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Myofascial trigger point pain

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Scientific Article
Myofascial Trigger Point Pain
Bernadette Jaeger, DDS

INTRODUCTION frequency of non-odontogenic toothache after endodontic

Musculoskeletal pain is the most common cause of treatment is as high as 50%.8 Unrecognized referred
chronic pain and suffering. Use of the term neuro- pain into the teeth from MFTrPs has led to numerous
musculoskeletal pain is actually more accurate as there is unnecessary root canals, apicoectomies and extractions.
evidence that the nervous system is fundamentally and Trigger points may be “active” or “latent.” They are
sometimes irreversibly altered with chronic painful input.1 considered active when the referred pain pattern and
This is certainly true in the neck, head and face, where the associated symptoms are clinically present and latent when
most common and entirely underappreciated non-articular they are not clinically present but can be elicited with
muscle disorder that causes chronic or persistent pain is palpation. Trigger points will vacillate between active and
myofascial pain due to trigger points, a chronic muscle latent states depending on the amount of psychological
pain disorder with referred pain, central sensitization, and stress the individual is under and the amount of muscle
abundant secondary central excitatory effects. overload being placed on the affected muscle.
Myofascial pain (MFP) is a referred pain syndrome MFP is poorly recognized as a cause of chronic pain by
associated with focally tender nodules called trigger almost all health care providers. Almost 30% of patients
points (TrPs) that are located in taut bands of skeletal presenting themselves with a complaint of pain in an
muscle. These are characteristically distant from the site internal medicine practice had MFP as a primary diagnosis.3
of pain and can only be diagnosed with systematic Over 80% of patients enrolled in an inpatient chronic pain
palpation of the soft tissue by a knowledgeable examiner.2 program also had MFP as the primary diagnosis.9 In a
Despite the muscular origins of the pain, the chief chronic orofacial pain setting, over 54% of patients have
complaint is NOT necessarily located in a muscle3,4 and myofascial pain as the primary diagnosis.10,11
may be associated with referred sensory, motor and The intensity of the referred symptoms from
autonomic symptoms, easily misleading the diagnostician. myofascial trigger points should not be underestimated.
The pain referral pattern for any particular trigger Visual Analog Scale pain ratings for myofascial pain in a
point is predictable and reproducible from patient to general medical practice were as severe or more severe than
patient and from one time to the next,2,5,6 helping the pain from other causes.3
clinician who has familiarity with the referral patterns to
identify the associated trigger points. Body maps detailing CLINICAL PRESENTATION
the referral patterns for almost all muscles have been In MFP, the presenting pain complaint is almost always a
developed and published.2,7 referred symptom, typically, but not exclusively, with a
For example, MFTrPs in the temporalis muscle will deep, dull aching or cramping quality. It is important to
refer pain into various maxillary teeth. Trapezius and understand that the referred pain site is NOT necessarily
masseter points will refer pain into the mandibular molars; in another muscle and, in the head and neck region, more
the anterior digastric into the lower anterior teeth. The often than not, patients present with complaints in various
structures of the head: the ears, eyes, sinuses, teeth, throat,
TMJs, temples, occiput, vertex and forehead; in short, any
structure of the craniofacial complex. Careful evaluation
B. Jaeger — Adjunct Associate Professor, of the site of the pain does not yield any findings of
Section of Oral Medicine and Orofacial Pain
pathologic change. In fact, any undiagnosed deep, dull,
UCLA School of Dentistry, Los Angeles, CA
Correspondence to: Dr. Bernadette Jaeger,
aching pain may be myofascial in origin and other pains
9400 Brighton Way, Suite 407, Beverly Hills, often have a contributing myofascial referred pain
CA 90210; E-mail: [email protected] component (Figs. 1-9).
Overlapping pain referral patterns from several
different trigger points will mimic certain unilateral and
bilateral primary headache disorders as well (Fig. 10).6

14 Alpha Omegan 106:1/2, 2013

Fig. 1 The solid red shows the
most common referred pain
pattern from a trigger point
(marked with “X”), located in
the upper part of the trapezius
muscle. The red stippling repre-
sents spillover pain patterns from
the same trigger point. (Reproduced Fig. 2A,B The solid red shows the most common referred pain pattern from trigger points (marked with “Xs”) locat-
with permission from: Travell JG, ed in the sternal and clavicular divisions of the sternocleidomastoid muscle respectively. The red stippling
Simons DG. Myofascial Pain and represents spillover pain patterns from the same trigger points. The clavicular (deep) division causes referred pain
Dysfunction: The Trigger Point that replicates frontal “tension headaches”. Trigger points in both heads of the SCM may also cause a variety of
Manual, Vol. 1, 2nd Ed., Williams & autonomic symptoms such as tearing, runny nose, ptosis, and postural dizziness. (Reproduced with permission from:
Wilkins, 1999.) Travell JG, Simons DG. Myofascial Pain and Dysfunction: The Trigger Point Manual, Vol. 1, 2nd Ed., Williams & Wilkins, 1999.)

