Myofascial Pain Syndrome - Brisbane MSK Clinic

What is Myofascial Pain Syndrome?

Myofascial Pain Syndrome (MPS) is a chronic condition involving local and referred pain due to trigger points affecting muscles and fascia. Research has linked the presence and involvement of trigger points to many myofascial pain conditions. It is also widely accepted that the most likely causes of trigger points are injury and overuse. However, there may be other possible causes, such as lack of use or misusing tissues.

What is fascia and why is it relevant?

Fascia is a form of connective tissue and, as per the name, it connects structures within the body. It also exists throughout the human body and looks similar to cotton wool or spider silk under the microscope. It is a densely woven collagen fibre matrix that covers, supports, and separates muscles and organs (Kumka et al., 2012; Bordoni et al., 2022). Without fascia, our muscles would lack their unique shapes. However, fascia also provides stability (Gatt et al., 2022)for joints and enables efficient mobility. Research also indicates that fascia thickness, density, and stiffness vary based on function. Fascia tends to be thicker, denser, and stiffer in areas of increased load (Fede et al., 2021). In many respects, it would appear that fascia can remodel, much like bone (Wolff's Law) and other soft tissues (Davis's Law); see the article on Soft Tissue Adaption for further details. Equally, there is evidence of fibroblast cells within the fascia, which are involved in injury repair (Jiang et al., 2020).

There is also a good deal of research that fascia operates as a global bodily communication system. Hence, the state of fascia has relevance to Myofascial Pain Syndrome and the treatment of many other conditions. Research shows that fascial tissues contain a high density of nerves (neurons) and tiny tubes or a primo vascular system (Fede et al., 2021; Gonzalez et al., 2018). Possible communication paths may include tensional, neurological, and biochemical (including hormones). Research also suggests that fascia has a role in proprioception. Our bodies effectively have a “GPS”, which gives us a sense of joint and limb position, and movement in space. Changes in the state of fascia can impact mobility and our built-in “GPS” sensors.

Normal or healthy fascia is smooth, translucent, durable, slippery, and well-hydrated. In a normal state, fascia allows tissues and joints to move with ease and without pain. Hyaluronic acid works like "oil", enabling fascial surfaces to glide over one another in healthy fascia. Unhealthy fascia is sticky and poorly hydrated, resulting in tension, pain, and restricted mobility. It is easy to see fascia within a piece of raw chicken breast or other meat. A chicken breast typically has a thin, translucent fascia portion between the breast meat and the tenderloin.

Biomechanically, fascia also has viscoelastic and anisotropic properties. The structural makeup of fascia varies within the body and based on function. This anisotropic nature means that fascia responds differently according to the direction of applied force and based on specific fascial makeup. Equally, the viscoelastic properties mean that fascia has both viscous (fluid) and elastic properties. Hence, fascia responds differently based on the type of force, speed, and duration. The properties of healthy fascia have huge relevance for highly efficient movement.

Elastic recoil enables a variety of soft tissues, including fascia, ligaments, tendons, and muscles, to store energy for later use. Equally, energy can also be stored in fascia and tissues due to trauma and unresolved trauma. Without elastic recoil, muscles would consume more energy for the same level of effort and fatigue far more quickly. Hence, tissue fatigue is another common sign of unhealthy fascia. A kangaroo is a good example of an animal using the principles of elastic recoil. Kangaroos appear to bounce at high speed, for long durations, in hot climates, and over varied terrain with little effort.

The anatomist Tom Myers has been working on fascia and the fascial system for over 20 years. During his research, Myers identified multiple specific fascial lines that support functional movement: the superficial front and back lines, lateral lines, spiral lines, arm lines, functional lines, and deep front lines. There are at least four distinctive "solid" fascia types, each providing a different function, including the inter-structural, spinal, structural, and visceral, often classed as solid fascia. However, a more recent concept is liquid fascia, which includes blood and lymph (Bordoni et al., 2018).

