carolyn Kisner,Therapeutic Exercise p.318
Myofascial pain affects up to 85% of the general
population.
Simons DG: Clinical and Etiological Update of Myofascial Pain
from Trigger Points. Journal of Musculoskeletal Pain 1996, 4:93-122

4. ANATOMY OF FASCIA
• Fascia is a thin membrane of loose or dense
connective tissue that covers the structures of
the body, protecting them and binding them into
a structural unit.
• Fascia separates the skin, layers of muscle, body
compartments, and cavities. In addition, it forms
sheaths for nerves and vessels that anchor them
near the structures they regulate or nourish.
• It also forms or thickens ligaments and joint
capsules.

5. Fascia Layers
-lies directly under the dermis of the skin.
-stores fat and water and creates passageways
for nerves and vessels.
• Superficial fascia -Also called as the hypodermis.
-made of loose connective tissue.
-formed by a connective membrane
that sheaths all muscles.
-It aids in muscle movements, provides
passageways for nerves and vessels, provides
• Deep fascia muscle attachment sites, and cushions muscle
layers.
-This fascial layer is made of dense connective
tissue.
-separates the deep fascia from the membranes
that line the thoracic and abdominal cavities of
• Subserous fascia the body.
-The loose connection between these layers
allows for flexibility and movement of the internal
organs.
-dense connective tissue.

7. Superficial fascia Deep fascia

8. Throughout the body there is a subcutaneous layer of
loose connective tissue called the superficial fascia. It
contains collagen fibers as well as variable amounts of
fat. Superficial fascia increases skin mobility, acts as a
thermal insulator, and stores energy for metabolic use.
The dense connective tissue envelope that invests and
separates individual muscles of the limbs and trunk is
deep fascia. It is also composed primarily of collagen
fibers.
JAOA • Vol 103 • No 12 • December 2003 • 5 8 3

9. Moving on to a more functional description of the fascia, Chila
eloquently and succinctly defined its role in structural support,
motion, and maintenance of balance:
• Fascia of the human body can be described as a sheet of fibrous
tissue that envelops the body beneath the skin;
• it also encloses muscles and groups of muscles, separating their
several layers or groups....
• In addition to extensive attachment for muscles, the fascia of the
human body is provided with sensory nerve endings and is thought
to be elastic as well as contractile.
• Fascia supports and stabilizes, helping to maintain balance.
• It assists in the production and control of motion and the
interrelation of motion of related parts.
• Many of the body’s fascial specializations have postural functions in
which stress bands can be demonstrated.

10. Langer's lines:
These are normal, permanent
skin creases that reflect the fiber
orientation of the superficial
fascia and the muscles that lie
below.

11. Myofascial Unit (mf)
• A myofascial unit (mt) is composed of a group of
motor units that move a body segment in a
specific direction, together with the fascia that
connects these forces or vectors.
• The myofascial unit (mt) is, after the motor unit,
the structural basis of the locomotor system.
Fascial manipulation for musculoskeletal pain, Luigi Stecco,2004.

12. The structure of the myofascial unit
Movement at each joint of the body is coordinated
by six unidirectional mf units . The following
components are found in each mf unit:
• monoarticular and biarticular muscle fibres that
are partially free to slide in their fascial sheaths;
• deep muscle fibres that transfer their tension to
the superficial fascial layers via the endomysium,
the perimysium and the epimysium;
• some muscle fibres of the agonist mf unit that are
attached to the fascia of the antagonist mf unit.

13. Differential diagnosis
• Fibromyalgia
• Polymyositis
• Polymyalgia rheumatica
• Somatization disorder
• Poor sleep
• Psychogenic rheumatism
• Migraine and tension headaches
• Shoulder impingements
• Muscular sprains and strains
• Bursitis and tendinitis
• Radiculopathy
• Complex regional pain syndrome

14. History
• Patients can be of any age or either sex. They
generally describe poorly localized pain in
muscles and joints with sensory disturbances
that are usually worse with exercise and
stretching.
• The onset can be acute (after a specific event)
or chronic from overuse or poor posture.