Prolonged pain commonly causes associated symptoms the clinician to identify probable etiologic TrPs. In
due to the development of secondary physiologic sensory, chronic conditions, multiple TrPs often produce
motor, and autonomic effects.12.13 Associated sensory overlapping areas of referred pain (Fig. 10). The clinician
complaints may include tenderness in the referred pain site, must systematically examine all suspected muscles using
such as tenderness to palpation of the lateral poles of the the tip of the index finger to identify taut bands and focal
TMJ without concomitant pain with joint movement or tenderness. Some muscles such as the masseter,
limited range of jaw motion, scalp pain on brushing the hair, sternocleidomastoid and upper trapezius muscles can
or abnormal sensitivity of the teeth or gums.14 be palpated between the index finger and thumb with
Motor effects include increased EMG activity in the pincer-type palpation (FIG. 12,13). Most muscles
pain reference zone when the pain reference includes develop trigger points in consistent locations from patient
another muscle.12,13,15-17 This referred motor activity to patient, simplifying the examination process. Once a
frequently results in the development of “satellite” taut band is found, the TrP will be the most tender spot
myofascial trigger points in the secondary muscle, often along this band. It is necessary to apply 2 to 4 kg/cm2 of
creating additional referred pain and further confusing the pressure for at least 6 to 10 seconds to allow the referred
clinical picture (Fig. 11).16,17 pain pattern to develop. This is why the tip of the index
Autonomic changes such as pallor,12 sweating, finger is ideal: it is about 1cm in diameter. The fingernail
tearing, runny nose, ptosis, increased salivation, nausea should blanche.
and vomiting, as well as tinnitus are also seen.2,18 The examination may replicate the patient’s pain so
Psychological stress, cold weather, immobility, and precisely that there is no doubt about the diagnosis. If
overuse of the involved muscles will aggravate the pain. uncertainty exists, specific TrP therapies, such as “spray
Hot baths, rest, warm weather, and massage are alleviat- and stretch” or TrP injections, described below, may be
ing, but not curative. used diagnostically.
All head and neck muscles should be routinely
EXAMINATION examined in patients with a persistent pain complaint
Because the patient’s pain complaint is usually distant keeping in mind that cervical muscle myofascial TrPs
from the muscle containing the guilty TrP,2,19 familiarity (e.g., upper trapezius or sternocleidomastoid) (Fig. 11) are
with the typical referral patterns for each muscle will help almost always the “key” trigger points, their secondary

Myofascial Trigger Point Pain — Jaeger 15

Fig. 3A,B,C,D The solid red shows the essential referred pain pattern
from various trigger points (marked with “Xs) located in the superficial Fig. 4A,B,C,D Patterns of referred pain and tenderness from various
and deep fibers of the masseter muscle, several of which include either trigger points (marked with “Xs”) located in the temporalis muscle.
upper or lower posterior teeth. Deep masseter muscle trigger points are Please note referral to the maxillary teeth. (Reproduced with permission from:
also associated with tinnitus. The red stippling represents spillover pain Travell JG, Simons DG. Myofascial Pain and Dysfunction: The Trigger Point Manual,
patterns from the same trigger points. (Reproduced with permission from: Vol. 1, 2nd Ed., Williams & Wilkins, 1999.)
Travell JG, Simons DG. Myofascial Pain and Dysfunction: The Trigger Point Manual,
Vol. 1, 2nd Ed., Williams & Wilkins, 1999.)

referred motor effects feeding and perpetuating “satellite”

trigger points in the masticatory muscles (e.g., the
masseter and temporalis).2,13

