ArticlePDF AvailableLiterature Review

Understanding of myofascial trigger points

  • Shanghai Ciyuan Rehablitation Hosipltal & Shanghai University of Sport

Abstract and Figures

To investigate the current practice of myofascial pain syndrome (MPS) including current epidemiology, pathology, diagnosis and treatment. The data analyzed in this review were mainly from relevant articles without restriction on the publication date reported in PubMed, MedSci, Google scholar. The terms "myofasial trigger points" and "myofacial pain syndrome" were used for the literature search. Original articles with no limitation of research design and critical reviews containing data relevant to myofascial trigger points (MTrPs) and MPS were retrieved, reviewed, analyzed and summarized. Myofascial pain syndrome (MPS) is characterized by painful taut band, referred pain, and local response twitch with a prevalence of 85% to 95% of incidence. Several factors link to the etiology of MTrPs, such as the chronic injury and overload of muscles. Other factors, such as certain nutrient and hormone insufficiency, comorbidities, and muscle imbalance may also maintain the MTrP in an active status and induce recurrent pain. The current pathology is that an extra leakage acetylcholine at the neuromuscular junction induces persistent contracture knots, relative to some hypotheses of integration, muscle spindle discharges, spinal segment sensitization, ect. MTrPs can be diagnosed and localized based on a few subjective criteria. Several approaches, including both direct and supplementary treatments, can inactivate MTrPs. Direct treatments are categorized into invasive and conservative. This review provides a clear understanding of MTrP pain and introduces the most useful treatment approaches in China.
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Chinese Medical Journal 2014;127 (24) 1
DOI: 10.3760/cma.j.issn.0366-6999.20141999
Department of Rehabilitation, Guangxi National Hospital, Nanning,
Guangxi 530001, China (Zhuang XQ and Tan SS)
Department of Sport Medicine and Pain Clinic, Center of Sports
Rehabilitation, School of Sport Science, Shanghai University of
Sport, Shanghai 200438, China (Huang QM)
Correspondence to: Huang Qiangmin, Department of Sport Medicine
and Pain Clinic, Center of Sports Rehabilitation, School of Sport
Science, Shanghai University of Sport, Shanghai 200438, China (Tel:
86-21-51253357. Email:
This study was supported by grant from Ministry of Education and
the provincial open fund of Sports University of Shanghai, and Key
Laboratory of Exercise and Health Sciences (Shanghai University of
Conict of interest: none.
Review article
Understanding of myofascial trigger points
Zhuang Xiaoqiang, Tan Shusheng and Huang Qiangmin
Keywords: myofacial pain syndrome; myofascial trigger points; etiology; pathology; diagnosis; treatment
Objective To investigate the current practice of myofascial pain syndrome (MPS) including current epidemiology,
pathology, diagnosis and treatment.
Data sources The data analyzed in this review were mainly from relevant articles without restriction on the publication
date reported in PubMed, MedSci, Google scholar. The terms “myofasial trigger points” and “myofacial pain syndrome”
were used for the literature search.
Study selection Original articles with no limitation of research design and critical reviews containing data relevant to
myofascial trigger points (MTrPs) and MPS were retrieved, reviewed, analyzed and summarized.
Results Myofascial pain syndrome (MPS) is characterized by painful taut band, referred pain, and local response twitch
with a prevalence of 85% to 95% of incidence. Several factors link to the etiology of MTrPs, such as the chronic injury
and overload of muscles. Other factors, such as certain nutrient and hormone insufciency, comorbidities, and muscle
imbalance may also maintain the MTrP in an active status and induce recurrent pain. The current pathology is that an extra
leakage acetylcholine at the neuromuscular junction induces persistent contracture knots, relative to some hypotheses of
integration, muscle spindle discharges, spinal segment sensitization, ect. MTrPs can be diagnosed and localized based on
a few subjective criteria. Several approaches, including both direct and supplementary treatments, can inactivate MTrPs.
Direct treatments are categorized into invasive and conservative.
Conclusion This review provides a clear understanding of MTrP pain and introduces the most useful treatment
approaches in China.