15. Physical examination
• Posture.
• The range of motion of all affected limbs and spine.
• Assess for pain with movement or joint subluxations.
• Muscle power.
• Soft tissue palpation (including superficial and deep tissue texture
with about 3 lbs of force) should be performed, observing for taut
bands, twitch response, jump sign, or reproducibility of the
patient’s symptoms.
• Patient’s typical pattern of referred pain.
• A local twitch response is elicited by snapping the trigger point
manually.
• The involved region may exhibit decreased range of motion and
some pain-related local muscle weakness.

16. Investigations
• No specific imaging or lab work is diagnostic.
They can be used to rule out other causes of
pain.

17. MANAGEMENT

18. Spray-and-stretch technique
This involves passive stretching of the affected muscle.
• Position the patient for maximum decrease in muscle
tension.
• Clearly identify the trigger points and mark them.
• Apply vapocoolant (ethyl chloride) over the entire length of
the affected muscle.
• Passively stretch the muscle by applying gentle pressure.
• Repeat “spray and stretch” until full range of motion is
attained.
• Use caution with vapocoolant—do not spray for >6–10
seconds with each stretch.

19. Osteopathic manipulative treatment
• Strain–counterstrain technique
• Facilitated positional release (FPR) technique
• Progressive inhibition of neuromuscular
structures (PINS) technique

20. Physical therapy and modalities
• TENS
• Ultrasound
• Massage
• Myofascial release technique
Bron C, Wensing M, Franssen JL, Oostendorp RA: Treatment of myofascial
trigger points in common shoulder disorders by physical therapy: a randomized
controlled trial [ISRCTN75722066]. BMC Musculoskelet Disord 2007, 8:107.

21. Other treatments
• Aerobic exercises
• Acupuncture
Ga H, Choi JH, Park CH, Yoon HJ: Acupuncture needling versus lidocaine
injection of trigger points in myofascial pain syndrome in elderly patients–
a randomised trial. Acupunct Med 2007, 25:130-136.
• Medication
• Short-term use of muscle relaxants and NSAIDs
(can be used in combination)
• Analgesics
Wheeler AH: Myofascial pain disorders: theory to therapy.
Drugs 2004, 64:45-62.

22. Invasive technique
Trigger point injection
• Local anesthetic:
• <1 mL of 1% lidocaine is used most often.
• Procaine is preferred because it is selective for small unmyelinated fibers that
control pain perception.
• Steroids: use if there is an adjacent area of infl ammation, e.g., frozen
shoulder
• Botulinum toxin: emerging therapy
(4 concluded that it was not effective for reducing pain
arising from trigger points)
Ho KY, Tan KH: Botulinum toxin A for myofascial trigger point injection: a qualitative
systematic review. Eur J Pain 2007, 11:519-527.
• Dry needling: multiple advances of a needle into the trigger point
Tough EA, White AR, Cummings TM, Richards SH, Campbell JL: Acupuncture and dry needling in
the management of myofascial trigger point pain: a systematic review and meta-analysis of
randomised controlled trials. Eur J Pain 2009, 13:3-10.

23. Complications of Trigger Point injections
• Pneumothorax
• Hematoma
• Bleeding
• Transient nerve block
• Soft tissue infection
• Postinjection soreness
• Allergic reaction

24. Complications
• Chronic pain syndrome
• Insomnia
• Depression
• Obesity
• Medication dependence
• Anxiety

25. “Neither standard diagnostic procedures to
identify myofascial pain nor discriminating
variables to distinguish the different entities of
myofascial pain syndrome are available.
Therefore we conclude that multiple diagnostic
approaches may lead to therapeutic confusion.”
Discrepancy between prevalence and perceived effectiveness of treatment
methods in myofascial pain syndrome: Results of a cross-sectional,
nationwide survey
Fleckenstein et al. BMC Musculoskeletal Disorders 2010, 11:32
http://www.biomedcentral.com/1471-2474/11/32