CAUSES
Myofascial TrPs may be “primary” or “secondary.”
When primary, the history usually includes a clearly
identifiable injury or “macrotrauma” that preceded the
onset of the pain, such as a fall, motor vehicle accident, or
even prolonged jaw opening at the dental office.
Alternatively, myofascial TrPs also develop with chronic
muscle overuse or “microtrauma” due more insidious
factors such as poor posture and body mechanics, or
repetitive motion activities.
Secondary myofascial TrPs develop in response to any
prolonged painful process or disease such as inflammatory
disorders of the TMJ, chronic ear infections, persistent
toothaches, migraine, cancer or any other chronic painful
Fig. 5A,B,C Referred pain pattern (red) and the responsible trigger point condition. The primary noxious stimulus (for example, a
(X) in the medial pterygoid muscle. Note that the pain may be deep inside third molar infection) causes a protective spinal reflex
the mouth, (hard and soft palate, throat, pharynx,), and also in the TMJ
and deep in the ear. (Reproduced with permission from: Travell JG, Simons DG. response (myospasm or trismus). Initially the increased
Myofascial Pain and Dysfunction: The Trigger Point Manual, Vol. 1, 2nd Ed., motor activity is dependent on the primary pain source, but
Williams & Wilkins, 1999.) if the primary pain problem persists long enough, the motor

16 Alpha Omegan 106:1/2, 2013

Fig. 6 Referred pain pattern (red) from trigger points (X) found in the
superior and inferior heads of the lateral pterygoid muscles. These
trigger points cannot be directly palpated and may be examined using
protrusion or opening against resistance. If these maneuvers cause
referred pain, the lateral pterygoid has trigger points. (Reproduced with per-
mission from: Travell JG, Simons DG. Myofascial Pain and Dysfunction: The Trigger
Point Manual, Vol. 1, 2nd Ed., Williams & Wilkins, 1999.)

Fig. 7A,B,C Referred pain pattern from trigger points (X) in the posterior
and anterior bellies of the digastric muscles, respectively. Note the
referral from the anterior belly into the lower teeth. (Reproduced with
permission from: Travell JG, Simons DG. Myofascial Pain and Dysfunction:
The Trigger Point Manual, Vol. 1, 2nd Ed., Williams & Wilkins, 1999.)

Fig. 8 Location of trigger

points (X) and pain referral
patterns from (A) the orbital
portion of the orbicularis spontaneous electrical activity and localized presence of
oculi muscle, (B) the zygo- endogenous substances such as bradykinin, serotonin,
maticus major muscle and prostaglandins and others, the structure and exact
(C) the right platysma pathophysiology of TrPs remains elusive.
muscle. (Reproduced with Clinically, pressure algometry studies have
permission from: Travell JG,
Simons DG. Myofascial Pain and documented that TrPs are truly focally tender areas in
Dysfunction: The Trigger Point muscle; pain with palpation is not due to generalized
Manual, Vol. 1, 2nd Ed., Williams muscle tenderness.20-22 In fact, non-TrP sites in subjects
& Wilkins, 1999.) with MFP are no more tender than muscle sites in people
with no myofascial pain.20,22
activity becomes an independent, self perpetuating primary In 1993, myofascial pain was established as a
pain source in the muscle (a trigger point) that persists even “neuro”-muscular pain with an electromyographical
after the primary pain source (the infected third molar) is marker when careful monopolar needle EMG evaluation
removed. The pain from this secondary myofascial trigger revealed spontaneous electrical activity at TrP sites, while
point typically refers pain back to the same site as the initial similar EMG evaluation of the muscle surrounding the
primary pain causing the clinician to believe that there is TrP was normal.23 Furthermore, this spontaneous
persistent pathology, too often resulting in additional electrical activity was significantly higher in subjects with
unnecessary treatments. clinical pain due to active TrPs than in subjects without
Secondary myofascial pain needs to be identified and clinical pain who had latent or no TrPs.23, 24
treated to reduce unnecessary treatments and also to Psychological stress, which causes increased
reduce pain and improve response to other therapies when sympathetic output, was shown to increase the spontaneous
the initiating source is also a chronic pain such as electrical activity recorded from TrPs, whereas the EMG
migraine or post herpetic neuralgia. activity of adjacent non-TrP sites remained unchanged.25
These data parallel the clinical observation that emotional
PATHOGENESIS stress activates or aggravates pain from TrPs.
Despite the comparative ease of clinical identification In 2005, using a unique in vivo microanalytical
of TrPs, and advances in research identifying their technique, active myofascial trigger point sites were

Myofascial Trigger Point Pain — Jaeger 17

Fig. 9A,B Referred pain from a trigger point (X) in the buccinator muscle
will typically be located in the cheek and deep in the subzygomatic
portion of the jaw. (Reproduced with permission from: Travell JG, Simons DG.
Myofascial Pain and Dysfunction: The Trigger Point Manual, Vol. 1, 2nd Ed.,
Williams & Wilkins, 1999.)