Chin Med J 2014;127 (24):
2014-1999 P7
Most pains are often associated with myofascial pain
syndrome (MPS), which is caused by myofascial
trigger points (MTrPs). The prevalence of MTrPs was
reported by 85% of patients visiting a tertiary pain clinic1
and even 95% of people with chronic pain disorders
involving MTrPs.2 As many as 9 million people in
the United States suffer from such illness.3 MTrPs are
hyperirritable spots located at the muscle, fascia, or
tendinous insertions, in which the local pain is perceived
as deep and aching in palpable taut band, referred pain in
the same or a distant position, and local twitch responses
(LTRs) in forceful palpation and/or needling.4,5 All types of
population can suffer from MPS, especially individuals who
often participate in sports6,7 and those who experience age-
related degeneration.8,9 The pain of almost all orthopedic
disorders is involved in this category.10,11 Numerous studies
have conrmed that several pain syndromes are associated
with the activation of MTrPs in the skeletal muscles.12-14
In clinical practice, MTrPs can be classified into either
latent or active.4,6 Active MTrPs are both tender and
spontaneously painful, whereas the latent ones are tender
without spontaneous pain.4,6,15 This pain syndrome can be
primary MTrPs from an old muscle injury or secondary
from other disorders.5,16 The pain from MTrPs can be
alleviated through various clinical therapies, which render
them inactive.4,5,17
Etiology of MTrPs
In studying MTrPs in newborn infants and young children,
a latent trigger point can be identied in some muscles after
the age of 4 years.18,19 Therefore, the onset of MPS depends
on whether or not the latent MTrP exists. The etiology of
MTrP often includes precipitating and perpetuating factors
(Table 1), which can concurrently exist in a patient.
Various traumas, such as contusions, sprains, and strains,
may induce acute MTrPs. The onset of these trigger points
may be initiated by repetitive micro-injuries, including the
overloading and overuse of muscles, which often heighten
chronic MTrPs.20,21 According to the principle of muscle
fiber size, a low load force acting on a joint or spine for
a long time can cause myalgia.21 When maintaining a
continuous static loading, type I smaller muscle bers are
initially recruited and then rolled off. Hence, this type of
muscle fibers, which are called Cinderella fibers, can be
Chin Med J 2014;127 (24)
easily injured.20,21 MTrPs frequently occur in this type of
muscle bers that have more ratios within the muscles for
postural maintenance.22 In this event, the upper trapezius
and levator scapulae can also readily acquire injury; in these
two muscles, MTrPs can often be generated.23 The aging
degeneration of musculoskeletal system, with the gradual
loss of myofascial exibility, is vulnerable and eventually
results in active MTrPs.9,24 A certain compression or non-
bacterial inflammation of the spinal column may irritate
the nerve root, causing the sensitization of the spinal
segment and active MTrPs in the innervated muscles.25,26
Emotional stress can increase sympathetic output and sleep
deprivation, considerably increasing muscle tension and
fatigue, including anxiety and insomnia, and decreasing the
pain threshold.4,5 Endocrine and metabolic deciencies and
thyroid and estrogen insufficiencies can irritate the latent
MTrPs to be active.4,5 Meanwhile, nutritional deficiencies
from vitamins and minerals, especially B12, C, folic acid,
iron, and calcium, may perpetuate the activeness and
recurrence of MTrPs.5,27 Moreover, chronic infections, such
as viral, parasitic, and fungal infection, may perpetuate the
activity of MTrPs.5,28
Skeletal muscles may be classified into two categories
according to their functions, dynamics, and postural
requirements.22,29,30 Accordingly, a sedentary lifestyle, in
which one spends more time in static postures than in
motion, can progressively inhibit dynamic muscles and
cause tightness and inexibility in postural muscles. In this
event, a biomechanical imbalance between the dynamic and
postural muscles may gradually develop. When a muscle
generates MTrP, the local mechanical balance worsens.30
Moreover, if the pain of the muscles is untreated for a long
time or is repeatedly activated, a chronic biomechanical
imbalance is maintained and secondary MTrPs gradually
develop in other muscles. Thereafter, an entire joint
dysfunction (e.g., periarthritis of the shoulder) may possibly
Pathology of MTrPs
The taut bands of muscles are common contracture
