Myofascial Pain Syndrome
What is myofascial pain syndrome?
Myofascial pain syndrome is a pain condition that affects your muscles and fascia. “Myo” means muscle and “fascial” means fascia. Your fascia is the thin, white connective tissue that is wrapped around every muscle.
Here’s an easy visual: If your body was an orange, your skin would be the outside orange peel, your muscles would be the fleshy orange fruit itself and the thin white membrane surrounding each orange segment would be the fascia. Fascia surrounds every level of muscle tissue —muscle fibers, single muscles and muscle groups.
Muscle pain isn't picky — it can strike anyone at any time in their life. Everyone from the mother carrying her child and the roofer laying shingles to the best friend helping lift boxes during a move can experience muscle pain. Unfortunately, for some people, this pain can be unbearable and it sticks around long after it should have faded. If you experience muscle pain that won't go away for a long period of time, it could be myofascial pain.
What does the fascia do?
Simply put, your fascia holds your muscles together, which allows them to contract and stretch. Fascia also provides a slick surface so that individual muscle fibers, single muscles and muscle groups can slide against each other without creating friction, tearing or causing other problems.
Actually, fascia is everywhere inside your body. Besides your muscles, all organs and blood vessels are connected to or surrounded by fascia. Fascia is a complex substance. It contains nerve endings. Scientists are still discovering all of the functions and roles of fascia.
What happens when a person experiences myofascial pain syndrome? How does it start?
Myofascial pain is a common syndrome. If you have myofascial pain syndrome, you may feel pain and tenderness in muscles in a certain area of your body. This pain and tenderness is often related to one or more “trigger points.” To the touch, trigger points feel like small bumps, nodules or knots in your muscle.
If you could look at a trigger point under a microscope, you’d see that it lies within a taut band, which is a tight strand of muscle that feels like a cord or tendon. The trigger point itself — the “knot” — is actually many nearby segments of muscle fibers that are stuck in the contracted state.
When muscle fibers are stuck in contraction, blood flow stops. If blood flow to the area stops, that area of muscle is not getting the oxygen it needs. Waste materials also build up in these fibers. This irritates the trigger point, which reacts by sending out a pain signal. Your brain responds by telling you not to use that muscle. Lack of use actually causes the muscle to tighten, become weak and it causes a loss in your range of motion. Muscles around the affected muscle have to work harder to do the work of the affected muscle. Trigger points can develop in these muscles too and add to the localized pain you feel.
Trigger points can develop in all muscles, and in many muscles at the same time. This is one of the reasons why it may seem like your pain in shifting or moving around. Trigger points can also be tricky in that pain can occur at the site of the trigger point (when lightly pressed) or cause pain in a nearby area. This is called referred pain.
How common is myofascial pain syndrome?
Myofascial pain occurs in about 85% of people sometime during their life. Even this high percentage may not be accurate. Myofascial pain is often underdiagnosed, misdiagnosed or overlooked because it’s hidden in another type of diagnosis such as headache, neck and shoulder pain, pelvic pain, limb pain or nerve pain syndrome.
Men and women are equally affected, though middle-aged inactive women are at the highest risk.
Where does myofascial pain syndrome most commonly occur?
Myofascial pain and trigger points can develop in any muscle in the body. However, the most commonly affected muscles are those in the upper back, shoulder and neck. These muscles include the:
- Sternocleidomastoid: This large muscle helps rotate your head to the opposite side and flexes your neck. It is located on both sides of your neck, running from your skull behind your ear area to your collarbone and breast bone.
- Trapezius: This large, broad, flat triangular back muscle tilts and turns your head and neck, shrugs and steadies your shoulders, and twists your arms. The muscle extends from the base of your skull to the middle of your back.
- Levator scapulae: This pair of strap-like muscles help raise and rotate each of your shoulder blades. They run from the first four cervical vertebra to the top edge of your shoulder.
- Infraspinatus: This triangular muscle, located on the back side of each of your shoulder blades, helps rotate and stabilize your shoulder joints. It’s one of four muscles of the rotator cuff.
- Rhomboids: This pair of upper back muscles pull your shoulder blades together when they contract and attach the upper limbs to your shoulder blade. These muscles run diagonally from the neck and chest vertebrae of the spine down to the back of the shoulder blades.
Symptoms and Causes
What are the symptoms of myofascial pain syndrome?
Symptoms are different for each person with myofascial pain syndrome. Sometimes the pain happens suddenly and all at once, and that is called a “flare-up” of symptoms. At other times it’s a constant, dull pain that sort of lingers in the background.