Fig. 10 Overlapping pain referral patterns (red) from myofascial trigger

shown to have significantly higher concentrations of points in various masticatory and cervical muscles produces typical
several factors including bradykinin, calcitonin gene-related clinical presentations consistent with unilateral or bilateral migraine
without aura and/or tension-type headaches. (Reproduced with permission
peptide, substance P, serotonin, and norepinephrine than from: Travell JG, Simons DG. Myofascial Pain and Dysfunction: The Trigger Point
latent or non trigger point sites. In addition, pH was Manual, Vol. 1, 2nd Ed., Williams & Wilkins, 1999.)
significantly lower in the active TrP sites than the other
two groups.26,27 Interestingly, concentrations of these
substances decreased after impaling the trigger point with
a needle and eliciting a twitch response. (A twitch
response is a characteristic feature of trigger points that CASE HISTORY #1
has been well studied in rabbits.28-30 It represents a spinal A 47-year-old male presented with a complaint of acute
cord reflex resulting in brief contraction of the taut band left temporomandibular joint (TMJ) pain. He had a history
containing the trigger point when it is stimulated with of chronic painless bilateral TMJ osteoarthrosis. On
snapping palpation or needle penetration.) examination jaw opening was 41mm with tenderness to
When the musculoskeletal pain becomes chronic, the palpation over the left TMJ. He is instructed in palliative
constant bombardment of the nervous system with painful care including rest, soft diet, gentle hinge axis jaw
afferent stimuli results in central neuroplastic changes stretching and seven days of non-steroidal anti-
that are sometimes irreversible. This is why the term inflammatory medications. He returned a week later
neuro-musculoskeletal pain may be more accurate, as it saying that the severe symptoms had improved, but he still
reflects the neural changes that inevitably accompany had “persistent aching of the left jaw” along with a
ringing in his left ear, especially with clenching. Active
chronic musculoskeletal pain.1 “Active MTrPs function as
range of motion of the jaw had increased from 41 to 47mm
dynamic foci of peripheral nociception that can initiate,
and the left TMJ was now NON-tender to palpation. Why
accentuate, and maintain central sensitization and chronic
did he still have pain? Was it due to the osteoarthrosis?
pain states. Continuous nociceptive input from MTrPs can The less astute clinician may still direct his or her
increase excitability of dorsal horn neurons [causing energies toward treating the TMJs, especially since there
allodynia and hyperalgesia].”1 At the same time this was documented osteoarthrosis bilaterally, worse on the
continuous bombardment of the dorsal horn allows left. However, the source of the pain was now from
diffusion of substance P and CGRP to other levels of the myofascial TrPs and not the joint. Palpation of the
spinal cord, allowing latent or ineffective synapses to be masseter muscle, particularly the deep fibers, reproduced
activated or “unmasked” — resulting in new receptive the patient’s current symptoms, including the ringing in
fields and referral of pain.19,31 his left ear (Fig. 3D). Trigger points in this part of
The following cases are typical scenarios involving the masseter muscle have also been reported to cause
myofascial pain that may provide a diagnostic challenge unilateral tinnitus and accounted for the high-pitched
for the general dentist. sound the patient complained of with clenching.

18 Alpha Omegan 106:1/2, 2013

Fig. 11 Examples of key trigger points (red Xs) and corresponding satellite
trigger points (black Xs) in other muscles. Satellite trigger points typically
develop in muscles found in the referred pain sites of the key trigger points.
In this figure, trigger points in the upper trapezius muscle and sternal head
of the sternocleidomastoid muscle are shown inducing the development
of satellite trigger points in the masseter and temporalis muscles. These
satellite trigger points in the masticatory muscles may, in turn, refer pain in
their usual and customary pattern. This is very common after whiplash injury
and the resultant “jaw” pain is often misdiagnosed as a “TMJ” problem.
Treatment, however, must be directed at the key trigger points for
appropriate resolution of the pain. (Reproduced with permission from: Travell JG,
Simons DG. Myofascial Pain and Dysfunction: The Trigger Point Manual, Vol. 1, 2nd
Ed., Williams & Wilkins, 1999.)