fascicles with MTrPs and TrPs.5,12 Huang et al32 observed
a number of contracture knots gathered together in the
longitudinal section of MTrPs. This observation conrmed
the assumption of Simons et al. regarding the hypothetical
sketch of contracture knots of MTrPs.5,33 In the observed
cells, the mitochondrial numbers decreased and the nucleus
of the cells moved into the middle.34
Based on these results of both clinical and morphological
features, MTrPs are speculated as a complex, that is, central
MTrPs (cMTrPs) and attachment MTrPs (aMTrPs).5,33
cMTrP is a painful nodule along taut band in the muscle
belly (Figure 1). Meanwhile, aMTrPs are also painful
places in the combination between muscle and its tendon
as well as the tendon attachment to the bone, which often
link to an enthesiopathy and tenosynovitis;35 the typical
aMTrP appears as a cyst of the tendon sheath and narrow
Studies on MTrPs in the previous century reported a high
frequency of spontaneous electrical potentials (SEA)5,33,37
and contracture knots in the skeletal muscles of animals
and human.38 Simons et al5 speculated that acetylcholine
(ACh) abnormally increased at the neuromuscular junction
in MTrPs. Local contracture knots were generated by
injecting an anti-acetylcholine esterase into a local normal
muscle.38 Therefore, the hypothesis of extra-leakage ACh
at the nerve endings in motor endplates was proposed.5,33,38
The literature review indicated that several theories are
related to this occurrence on MTrPs.
Hypothesis of integration
This hypothesis posits that an extra leakage of ACh at
the nerve endings causes a failure in the local motor
endplate function. In particular, the leakage excites the
ACh receptors of postsynaptic membrane, produces local
continual depolarizations, and prompts the sarcoplasmic
reticulum to release large amounts of calcium.5,33 These
procedures result in the sustained contracture knots of
muscle fibers and increased muscle tone by shortening
sarcomeres.5,15,39,40 In this condition, the muscle bers at the
nerve endings become cramped, causing local ischemia and
hypoxia with increasing local metabolic requirement.5,33
Meanwhile, the concentrations of serotonin, histamine,
bradykinin, and substance P increase in the surroundings
of the contracture knots,41 aggravate the local ischemia, and
sensitize the afferent nerves. These occurrences result in
MTrP pain and local sympathetic symptoms.5,42 Moreover,
these pathological changes induce a feeling of local cold
(vasoconstriction),43 anxiety, and mental stress.4,5,44
Table 1. Etiological factors of MTrPs
Precipitating factors Perpetuating factors
Various traumas Endocrine and metabolic deciencies
Repetitive micro injuries and
overload injuries
Nutritional deciencies (certain vitamins
and elements), anemia
Mechanical injuries Chronic Infection
Ageing structural degeneration of
bones and joints
Chronic biomechanical imbalance
Certain compression or non-bacteria
Inammation of spinal column
Repetitive bad posture, bad working
Emotional stress
Figure 1. Structural graphic of myofascial trigger point. cMTrP
refers to the central MTrP and aMTrP denotes the attachment
MTrP. A muscle directly attaches to a bone (right side) and via a
tendon to the bone (left side).
Chinese Medical Journal 2014;127 (24) 3
A dysfunctional motor endplate in MTrPs has numerous
small loci,45,46 including the sensory and motor loci,5,47 such
as “sensitive locus” and “active locus”.48 The sensitive
locus is a receptor for pain and local twitch response,
and is also a site for the sensitization of nerve endings,
which distribute throughout all muscles.48 Active loci are
contracture knots, which can be recorded as the SEA with
high frequency of low amplitude potentials.5,34,45,48,49 Among
these potentials, some intermittent abnormal high amplitude
potential bursts emerge.32,34
Hypothesis for muscle spindle discharges
Conducting electromyography (EMG) studies allows
the identification of two types of independent electrical
potentials at the location of MTrPs; one type is the low
potentials with amplitude of approximately 10 µV to 80
µV, and the other is the high potentials with amplitude of
approximately 100 µV to 600 µV with both normal and
abnormal wave shapes.32,34,37 Several scholars deemed that
the high spike of abnormal discharges recorded from the
location of MTrPs may emerge from the muscle spindle
stimulated by an excited sympathetic nerve.37,42 This
hypothesis implies that the MPS symptoms are likewise
associated with autonomic nervous irritation.
