Myo-fascial pain syndromes
This section will interest anyone who may be complaining of the remarkably common myofascial pain that originates in muscle. Pain and tenderness are characteristically referred from myofascial trigger points (TPs) that are located in muscle remote from the site of the pain.
This is confusing to the patient and misleading to the practitioner.
Despite its cryptic origin, referred pain from TPs can be devastatingly severe. Fortunately, pain due to myofascial TPs can be identifiable by careful history and skillful physical examination; it is quickly responsive to
physical medical management in the absence of serious perpetuating factors.
Skeletal muscle is the largest organ of the body. It makes up nearly half of body weight. Muscles are the motors of the body. They work with and against the ubiquitous
spring of gravity. Together with the cartilage, ligaments, and intervertebral discs, they serve as the body's mechanical shock absorbers. Each one of the approximately 500 skeletal muscles is subject to acute and chronic strain. Each muscle can develop myofascial TPs
and has its own characteristic pattern of referred pain.
Acute cases of a single-muscle myofascial pain syndrome (MPS) can often be treated readily and effectively when the specific muscle harboring the TP responsible for
the pain is promptly recognized. Prompt resolution of an acute single-muscle MPS prevents the needless persistence
of disabling pain. Perpetuating factors can increase irritability of muscles, leading to the propagation of TPs and increasing the distribution and severity of pain. This
progression leads, in time, to the complex disaster, chronic pain.
A myofascial TP is defined as "a hyperirritable spot, usually within a taut band of skeletal muscle or in the muscle's fascia, that is painful on compression and that can give rise to characteristic referred pain, tenderness,
and autonomic phenomena. The term myofascial pain syndrome is used here either
with a specific or a collective meaning. A single-muscle MPS refers to the signs and symptoms caused by active TPs in one specific muscle. Generically, MPS as used in
the title, refers to the diagnosis and the signs and symptoms associated with one or many single-muscle myofascial pain syndromes due to TPs.
Confusion developed over the past century because successive research authors recognized different, often overlapping,
aspects of pain due to myofascial TPs and sometimes included features of other conditions. Many authors used general terms applicable to the whole body, such as fibrositis (which has accrued multiple meanings through the
years), fibromyalgia, muscular rheumatism (used in Europe for nearly a century), nonarticular rheumatism, myogeloses (muscle gelling), Muskelharten (muscle
hardenings) in Germany, interstitial myofibrositis in America, myalgia or myalgic spots in England, and osteochrondrosis in Russia.
Other authors used terms applicable to one region of the body without noting its muscular origin or its commonality with other parts of the body. Examples include: occipital neuralgia, tendinitis, tennis elbow,16 chest wall syndrome, scapulocostal syndrome, lumbago, and
sciatica. Each of these terms may be used to identify at least two conditions, one of which is often MPS due to TPs.
Schematic of sarcomeres that are of equal length in normal muscle fibers as compared with the likely distribution of unequal
sarcomere lengths in the fibers of a palpable taut band passing through a trigger point. Shortened sarcomeres in the region of the trigger point would increase the tension in the fascicles of the taut band and restrict the stretch range of motion of the muscle. The ropy sensation produced by rubbing the tip of the palpating finger across the muscle fibers of a palpable taut band at the TP can be
explained by contracture.
Palpation of the muscle reveals increased muscle tension
due to tautness of the palpable band.
Schematic of a cycle of events that could maintain sarcomere shortening. The process would begin with release of ionized calcium
from ruptured sarcoplasmic reticulum. Vigorous contractile activity increases local metabolic'demand. Vigorous local sarcomere shortening compromises local circulation producing anemic hypoxia, which could compromise the adenosine triphosphate (ATP) energy supply of the sarcoplasmic reticular compartment. The resulting failed calcium pump of the sarcoplasmic reticulum (SR) would leave the ionized calcium free to maintain the spontaneous contractile activity.
The movie above demonstrates the skill of myo-articulation. This a method which combines an incremental stretching of the muscle and tendon whilst fixating the muscle at the various trigger points or tight zones along its length.
Above all these techniques require great palpatory skill and a deep knowledge of the structures and tissue behaviours involved.
It is important that therapists do not not 'damage' the muscles due to heavy, sudden and irritating technique application. All pain is NOT gain.
There are various general factors involved in the pathological process.
2. Previous strains
4. Tissue type
5. Reflex threshold of an individual
6. Underlying medical conditions
8. Mineral deficiencies
9. Reflex sympathetic dystrophies
10. Joint injuries
11. Spine tension patterns
12. Lack of sleep
The most common precipitating cause of problems in the forearm and hand appears to be long, intense periods of work. For example working 14 hours a day for two weeks on an IT project or rehearsing for a performance in the case of musicians.
This period makes the deep, stabilising muscles gain tone (hypertonus). These muscles tend not to relax when not in use.. Thus tension can build in them until the 'last straw' comes along and the muscle seizes up with pain.
Very minor repetitive activities such as using your thumbtip to navigate your mobile phone can cause problem in the little thumb flexor tendons. this can proceed to osteo-arthritic changes in the local joints.
Any reduction of the range of movement to the joints will be a major contributing factor. These need to be mobilised, their ligaments stretched and the joint space to be increased via various techniques.