Treatment must be directed at rehabilitating the masseter Fig. 12 Cross-sectional drawing depicting the flat palpation technique for
muscle and not at the asymptomatic joint. trigger points. This technique is useful for muscles that can only be
approached from one side, such as the temporalis or medial pterygoid.
CASE HISTORY #2 (A) The skin is pushed to one side and (B) the fingertip slides across the
A 40-year-old woman sustained a luxation injury to muscle fibers to feel the cord-like texture of the taut band rolling beneath
tooth #9 when her face hit the steering wheel during a it. (C) The skin is pushed to the other side when palpation is complete.
motor vehicle accident. The tooth was repositioned and This same movement performed vigorously, is snapping palpation. Once
the trigger point is located, 2-4 kg/cm2 of pressure should be applied for
stabilized by her regular dentist, but the pain did not
at least 10 seconds to allow the pain referral pattern to develop.
subside. After six months she had a root canal treatment. (Reproduced with permission from: Travell JG, Simons DG. Myofascial Pain and
The pain persisted. A subsequent apicoectomy was Dysfunction: The Trigger Point Manual, Vol. 1, 2nd Ed., Williams & Wilkins, 1999.)
equally ineffective in relieving the pain. The tooth was
extracted. A deep aching pain persisted. As a result, her
oral surgeon prescribed 800mg Ibuprofen and Vicodin.
She went to see a neurologist who placed her on
gabapentin with no improvement. What could possibly be temporalis muscle (Figs. 4A, 11). Treatment must be
causing her persistent pain? primarily directed at the TrPs in the cervical muscles
This is an example of key trigger points in the to reduce TrP activity in the temporalis muscle.
sternocleidomastoid and upper trapezius muscles from the Unfortunately, this patient lost her upper anterior incisor
initial whiplash injury, along with prolonged dental pain, because the dentists she saw were unaware of myofascial
inducing secondary myofascial trigger points in the pain as a potential cause of this type of persistent pain,

Myofascial Trigger Point Pain — Jaeger 19

 Fig. 14 Sequence of steps to use when stretching and spraying any
muscle for myofascial trigger points using the upper trapezius as an
example. 1. Patient must be supported in a comfortable and relaxed
position. The patient must be WARM. Placing a hot pack on the stomach
will help maintain a warm body temperature. This is important because
the patient and their muscles must be warm in order to allow a muscle
to stretch. 2. One end of the muscle should be anchored. Here we see
the patient anchoring the acromioclavicular end of the trapezius by
placing their hand under their thigh. 3. Skin is sprayed with three to four
parallel sweeps of vapocoolant spray running the length of the muscle
toward and including the referred pain areas. Too many sweeps of
Fig. 13 Cross-sectional drawing depicting pincer palpation of a taut band
spray too close together will cause a drop in the temperature of the
at a trigger point. Pincer palpation is used for muscles that can be picked subcutaneous tissues and the muscle itself. This is NOT desired. The
up between two digits, such as the sternocleidomastoid and the upper spray is simply a distraction. It is NOT designed to chill or cool the mus-
trapezius. (A) Muscle fibers surrounded by thumb and fingers in a pincer cle! 4. Pressure should be applied to the free end of the muscle to take
grip. (B) Hardness of the taut band is felt as the muscle is rolled between up the slack. This can be done while spraying or after applying the vapo-
the fingers. (C) The taut band sometimes will escape from the pincer coolant spray. 5. Rewarm the skin with your hands or a hot pack and
grasp due to a local twitch response. Once the trigger point is located, repeat steps 2,3,4 and 5 until maximum range of motion is achieved. 6.
2-4 kg/cm2 of pressure should be applied for at least 10 seconds to Follow with several cycles of full active range of motion of the treated
allow the pain referral pattern to develop. (Reproduced with permission from: muscle. This helps the brain to register the newly restored muscle length.
Travell JG, Simons DG. Myofascial Pain and Dysfunction: The Trigger Point Manual, (Reproduced with permission from: Travell JG, Simons DG. Myofascial Pain and
Vol. 1, 2nd Ed., Williams & Wilkins, 1999.) Dysfunction: The Trigger Point Manual, Vol. 1, 2nd Ed., Williams & Wilkins, 1999.)