Hypothesis of central or spinal segment sensitization
Central theories or spinal segment sensitization focus on
developing the central sensitization of the spinal segment
dorsal and motor horn cells through the persistent noxious
input if MPS is left untreated.5,50,51 Whether central
sensitization causes MTrPs or merely perpetuates and
amplifies them remains an issue. When active MTrPs
exist, a constant nociceptive input into the dorsal horn
emerges, thus increasing an excitability of neuron in
the dorsal horn and enlarging neuron receptors pool to
perpetuate the altered motor control strategies. This central
sensitization increases muscle tone and chronic mechanical
imbalance.52,53 Therefore, this hypothesis explains why the
referred pain and local response twitch can occur in the
MTrPs controlled by the spinal cord.
Hypothesis of scar and brosis in the muscles
Several scholars in the early 20th century considered scar
brosis as the cause of a string of indurations in muscles.54
Chinese scholars discovered some biochemical changes,
including a high concentration of bradykinin, serotonin,
and substance P, in these soft tissues and their surroundings
after acute or chronic injuries.33 In the repairing period,
the scar, adhesion, and spasm of muscles or soft tissues, as
well as a microcirculation block in the region of lesions,
were formed due to several pathological and physiological
processes.55 Based on this theory, Chinese doctors obtained
positive effects on treating numerous pain syndromes
using the needle mini-knife therapy.55 This hypothesis was
later substituted by other hypotheses on MTrPs due to the
lack of further studies on tissue morphology and electrical
Relationships between MTrPs and acupoints
Some scholars recently investigated 255 MTrPs and
compared them with the traditional acupoints.56,57 They
reported that 92% of the trigger points corresponded to the
acupoints in the anatomical position, 79.5% were related to
the acupoints in clinical indications, and 76% of the referred
pain distributions of MTrPs corresponded to the meridian
running. However, the proposition of Trevell and Simons
on trigger points is different from the acupoints map of
the traditional Chinese medicine. The location of trigger
points is based upon different individuals, and the referred
pain relies on the severity of the disorder. From a clinical
viewpoint, the trigger points that are diagnosed today must
be assumed similar to the ancient Chinese acupoints, which
were developed before the Song dynasty.58 Prior to the
Song dynasty, the acupoints were localized according to the
running of meridian similar to the case of human fascia.58
Diagnosis and localization of MTrPs
Once the MTrPs are activated, the patient can feel a local
pain and musculoskeletal dysfunction with autonomic
nervous symptoms and a series of other syndromes in the
joints or visceral organs.5 In the previous century, Trevell
realized that a certain pain area complained by a patient
was not always at the site where the pain originated. This
pain was a referred pain associated with MTrPs.59 Other
than the referred pain, a hard nodule is painful with a
palpation in approximately 2 kg to 6 kg compression.60 This
nodule is a sensitive area along the taut band that is often
associated with an intolerable pain or obvious soreness and
swell feeling.39 Once the latent MTrPs become activated,
the referred pain in some MTrPs emerges in another
place, not following a distribution of nerve running.3 9
While puncturing the MTrPs, a muscle jump (local twitch
response), withdrawal response, or needling referred pain
can be elicited by needling,5,39,61 indicating that the MTrPs
localized by a palpation is certain.
An effective treatment of MPS requires the inactivation of
MTrPs. Therefore, accurately localizing the MTrPs plays
an important role in treating MPS. According to some
subjective criteria and distributions of referred pain for
diagnosis provided by Simons et al, the clinical diagnosis of
MTrPs is typically based on the following steps:5,39,61
Diagnosis of affected muscles
Histories and physical examinations are helpful in
treating MPS. In particular, a clinician or therapist must
determine which muscle of the patient is affected and
which precipitating and perpetuating factors are related
to such pain. The symptoms and signs of MPS generally
depend upon the location of the MTrPs in the affected
muscles, such as headache and dizziness in neck muscles,13
dysfunction and pain of shoulder in the muscles of
surrounding scapula and humerus,7 and menorrhalgia
in abdominal and pelvic muscles.62,63 In most cases, the
symptom of fear of cold in the local region often emerges.
