Four types of myofascial pain and their different pathology

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The majority of clinical pain is myofascial. It has been reported that 85% of back pain and 54.6% of chronic headache and neck pain is myofascial pain.8 We currently categorize myofascial pain into four types:

1. Trigger points

2. Muscle spasm

3. Muscle tension

4. Muscle deficiency

Each type of myofascial pain requires a different dry needling technique and will follow its own healing pattern. Unfortunately many clinicians are trained to concentrate on trigger points to the exclusion of the other types of myofascial pain. Such narrow emphasis is contrary to the clinical realities and reflects a lack of understanding of the pathophysiolology of myofascial pain.9

Myofascial pain includes various types of soft tissue dysfunction. An analysis of such soft tissue pain involves at least the following types of pathology:

1. Tissue inflammation

2. Tissue contracture

3. Microcirculatory deficiency, which includes blood and lymphatic circulation, ischemia and/or edema

4. Trophic deficiency, including tissue degeneration

5. Tissue adhesion

6. Scarring of tissue

7. Biomechanical imbalance of the musculoskeletal system, including improper posture.

Soft tissue pain, especially chronic pain, always involves all these dysfunctions and clinicians should treat all of them to achieve the optimum level of pain relief and recovery of tissue function. For example, when a joint is out of alignment, it causes both the attached and opposing muscle groups to be shortened or lengthened, which compromises the surrounding neuromuscular structures and connective tissues. Muscle spasm, muscle tension, and increased sympathetic output ensue, resulting in soft tissue pain, and the development of trigger points, edema, ischemia, and tissue degeneration. If the condition continues to the point of becoming chronic, tissue adhesion and the formation of scar tissue will occur and central sensitization will follow.

Myofascial trigger points are small, circumscribed, hyperirritable foci in muscles and fascia, often found within a firm or taut band of skeletal muscles.10 Trigger points may also occur in ligaments, tendons, joint capsules, skin and periosteum. They have been described as tender nodes of degenerated tissue that can cause local and radiating or referred pain. The extent of the area of referred pain has been defined as the zone of reference. Please note that referred pain patterns do not correspond to dermatomal, myotomal or scle-rotomal patterns and that the patterns of referred pain from a particular trigger point are not always the same. Myofascial pain symptoms presented by a patient may include pain, muscle weakness, decreased joint motion, and paresthesia, as well as autonomic symptoms like sweating, lacrimation, localized vasoconstriction, and pilomotor activity.

Trigger points show dynamic features. They can be asymptomatic (latent) or symptomatic (active). Primary trigger points develop independently and are not related to trigger-point activity elsewhere.

Secondary trigger points develop in neighboring and anatagonistic muscles as the result of stress and muscle spasm. Satellite trigger points appear in the area of referred pain as the result of persistent resting motor unit activity.

Muscle spasm is the involuntary contraction of muscle caused by acute or chronic trauma, excessive tension, or visceral disorder. An untreated spasm will lead to decreased blood flow in the muscle and edema in the tissue, which initiates a vicious cycle of more muscle spasm and pain.

Muscle tension is defined by Hans Kraus as "a prolonged contraction of a muscle or muscle groups beyond functional or postural need."11 Muscle tension may have postural, emotional, or situational causes. Improper posture or a negative emotional experience (e.g., unresolved anger or psychological stress) can cause muscle tension and result in muscle pain.

Muscles are considered deficient when they are weak or stiff and proper posture and muscle function cannot be maintained. Muscle deficiencies can be a source of pain and make a person prone to injury. The fact that weakened abdominal muscles can cause back pain is a typical example of this causal connection.

Clinicians should keep in mind that chronic pain may involve all types of soft tissue dysfunction and varied techniques should be incorporated to achieve maximal healing and restoration of function. There is considerable clinical evidence that focusing only on pain and ignoring the healing of soft tissue can be disastrous for athletes.

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