20 Alpha Omegan 106:1/2, 2013

and, despite any clear pathology, chose instead to focus on true TMJ capsulitis, pulpitis, a primary headache disorder
a presumed dental origin for the pain. or chronic deafferentation pain, must also be treated
or managed.
TREATMENT
Acute myofascial pain that involves only one or two SPRAY AND STRETCH
muscles or has been present for less than four months can Spray and stretch is a highly successful technique for the
be “treated” with stretching, trigger point injections treatment of myofascial TrPs that uses a vapocoolant
and/or deep tissue massage and stretch. However, chronic spray (Gebauer, Co.; Cleveland, OH) to facilitate muscle
myofascial pain, pain involving trigger points in several stretching. Muscle stretching has been shown to reduce
muscles, with concomitant psychological factors and of the intensity of referred pain and TrP sensitivity in
over four months duration requires “management.” In this patients with myofascial pain.35 Vapocoolant is applied
regard it is important to understand that, when present, slowly in a systematic pattern over the muscle being
cervical muscle TrPs (“key” TrPs) almost always perpetuate stretched and into the pain reference zone (Fig. 14). This
TrPs in the masticatory muscles that belong to the technique and alternatives to vapocoolant are described in
referred pain area (satellite TrPs) and must be treated for detail in Travell and Simons Trigger Point Manual.2
successful management.
The most important aspect of managing myofascial TRIGGER POINT INJECTIONS
pain is the identification and control of causal and Needling of TrPs with or without injection of solution has
perpetuating factors. This requires taking a careful also been shown to be helpful in reducing TrP activity to
history to identify mechanical, psychological, nutritional, allow stretching.33,35,36 Dry needling or injection of “key”
and hormonal perpetuating factors, followed by patient myofascial trigger points has been shown to reduce
education to correct the these factors, and specific home activity and tenderness in related satellite TrPs.13,37
stretching exercises for the involved muscles. Therapeutic Clinically it is essential to first determine the exact
techniques such as “spray and stretch,” voluntary contract- location of the trigger point with palpation, stabilize the
release, TrP pressure release, and TrP injections32,33 trigger point between two fingers, and elicit a twitch
are useful adjunctive techniques that usually facilitate response with needling.38 The twitch response confirms
the patient’s recovery once most perpetuating factors that the trigger point has been impaled and the clinical
are controlled. result will be profound. Just injecting randomly and
Mechanical factors that place an increased load on flooding the area with local anesthetic is NOT effective.
the muscles, such as chronic poor posture and body Injection must always be followed by stretch.2
mechanics are the most common perpetuating factors. Trigger point injection in the absence of a home program
Teaching patients good posture and body mechanics will that addresses relevant perpetuating factors will only
go a long way in reducing referred pain from myofascial provide temporary relief.
TrPs, especially in the head and neck region.34 Although dry needling is effective, use of a local
Psychological stress, which has been shown to cause anesthetic reduces post-injection soreness.35 Use of 0.5%
TrP activation,25 or depression that lowers pain thresholds, procaine or 0.5% lidocaine is recommended due to their
will also contribute to and perpetuate MFP. Sleep minimal myotoxic effects. Longer-acting amide local
disturbance and inactivity are common perpetuating anesthetics or local anesthetics containing epinephrine
factors too. Teaching patients simple relaxation, stress and cause hyaline degeneration of the muscle.39 Randomized
time management skills, is invaluable in controlling the controlled studies looking at the efficacy of botulinum toxin
associated increased TrP irritability. Mild depression and in comparison to dry needling, saline or other placebo
sleep disturbance can be treated with low doses of solutions in trigger point injections have shown that,
tricyclic antidepressant drugs and a structured exercise/ overall, Botox was no more effective than dry needling or
activation program. Having patients perform their muscle other solutions.40,41
stretching exercises slowly with long slow deep breaths
and stretching on the exhalation, will allow the sympa- SUMMARY
thetic nervous system to calm down at the same time as Myofascial trigger point pain is an extremely prevalent
they are stretching out the muscles containing the TrPs. cause of persistent pain disorders in all parts of the body,
Other perpetuating factors include metabolic, not just the head, neck, and face. Features include deep
endocrine, or nutritional inadequacies that affect muscle aching pain in any structure, referred from focally tender
metabolism.2 Patients should be screened for general good points in taut bands of skeletal muscle (the trigger points).
health and nutrition, and referred to their physician for Diagnosis depends on accurate palpation with 2-4 kg/cm2
management of any systemic abnormalities. In secondary of pressure for 6-10 seconds over the suspected trigger
MFP, the primary concomitant painful disorder, such as a point to allow the referred pain pattern to develop. In the