In this event, the range of motion of the affected muscles
is limited, and muscle strength is weak. Moreover, active
MTrPs, particularly the MTrPs in the neck muscles, may
Chin Med J 2014;127 (24)
interfere with the sleeping pattern or condition of the
Localization of MTrPs
A guidance of the rough distribution of the referred pain
from MTrPs, which was sketched by Simons et al,5 and
subjective criteria elucidated that (a clear referred pain and
tenderness with the muscle tension and palpable nodule,
local twitch response)5,64 the trigger point in the affected
muscle can be localized by a finger of inspector. A deep
pressure may sometimes induce a pressing referred pain.60
Each MTrP has its own characteristic scope of referred
pain, but it may not completely run in accordance with the
sketch produced by Simons et al5. In numerous cases, the
MTrP may be secondary to chronic orthopedic or other
Objective indicators
MTrPs can be examined through EMG with the
spontaneous electrical activity65 and by employing magnetic
resonance imaging and ultrasound with a thickening
The diagnosis of chronic myalgia is another issue that is
regarded as the biomechanical imbalance of neuromuscular
system in local region.64 Therefore, a clinician or therapist
is required not only to understand the characteristics of
the active trigger points in a muscle but also to carefully
check for the presence of other MTrPs in the antagonistic
or synergistic muscles. In the treatment, all MTrPs should
be considered. Muscle jump and referred pain of needling
indicate the correct location of MTrPs found by clinician or
Treatment of MTrPs
The MTrP treatment aims to inactivate the trigger points.
Multidisciplinary approaches, which comprise direct
approaches, inactivate the MTrPs, consequently decreasing
the muscle tone. Meanwhile, supplementary approaches
correct the biomechanical imbalances of the local
muscles. These approaches include needling, stretching,
psychiatric therapies, massage and hand manipulation,
chiropractic technique, and medications (Table 2). Several
approaches not only directly inactivate the MTrPs but also
consolidate the effects of other therapies as supplementary
treatments.66,67 Chiropractic and exercise approaches may
be applied to correct the biomechanical imbalance of the
musculoskeletal system.
Needling approach
Several needling techniques focus on the MTrPs. If the
trigger points can be accurately punctured, the local twitch
responses of the muscle (a muscle jump) or needling
referred pain occur.5,45
Wet needling
This approach comprises two methods. The first method
involves repeatedly puncturing a syringe needle (gauge
5) into the MTrPs. Once the LTRs with a strong sour
or swelling pain are elicited at a local region, 0.1 ml to
0.2 ml of local anesthetics may be injected to relieve
this sore feeling.68 The beneficial effect of this therapy
is the lessening of the acute or chronic pain of MTrPs.68
Meanwhile, the second method of this approach involves
a slight addition of an anesthetic agent (0.3 ml to 0.5 ml),
which is simply injected into the location of a muscle jump.
A local light massage is subsequently administered to allow
the anesthetics to infiltrate the location of the MTrPs.5,69
This approach can considerably avoid the local needling
pain, but its effect is momentary compared with the former.
Hence, the treatment process of this approach must be
repeated. This method is appropriate for some patients who
are overly sensitive and unable to tolerate a needling pain.
Dry needling
This approach comprises several procedures.70,71 First,
if a patient can endure a needling pain, the MTrPs are
repeatedly punctured using an acupuncture needle
0.3 mm to Ф 0.5 mm) to elicit the LTRs. Second, once a
muscle jump emerges, a needle remains at the location
of the MTrPs for 10 to 15 minutes as an acupuncture
therapy in China. Third, the “Shanzen” is performed. The
“Shanzhen”, which is a treatment practiced in China, is
often associated with the concurrent application of local
hand manipulation and massage. During this approach,
massage and manipulation are initially applied. However,
if some painful nodules and areas are localized and do not
dissipate with the massage, a needle with Ф 0.3 mm is used
to puncture it for a few times into the location of the MTrPs
in a rapid back and forth movement, better with a local
twitch response.
Miniscalpel-needle therapy
This therapy is highly popular and effective in China.