The Kinetic Chain and Fascia

Kinetic Chain theory is a concept from engineering and is sometimes called the kinematic chain, dating back to the early 1800s. The theory views human movement as rigid levers (bones), joints, and muscles, creating a movement chain. Hence, mobility in one area of the chain can impact the rest of the chain. These segments or sections form a kinetic chain when one moves. The theory is that if all parts of the chain operate normally, one does not experience pain, discomfort, or restricted mobility. If tissues, joints, or other structures are not working correctly, this can affect how a specific segment moves and general mobility. Hence, if one section is not working correctly (as in a spinal fusion), it would soon lead to other areas in the kinetic chain having problems. However, such surgeries are the only option in some cases of trauma. The image shows the basic idea of the kinetic chain sections or joint structures, yet human movement is far more complex:-

• Cervical Spine (Neck)
• Thoracic Spine (Upper Back)
• Lumbar Spine (Lower Back)
• Hips
• Knees
• Ankles

The body is very good at adapting to avoid pain, so it may take a while to notice changes to the kinetic chain. Mechanically, the kinetic chain concept makes a great deal of sense. Dysfunction in one area of the kinetic chain can impact both above and below the affected segment and both sides of the body. Research into the roles of fascia and movement has identified specific supportive myofascial lines, which add to the simplicity of the "kinetic chain". Tom Myers (the anatomist) has noted that the myofascial lines/meridians he has identified perform different supportive functions and that dysfunction in one area can impact other areas. The theory of these myofascial meridians builds on aspects of the Kinetic Chain Theory. Research suggests that skeletal muscles within the human body are connected via connective tissues, forming a myofascial chain (Wilke et al., 2016). Myofascial Meridians appear able to transmit forces along their length, yet there is little research covering these lines' actual relevance and role. Equally, research has identified myofascial meridians connecting the neck, shoulders, and forearms, though there is little research on the mechanical relevance (Wilke et al., 2019). However, there is a great deal of logic to how these Myofascial Meridians have relevance for injuries, movement, pain, treatment, and rehabilitation.

Besides Myofascial Meridians, there are at least two other theoretical fascia models: Fascintegrity and Biotensegrity (Bordoni et al., 2019). Fascintegrity considers the relevance of solid and liquid fascia. In contrast, Biotensegrity takes a more mechanical view of fascia, and myofascial meridiansare more concerned with force transmission and movement, as already discussed. The article on Biotensegrity takes a much more detailed look at how changes in one body area affect another. Equally, although some view Biotensegrity as only relating to solid fascia, logically, any shape changes could impact liquid fascia, creating restrictions, increasing pressure, etc. The changes during pregnancy are a great example of Biotensegrity and tissue adaptation in action (see Biotensegrity in Pregnancy diagram). Sections of the "kinetic chain" above and below the pelvis adapt to changes in weight distribution. Such global bodily changes would not make sense by purely taking a kinetic chain theory approach. Equally, myofascial trigger points within tissues can impact multiple body areas due to the resulting changes in the fascial system.

Often, a symptom of an injury or problem is not the reason for symptoms, as might be the case with Achilles tendon pain. Typically, one might self-treat the area of pain and the Achilles tendon, which seems to make things feel better or worse. Failing to treat the reason for symptoms often leads to further injuries or seemingly unrelated injuries later. We have all met or know somebody who seems plagued by injuries and continues to try and resolve everything on their own. Equally, just because one specific self-treatment technique worked for one person does not mean it will work for another. No two injuries are the same due to many individual factors, so no two people should be treated with the same treatment, as personal factors need considering. As useful research is, it has limitations. Hence, strictly working in an evidence-based way rather than an evidenced-informed way can result in mixed patient outcomes.

Is myofascial pain a nerve pain?