Myofascial Trigger Point Pain — Jaeger 21

head and neck region, cervical muscle trigger points (key 19. Travell JG, et al. The myofascial genesis of pain. Postgrad Med 1952;
11: 425.
trigger points) often incite and perpetuate trigger points
20. Reeves JL, Jaeger B, Graff-Radford SB. Reliability of the pressure
(satellite trigger points) and referred pain from masticatory algometer as a measure of trigger point sensitivity. Pain 1986;
muscles. Management requires identification and control 24: 313.
of as many perpetuating factors as possible (posture, body 21. Vecchiet L, Giamberardino MA, de Bigontina P, Dragani L.
Comparative sensory evaluation of parietal tissues in painful and
mechanics, psychological stress or depression, poor sleep non-painful areas in fibromyalgia and myofascial pain syndrome. In:
or nutrition). Trigger point therapies such as spray and Gebhart GF, Hammond DL, Jensen TS (eds). Proceedings of the 7th
stretch or trigger point injections32 are best used as adjunc- World Congress on Pain. Progress in pain research and management.
tive therapy. ❏ Vol 2. Seattle: IASP Press, 1994: 177-249.
22. Hong C-Z, Chen Y-N, Twehous DA, et al. Pressure threshold for
referred pain by compression on the trigger point and adjacent areas.
REFERENCES J Musculoskeletal Pain 1996; 4(3): 61-79.
1. Shah JP, Gilliams EA. Uncovering the biochemical milieu of 23. Hubbard DR, Berkoff GM. Myofascial trigger points show
myofascial trigger points using in vivo microdialysis: an application spontaneous needle EMG activity. Spine 1993; 18: 1803.
of muscle pain concepts to myofascial pain syndrome. J Bodyw Mov 24. Kuan TS, Hsieh YL, Chen SM, Chen JT, Yen WC, Hong CZ. The
Ther 2008; 12(4): 371-384. Epub 2008 Aug 13. myofascial trigger point region: correlation between the degree of
2. Simons DG, Travell JG, Simons LS. Travell and Simons’ myofascial irritability and the prevalence of endplate noise. Am J Phys Med
pain and dysfunction. The trigger point manual. Vol 1. Upper half of Rehabil 2007; 86(3): 183-189.
body. 2nd ed. Baltimore: Williams and Wilkins, 1999. 25. McNulty WH, Gevirtz RN, Hubbard DR, Berkoff GM. Needle
3. Skootsky SA, Jaeger B, Oye RK. Prevalence of myofascial pain in electromyographic evaluation of trigger point response to a psycho-
general internal medicine practice. West J Med 1989; 151: 157. logical stressor. Psychophysiology 1994; 31: 313.
4. Couppe C, Torelli P, Fuglsang-Frederiksen A, Andersen KV, Jensen 26. Shah JP, Danoff JV, Desai MJ, et al. Biochemicals associated with
R. Myofascial trigger points are very prevalent in patients with pain and inflammation are elevated in sites near to and remote from
chronic tension-type headache: a double-blinded controlled study. active myofascial trigger points. Arch Phys Med Rehabil 2008; 89(1):
Clin J Pain 2007; 23(1): 23-27. 16-23.
5. Sikdar S, Shah JP, Gilliams E, Gebreab T, Gerber LH. Assessment of 27. Shah JP, Phillips TM, Danoff JV, Gerber LH. An in vivo micro-
myofascial trigger points (MTrPs): a new application of ultrasound analytical technique for measuring the local biochemical milieu of
imaging and vibration sonoelastography. Conf Proc IEEE Eng Med human skeletal muscle. J Appl Physiol 2005; 99(5): 1977-1984. Epub
Biol Soc 2008; 2008: 5585-5588. 2005 Jul 21.
6 Jaeger B. Tension Headaches and Myofascial Pain. In: Fricton J, 28. Fricton JR, Auvinen MD, Dykstra D, Schiffman E. Myofascial pain
Dubner R (eds). Advances in orofacial pain and TM disorders. New syndrome: electromyographic changes associated with local twitch
York: Raven Press, 1994. response. Arch Phys Med Rehabil 1986; 66: 314.
7. Travell JG, Simons DG. The Trigger Point Manual, Vol. 2. The Lower 29. Hong C-Z, Torigoe Y, Yu J. The localized twitch responses in
Extremities. Baltimore: Williams and Wilkins, 1992. responsive taut bands of rabbit skeletal muscle fibers are related to the