However, this approach is merely employed to cut the
thickening structures in the location of aMTrPs to loosen
the adhesion and contracture hardening capsule of the joint
and ligament.55,71
Massage and hand manipulation
Different from the traditional massage, massage and
hand manipulation require the location of MTrPs.72
Table 2. Treatment approaches of MTrPs
Directly inactive approaches Supplementary approaches
Wet needling: injection
inltration, repeatedly puncturing
Dry needling: acupuncture way,
repeatedly puncturing, fast needling
“Shanzhen”; Miniscalpel-needle
Muscle stretching
Exercise therapy
Massage and manipulation
Chiropractic technique
Physiatric therapies supercially
laser, ultrasonic wave, infrared light,
microwave, electrical stimulation,
Thermalism, et al.
Cold with muscle stretching
Massage and manipulation
Physiatric therapies deeply
Laser, ultrasonic wave, infrared
light, microwave, shockwave,
electrical stimulation, etc.
Paracetamol or muscle relaxants,
NSAID drug or COX-2 selective inhibitors,
Narcotic analgesics, Adjuvant analgesics,
antidepressants or anticonvulsants, Chinese
traditional medicine (jinkui shengqiwan and
different di-huang-wan)
Chinese Medical Journal 2014;127 (24) 5
Focusing on MTrPs, all varieties of massage skills may be
applied and are often incorporated with chiropractic and
muscle stretching therapies. If the result of this approach
is ineffective, the needling approach can be applied.
Moreover, massage approaches can serve as supplementary
treatments, which may decrease the uncomfortable response
of needling.
Psychiatric therapies
Deep laser, ultrasonic wave, microwave, infrared light, and
shockwave therapies are recommended to treat MTrPs.36,73
All of these approaches must focus on the trigger points,
rather than on a referred pain. Hence, a psychiatric therapist
must understand the process of localizing MTrPs.
Muscle stretching
Correctly performing muscle stretches can theoretically
relieve a local muscle pain.66,67 However, performing only
muscle stretches may be ineffective in inactivating the
MTrPs of a patient, who has been affected by the pain for a
long period. Therefore, under this approach, the best means
of treating MTrPs is by initially putting the needle, followed
by the application of massage and muscle stretching.
Moreover, this approach requires patients to perform
self-stretching of their affected muscles as homework.
Meanwhile, for some patients, a therapy that uses a cool
spray or cold compress on a certain local region, combined
with muscle stretching, may also obtain a desirable effect to
relieve muscle pain.5,74 Stretching technique is categorized
into two types, namely, self-stretching75 and a stretching
technique that is manipulated by a therapist.66,67
Chiropractic technique
A minor change in spine alignment may induce muscle
tension with pain to some extent. The chiropractic
technique can correct a minor change in the spinal
position.76 The misalignment of the spine can be restored
to the sequences of a normal spinal column. Therefore, the
chiropractic technique can prevent the recurrence of MTrPs
in the muscles that surround the spine or its other parts.
Exercise therapy
Exercise is essential in correcting muscle imbalance to
obtain good therapeutic results after needling the MTrPs
or administering other treatments together with muscle
stretching. Restoring the normal length and flexibility of
the muscles and increasing their endurance are important.
Exercise therapies are classified into two types, namely,
stretching (see above) and strengthening, particularly core
strengthening and stabilization.29 If they are begun too
early, strengthening exercises may cause more pain, spasm,
and tightness. Therefore, these exercises must only begin
after the pain has been fully relieved and must progress to
develop endurance with repetitive low resistance.
Paracetamol or muscle relaxants may be prescribed
for mild myofascial pain. If these medications are
ineffective, non-steroidal anti-inammatory drugs or cyclo-
oxygenase-2 selective inhibitors may be used, particularly
if the myofascial pain has a local inammatory component.
Narcotic analgesics may sometimes be necessary for
severe myofascial pain. Adjuvant analgesics, such as
antidepressants and anticonvulsants, may be added if the
myofascial pain has a neuropathic component. Somnolence,
which is an attending effect of muscle relaxants, narcotic
analgesics, antidepressants, and anticonvulsants, may be
useful at night for patients with emotional stress and sleep
deprivation. However, relieving pain through the sole use
of medication for a long period is not desirable.