Research now indicates fascia is a sensory organ brimming with nerve endings and plays a crucial role in myofascial pain syndrome. While sensory pain information is commonly transmitted via nerves to the brain, the body has other communication methods. Fascia pain differs from general nerve pain, manifesting as a distinct and often deep muscular aching sensation. Nerve pain often presents as sharp, shooting, stabbing, tingling, burning, electrical or a dull aching feeling. For instance sciatic pain might shoot from the lower back down the leg to the foot or toes. However, since nerves traverse tissues, fascial tension can also induce nerve pain.

Can MRI detect myofascial pain?

Modern MRI cannot detect myofascial pain syndrome as such, as pain is interpreted in the brain. However, it may be possible to see areas associated with pain perception light up in the brain on MRI. However, a vast amount of research shows evidence of myofascial trigger points within the skeletal muscle tissues of people with myofascial pain. Although historically, trigger points were not visible on MRI, it was always possible to feel the telltale signs within skeletal muscles. With advances in MRI and other imaging methods, it is now possible to see myofascial trigger points. Evidence also shows that effective treatment of such trigger points reduces fascial pain and symptoms. There is debate as to whether myofascial pain is the same as a trigger point, but there are clear links between the two things.

What are Myofascial Trigger Points (MTrPs or TrPs)?

The generally accepted definition of Myofascial Trigger Point includes terms such as a palpable taut band of hyperirritable skeletal muscle (Bron et al., 2012). Trigger Points are small sections of taut fibres (sarcomeres) within the muscle tissues and the fascial system. These taut bands become stuck in a contracted state, affecting the overall muscle function. These stuck areas tend to result in local or referred fascial pain. The exact cause or etiology of why trigger points form is not fully understood. However, there is some consensus that direct trauma and muscle overuse may play a part. Several studies have also shown neuromuscular junction involvement with the motor neuron axon and the connection to the muscle fibres. Such studies have noted links between excessive acetylcholine levels, causing "end plate" noise and myofascial trigger points (Simons et al., 2002; Kuan et al., 2007).

The following diagram depicts a typical skeletal muscle and a magnified section of muscle fibres. Trigger points are not visible to the human eye, and the shaded muscle area illustrates the concept. However, one might feel a knotted sensation, with or without fascial pain. The thin and thick muscle fibres are visible in the diagram. One can also see evenly spaced sections (sarcomeres) in the unaffected fibres. Affected fibres have small blob-like or bulging areas and uneven sarcomere spacing. In many respects, it is as if the sections in the affected fibres have become glued together. These bulges will change tensional forces within the affected muscle fibres and alter the pressure on surrounding structures. These microscopic changes result in a larger affected area or a trigger point (TrP). The tiny changes within the muscle fibres and the trigger points impact overall biotensegrity (see related articles later). Research has shown a relationship between trigger points and many types of headaches, and migraines (see the article on headache pain treatment). Equally, there is evidence for treating headaches and migraines with specific myofascial release techniques.

There are also different types of trigger points, latent and active. People tend to be aware of active trigger points, as one can feel muscular pain in an area. Such areas may refer pain pain to other parts of the body when pressed. One can also often feel the taut bands of tissue or what some might call "knots". Latent trigger points are also taut bands, though they tend not to cause pain or symptoms when pressed. Hence, one may be unaware of the presence of some trigger points. However, taut bands within tissue structures will subtly affect mobility in some shape or form. Trigger points can occur for many reasons, including trauma, habits, and more. The articles on Tissue Healing/Soft tissue repair, Adaptation, and Biotensegrity are hugely relevant.