Symptoms of myofascial pain syndrome include:
- Pain that’s described as deep aching, throbbing, tight, stiff or vice-like.
- Trigger points (a small bump, nodule or knot in the muscle that causes pain when touched and sometimes when it’s not touched).
- Muscles that are tender or sore.
- Weakness in the affected muscle(s).
- Reduced range of motion in the affected areas (e.g., you may be unable to completely rotate your shoulder).
People with myofascial pain syndrome often have other health problems that coincide. Commonly reported problems include:
- Poor sleep.
- Stress, anxiety, depression.
- Feeling tired (fatigue).
What causes myofascial pain syndrome?
The jury is still out about all of the causes, contributing factors and exactly how the pain mechanism works.
Causes of myofascial pain syndrome include:
- Muscle injury.
- Muscle strain/repetitive muscle use (e.g. hammering).
- Muscle weakness/lack of muscle activity (e.g. a leg in a cast will not get enough movement).
- Poor posture.
- Working in or living in a cold environment.
- Emotional stress (can cause muscle tension).
- Pinched nerve.
Other factors thought to contribute to the development of myofascial pain syndrome include:
- Metabolic or hormonal problems such as thyroid disease or diabetic neuropathy.
- Vitamin deficiencies, including vitamin D and folate.
- Presence of chronic infections.
Is myofascial pain syndrome an autoimmune disease?
It is not. Inflammation of the muscle or fascia is not caused by your body’s immune system incorrectly attacking healthy cells. Examples of autoimmune diseases are lupus, type 1 diabetes, celiac disease and multiple sclerosis.
Diagnosis and Tests
How is myofascial pain syndrome diagnosed?
Myofascial pain syndrome is often an underdiagnosed and overlooked condition. It might be mistaken for a problem with your nerves, bones, ligaments or tendons — but it’s not. It’s a problem in your muscles.
There are no tests — no imaging tests, laboratory tests/ blood work, electromyography or muscle biopsy — that can diagnose myofascial pain syndrome. In addition, there are no visible signs, such as redness, swelling or unusual muscle warmth.
The best method your healthcare provider can use to detect this syndrome is to physically examine your muscles — to feel for the taut bands of muscles and then find the exact spots of tenderness. Finding and applying pressure to a trigger point will result in pain, felt at the immediate spot or in an area a short distance away (referred pain).
There are four types of trigger points:
- An active trigger point typically lies within a muscle and pressure to it results in local or regional pain.
- A latent trigger point has the potential to be active, but is dormant.
- A secondary trigger point is located in a muscle other than the one that holds the active trigger point. It can be irritated at the same time as the active trigger point.
- A satellite trigger point is one that becomes inactive because it overlaps with the region of another trigger point.
Questions your healthcare provider may ask to diagnose myofascial pain syndrome:
Your healthcare provider may order a few tests to rule out other conditions and ask you questions about your pain, including:
- Where do you feel the pain?
- How would you describe your pain?
- How often do you experience pain?
- What makes your pain better?
- What makes your pain worse?
- Have you had any recent injuries?
- Do your symptoms get better at certain times during the day?
- What does your work day look like (to look for activities in which there is muscle strain/repetitive motion)?
Your healthcare provider may check your gait (how you walk) and your posture to see if there is a balance of muscle use and look for signs of muscle weakness. You may also be asked about other health problems that can contribute to myofascial pain syndrome including how much and how well you sleep and if you feel stressed, anxious or depressed.
What’s the difference between myofascial pain syndrome and fibromyalgia?
Myofascial pain and fibromyalgia pain feel similar. Both have trigger points that emit pain. However, while myofascial pain is contained in one specific area (or, if more than one area, those areas are typically on the same side of the body), fibromyalgia pain is felt throughout the entire body. A patient with fibromyalgia has more trigger points, general pain, worse fatigue and sleep issues, headaches, an irritable bowel, a sensation of swelling and sometimes a burning, prickling or tingling feeling. Some researchers believe that myofascial pain syndrome can transition into fibromyalgia.
Management and Treatment
How is myofascial pain syndrome treated?
If you have myofascial pain syndrome, treatment will be more successful if you see your healthcare provider early after symptoms develop — before trigger points are established. Many treatments are available and your medical professional will likely use a combination of the following to manage your pain and restore affected muscles:
- Physical therapy (to strengthen, stretch and relax muscles).
- Dry needling (pushing thin needles into the trigger point to decrease tightness, increase blood flow and relieve pain).
- Wet needling / trigger point injections (using a needle to inject lidocaine [or other anesthetic] into the trigger point to relieve pain).