Deficiencies of some vitamins, elements, and hormones
have been associated with musculoskeletal pain and are
thus considered a perpetuating factor. In particular, this
factor often meets a deciency of vitamins B12, D, C, B1,
B6, iron, calcium hypothyroidism, and growth hormone,
which have to be prescribed to the patients.77-79
In Chinese traditional medicine, the musculoskeletal pain is
considered a deciency of “Qi” in kidney. Therefore, two
empirical prescriptions, namely, the Jinkui Shengqi Wan
and different Dihuang Wans, may improve the deciencies
of “Qi” in kidney to help improve a condition of the entire
body of patients.
Summary and conclusion
MPS is a disorder of the musculoskeletal system with
MTrPs in muscles with a prevalence of 85% to 95% of
mobidity. MPS is characterized by painful taut band,
referred pain, and local response twitch. In MTrPs, an
extra leakage of acetylcholine at the neuromuscular
junction induces persistent contracture knots, forming into
a palpable painful nodule, relative to some hypotheses of
integration, muscle spindle discharges, spinal segment
sensitization, scar and fibrosis in the muscles. MTrP is
a complex of both cMTrP and aMTrP. Several factors
link to the etiology of MTrPs; the most commons are the
chronic injury and overload of muscles. Other factors,
such as certain nutrient and hormone insufficiency, some
comorbidities, and muscle imbalance may also maintain the
MTrP in an active status and induce recurrent pain. MTrPs
can be diagnosed and localized based on a few subjective
criteria. In particular, the effective treatment of MPS
depends on a correctable localization of MTrPs and on the
experience of a clinician and therapist. Several approaches,
including both direct and supplementary treatments, can
inactivate MTrPs. Direct treatments are categorized into
invasive and conservative. All treatment approaches must
focus on the location of MTrPs with local twitch responses
and strong sore and swelling pain. This review provides a
clear understanding of MTrP pain and introduces the most
useful treatment approaches in China.
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(Received August 21, 2014)
Edited by Ji Yuanyuan
... 58,60 In contrast, OA at L1-L4 evoked pain that remained more localized in the lumbar and gluteal regions. 59,61 Therefore, the findings of latent and active MTrPs only in the spine OA may somehow be associated with neck spine OA. Pedersini et al 42 did not report whether MTrPs was latent or active in individuals with thumb carpometacarpal OA. ...
... This may be likely because of the lack of a complete understanding of each pathophysiology condition (OA and MPS) which limits the assumptions of possible mechanisms underpinning the MPS and MTrP's coexistence with OA. Nevertheless, OA and MPS seem correlated with age 25,61,70,71 and often coexist clinically. 23,72 Thus, it is possible that their coexistence may be related to physiological mechanisms of aging such as inflammaging, metabolic syndrome, and chondrocyte senescence. ...
Objective: This review aimed to identify, summarize, and appraise the evidence supporting the coexistence of myofascial pain (MPS) and trigger points (MTrP) in osteoarthritis (OA), and the effectiveness of MTrPs treatments in OA-related pain and physical function outcomes. Methods: Three databases were searched from inception to June 2022. We included observational and experimental studies to fulfill our 2 study aims. Two independent reviewers conducted 2-phase screening procedures and risk of bias using checklist tools for cross-sectional, quasi-experimental, and randomized control trials. Patient characteristics, findings of active and latent MTrPs in relevant muscles, treatments, and pain and physical function outcomes were extracted from low-risk bias studies. Results: The literature search yielded 2898 articles, of which 6 observational and 7 experimental studies had a low bias risk and the data extracted. Active MTrPs in knee OA patients was more evident in the quadriceps and hamstring muscles than in healthy individuals. Dry needling on active MTrPs improved pain and physical function in the short term compared with sham treatment in hip OA patients. In knee OA, dry needling on latent or active MTrPs improved pain and functional outcomes compared with sham needling but did not result in better pain and physical outcomes when combined with a physical exercise program. Discussion: The presence of active versus latent MTrPs seems to be a more sensitive discriminating feature of OA given that latent is often present in OA and healthy individuals. Dry needling on active MTrPs improved pain and physical function in the short term compared with sham treatment in hip OA patients. However, the small sample size and the few number of studies limit any firm recommendation on the treatment
... MPS is characterized by the expression of deep, dull, and poorly localized aches or pains localized in the myofascial tissues (Gerwin 2001). Symptoms of MPS often are increased by activity, stress, anxiety, cold, and poor posture (Zhuang et al., 2014). Trauma, macro trauma-contusion and sprain, micro trauma-chronic muscle overuse migth cause myofascial tigger points (Yap, 2007). ...