8. Nixdorf DR, Moana-Filho EJ, Law AS, McGuire LA, Hodges JS, reflexes at spinal cord level. J Musculoskel Pain 1995; 3: 15.
John MT. Frequency of nonodontogenic pain after endodontic 30. Hong C-Z, Torigoe Y. Electrophysiological characteristics of
therapy: a systematic review and meta-analysis. J Endod 2010; 36(9): localized twitch responses in responsive taut bands of rabbit skeletal
1494-498. muscle. J Musculoskel Pain 1994; 2: 17.
9. Rosomoff HL, Fishbain DA, Goldberg M, Santana R, Rosomoff RS. 31. Mense S. Referral of muscle pain. New aspects. Am Pain Soc J 1994;
Physical findings in patients with chronic intractable benign pain of 3: 1.
the neck and/or back. Pain 1989; 37(3): 279-287. 32. Graff-Radford SB, Reeves JL, Jaeger B. Management of head and
10. Fricton JR, Kroening R, Haley D, Siegert R. Myofascial pain neck pain: the effectiveness of altering perpetuating factors in
syndrome of the head and neck: a review of clinical characteristics of myofascial pain. Headache 1987; 27: 186.
164 patients. Oral Surg 1985; 160: 615. 33. Sola A. Trigger point therapy. In: Roberts JR, Hedges JR, editors.
Clinical proceedings in emergency medicine. 2nd ed. Philadelphia:
11. Fricton JR. Atypical orofacial pain disorders: a study of diagnostic
WB Saunders, 1991: 828.
subtypes. Curr Rev Pain 2000; 4: 615-623.
34. Komiyama O, Kawara M, Arai M, et al. Posture correction as part of
12. Travell J, et al. Effects of referred somatic pain on structures in the
behavioural therapy in treatment of myofacial pain with limited
reference zone. Fed Proc 1944; 3: 49.
opening. J Oral Rehabil 1999; 26: 428.
13. Carlson CR, Okeson JP, Falace DA, et al. Reduction of pain and
35. Jaeger B, Reeves JL. Quantification of changes in myofascial trigger
EMG activity in the masseter region by trapezius trigger point
point sensitivity with the pressure algometer. Pain 1986; 27: 203.
injection. Pain 1993; 55: 397. 36. Lewit K. The needle effect in the relief of myofascial pain. Pain 1979;
14. Travell J. Temporomandibular joint dysfunction: temporomandibular 6: 83.
joint pain referred from muscles of the head and neck. J Prosthet Dent 37. Hsieh YL, Kao MJ, Kuan TS, Chen SM, Chen JT, Hong CZ.Dry
1960; 10: 745. needling to a key myofascial trigger point may reduce the irritability
15. Lewit K. Manipulative therapy in rehabilitation of the locomotor of satellite MTrPs. Am J Phys Med Rehabil 2007; 86(5): 397-403.
system. 2nd ed. Oxford: Butterworth Heinemann, 1991. 38. Hong C-Z. Lidocaine injection versus dry needling to myofascial
16. Simons DG. Referred phenomena of myofascial trigger points. trigger point. The importance of the local twitch response. Am J Phys
In: Vecchiet L, Albe-Fessard D, Lindblom U, Giamberardino MA Med Rehabil 1994; 73: 256.
(eds). New trends in referred pain and hyperalgesia. Pain research and 39. Benoit PW. Microscarring in skeletal muscle after repeated exposures
clinical management. No 27. Amsterdam: Elsevier Science, 1993: to lidocaine with epinephrine. J Oral Surg 1978; 36: 530.
341-357. 40. Qerama E, Fuglsang-Frederiksen A, Kasch H, Bach FW, Jensen
17. Hsieh YL, Kao MJ, Kuan TS, Chen SM, Chen JT, Hong CZ. Dry TS.A double-blind, controlled study of botulinum toxin A in chronic
needling to a key myofascial trigger point may reduce the irritability myofascial pain. Neurology 2006; 67(2): 241-245
of satellite MTrPs. Am J Phys Med Rehabil 2007; 86(5): 397-403. 41. Ho KY, Tan KH. Botulinum toxin A for myofascial trigger point
18. Rocha CA, Sanchez TG. Myofascial trigger points: another way of injection: a qualitative systematic review. Eur J Pain 2007; 11(5):
modulating tinnitus. Prog Brain Res 2007; 166: 209-214. 519-527. Epub 2006 Oct 27. Review

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