- “Spray and stretch” (spraying a trigger point with a coolant, then slowly, manually stretching the muscles).
- Low-level light therapy / cold laser (using lasers to stimulate the release of pain-relieving chemicals).
- Ultrasound (using sound waves to penetrate muscles).
- Transcutaneous electrical nerve stimulation (TENS therapy; pads are attached to your skin through which low-voltage electrical signals are sent).
- Acupuncture and relaxation therapies, including biofeedback and cognitive behavioral therapy (also good for improving sleep and reducing anxiety).
Prescription medication options may include:
- Pain-killing medications (analgesics).
- Nonsteroidal anti-inflammatory drugs (NSAIDs).
- Muscle relaxants.
- Sedatives to improve the quality of your sleep.
Treatments you can do at home include:
- Heat (as in a heating pad). Some people benefit from cold/ice packs.
- Exercise. Specifically weight-bearing exercises (to strengthen muscles), stretching exercises (to stretch muscles) and aerobic exercises (to get more oxygen into the muscles).
- Over-the-counter pain killers (such as acetaminophen) or NSAIDs (such as ibuprofen or naproxen). Don’t take these drugs if you are taking analgesics or NSAIDs prescribed by your healthcare provider.
- Relaxation techniques, including yoga (to stretch and relax muscles and decrease stress), breathing exercises and meditation.
- Dietary changes (avoid foods known to cause inflammation).
- Soaking in warm water.
The duration of myofascial pain syndrome varies from person to person. With treatment, it may go away after a day or a few weeks, but it can take longer for some. How fast your myofascial pain syndrome resolves depends on a number of factors, including:
- Your general health.
- Amount and quality of sleep.
- How vigilantly you obey your healthcare provider’s recommendations.
Who will treat/manage my myofascial pain syndrome?
Healthcare providers typically capable of managing myofascial pain syndrome include physiatrists (medical doctors who specialize in physical medicine and rehabilitation), pain management specialists, rheumatologists or orthopedists and physical therapists.
Can myofascial pain syndrome be prevented?
There are certain factors that can put you more at risk for developing myofascial pain syndrome. Managing these risk factors may not prevent you from developing the syndrome, but could help reduce the severity of the condition.
Many of the prevention suggestions to follow are also pain management strategies:
- Maintain proper sleep hygiene.
- Reduce your stress.
- Get exercise.
- Avoid preventable muscle injury. (e.g., is the shoulder bag/purse you carry too heavy and digging into the muscles in your shoulder?).
- Practice relaxation methods.
- Eat a healthy diet, such as the Mediterranean diet.
Some foods cause inflammation, and inflammation increases myofascial pain. Some foods to avoid include:
- Fried foods (French fries, for example).
- Dairy (milk, cheese, yogurt).
- Refined carbohydrates and foods with refined flour (pastries, white bread, pastas, breakfast cereals, pizza).
- Margarine (butter), vegetable oil.
- Sugary foods and beverages such as soft drinks.
- Red meat (burgers, steaks).
- Artificial sweeteners and general additives (“no sugar added” products, zero-calorie “diet” soft drinks, processed foods that include fruit, ice cream, candy).
- Processed meat (hot dogs, sausage).
Check your cupboards and your fridge. Empty it of any foods that will increase your myofascial pain syndrome symptoms.
Outlook / Prognosis
What can I expect if I have myofascial pain syndrome?
Each person’s pain — location of pain and severity — is unique. Pain can flare up from time to time or be ongoing and long lasting. Successful treatment usually requires finding healthcare providers you are comfortable with and following their treatment and management plan for reducing your pain.
How do I take care of myself?
Living with myofascial pain syndrome is uncomfortable at best, unbearable at worst. Take care of yourself by following your healthcare provider’s treatment plan and using your at-home remedies listed above. Exercise, change your diet, soak in warm water, get massages, etc. You’ll likely have to experiment to figure out what treatments work best to reduce your pain.
What questions should I ask my healthcare provider?
- Do I have myofascial pain syndrome or fibromyalgia?
- What medications will help with my myofascial pain syndrome?
- How did I get myofascial pain syndrome?
- Am I at risk for other pain conditions?
- What’s my treatment plan?
- Should I see a pain management specialist?
- What can I do to make myself feel better?
- How soon should I return to see you?
A note from Cleveland Clinic
Everyone experiences pain during their lifetime. But when that pain is unbearable or long-lasting, that’s when you need to consult your healthcare provider. Fortunately, most pain —including myofascial pain — can be reduced or eliminated with the right treatment! See your healthcare provider as soon as possible for evaluation and treatment.