Controversial history of Trigger Points

The concept of trigger points has a controversial history. Part of the issue is that TrPs are not visible to the human eye and historically could not be seen on imaging (X-rays, CT, MRI, and Ultrasound). Hence, General Medicine held the view that TrPs do not exist. However, it is possible to feel the telltale signs of TrPs within soft tissues. Soft tissue therapists and bodyworkers have known about TrPs, though under different names throughout the history of manual therapy. The presence or absence of pathology on an image may or may not indicate the root cause of a problem. Many people seeking routine imaging for unrelated conditions have disc or back-related pathologies and no symptoms. Equally, imaging for somebody with back pain may prove inconclusive as to the reason for symptoms (see article on Lower Back Pain). In other cases, imaging can highlight an obvious root cause. Diagnostic ultrasound and MRI imaging have improved hugely over the years and can now show more soft tissue structures. Research has even shown the presence of trigger points in the upper trapezius muscle of migraine sufferers using T2-weighted MRI (Sollmann et al., 2019). Magnetic resonance elastography (MRE) imaging has shown that trigger points are visible as areas of increased muscle stiffness (Qingshan et al., 2016). It has also been possible to indicate the presence of trigger points within muscle tissues using Diagnostic ultrasound (Dong-wook et al., 2011).

Besides changes in muscle stiffness, other ultrasound-based research has shown differences in vascular supply within trigger points (Sikdar et al., 2009). Changes in vascular supply are logical given that muscle fibres within trigger points are contracted and compressing areas of tissue. Other research using ultrasound and thermography has noted changes in the temperature of trigger points. Areas of trigger points are notably (warmer) and the immediate surrounding area (colder), again suggestive of vascular changes (Cojocaru et al., 2015). Biochemical analysis of active trigger points indicates a difference in biochemical makeup compared to normal tissues (Jay et al., 2008). Hence, although trigger points have a controversial history, it is now hard to refute the level of evidence for their existence.

Is massage good for myofascial pain?

Massage is a generic term covering a wide range of soft tissue therapy techniques. There are also huge variations in the levels of training, education, and experience of therapists within the industry. Some fascia massage therapy techniques may worsen symptoms, while others can be help. Anybody can call themselves a massage therapist with little to no training. Equally, many unique individual patient-specific factors can play a part in myofascial pain symptoms. Such factors are also likely to affect which types of myofascial release techniques are most suited to the patient's unique situation. Two people may have the same diagnosed condition but respond in different ways to a specific treatment method.

Does stretching make myofascial pain worse?

Some types of stretching techniques can worsen myofascial pain, be they self-stretching or from a therapist. Although myofascial trigger points are not the same as muscle spasms, some similarities exist. Both involve sections of muscle fibres, though a spasm is a more intense active contraction. A trigger point is more a section of stuck, contracted fibres. Stretching such areas may hurt at the time and then seem to provide some relief, only to be worse later. When stretching muscles, increased loads are placed on the muscle fibres and already tight trigger points. Which can result in micro trauma, leading to briefly reduced tension (pain). However, the body’s healing process then kicks in to repair the micro trauma, leading to inflammation and pain.

Do muscle relaxers work for myofascial pain?

The general medicine approach to myofascial pain may involve a mix of medications, including muscle relaxants, analgesics, antipsychotics, or anticonvulsants. Although such drugs may help manage pain levels and muscle spasms where relevant, they have a limited impact on the cause. However, such drugs may improve sleep quality for people who experience fascial pain syndrome or similar conditions such as fibromyalgia. Fascial pain can also greatly impact our quality of sleep, and research has shown direct links between sleep duration, quality, and our perception of pain. The less sleep we have, the higher we perceive pain levels to be, and often there is a cumulative effect in chronic cases.

How do I fix myofascial pain?

The best option is to see a professional in the first instance. There are many possible causes of myofascial pain. Taking the wrong approach can make things instantly feel worse or better and then worse later. There are still some self-care treatment options, but it is all guesswork if you don't know what you are treating or the limits of a fascia release technique. Although the internet may provide details of possible symptoms for various conditions, that is all it can do. A good, ethical professional will take a unique, detailed patient history, ask lots of questions, and perform tests to identify a root cause. There are occasions where using a specific technique is unwise or even dangerous (contraindicated).