Aims: The aim of the study is to investigate the short term effects of radial shock-wave therapy combined with self-stretching exercises in patients with myofascial pain syndrome (MPS). Methods: 30 patients with chronic cervical myofascial pain (4 males, 26 females) aged between 25 to 57 years (with average age 41,20±10,23 years) were included the study. Participants were divided into two groups as intervention group (n=15) and control group (n=15). Patients in intervention group received radial shock-wave application one times a week for six weeks and home based stretching exercises. Patients in control group (CG) received home based stretching exercises. Rest and activity pain (Visual Analog Scale), pressure pain threshold (PPT), cervical range of motion (CROM) and disability (Neck Disability Index) were assessed at baseline and after the treatment. Results: Rest and activity pain, pain pressure threshold, cervical range of motion and disability scores improved after the treatment in the intervention group (p<0,05). On the other hand, it was not found significant changes any parameter after the treatment in the control group (p>0,05) except activity pain (p<0,05). Conclusion: The results of the study showed that radial shock-wave therapy combined with stretching exercises was more effective at reducing pain, increasing cervical range of motion and improving disability level than stretching exercises in patients with chronic cervical myofascial pain. The clinical trial number of the study is NCT04814017. Several previous studies showed that ESWT has effects on musculosceletal diseases but the pathophysiology is not clear. There are several studies showing the effectiveness of focused ESWT for patients diagnosed MPS. , there are two studies which investigated the effect of radial shock-wave therapyin MPS but there is not significant differences.The combined treatment including radial shock-wave therapy and self-stretching exercise would be useful for physical therapists treating in a clinical settings.
... About one-third of the patients with musculoskeletal disorders meet the diagnostic criteria for this syndrome [2]. The prevalence of this disorder is up to 85% [3]. MPS is characterized by sensitive areas called trigger points [1,4,5]. ...
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Introduction: The purpose of the present study was to investigate the effects of single-session intramuscular electrical stimulation (IMES) on pain and dysfunction following active trigger points in the upper trapezius muscle. Materials and Methods: Volunteers (30 females) with active trigger points in the upper trapezius muscle were randomly divided into two IMES and placebo groups. For the IMES group, a needle was inserted into the trigger point, and electrical stimulation was applied to generate a pain-free contraction. For the placebo group, the intervention procedure was exactly the same, but there was no electrical stimulation. Pain by visual analog scale (VAS), pain pressure threshold (PPT), range of motion (ROM), and disability by neck disability index (NDI) were assessed as main outcome measures before, immediately after, and one week after conducting intervention by another blinded researcher. Results: The VAS scales were improved in both groups but were significantly lower in the IMES group one week after treatment. The PPT and ROM scores were substantially higher in the IMES group one week after the treatment. The NDI indexes significantly reduced for both groups, with no significant differences between them. Conclusion: IMES effectively improves pain, PPT, ROM, and NDI, following trigger points in the upper trapezius muscle. Further studies are required to investigate the IMES’s long-term effects.
... Trigger point will later become MPS complaints 20 . Secondly, muscles will experience fatigue due to the increased duration of activity which leads to micro-strains/ small-scale muscle tissue tears, injury to muscles is also a risk factor for MPS because it has an impact in terms of physiological changes in muscles 7 . ...
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Some things can cause a person to have a dependence on using a computer just like office work or in terms of getting entertainment such as playing video games among adolescents. Some research leads to the duration of playing video games which is one of the risk factors of the MPS. The prevalence of MPS in general population varies by up to 85%. The method used in this study is an analytical observational method with a cross sectional approach. This study used simple random sampling techniques and the study subjects were observed with a one-time measurement of dependent variables. This research design was used to find out whether there was a relationship between the duration of playing video games and myofascial pain syndrome of upper trapezius muscle in adolescents in Denpasar City. The results showed from the total of 59 study samples, there were 46 samples (78.0%) who had upper trapezius MPS and as many as 13 samples (22.0%) who did not experience upper trapezius MPS. The distribution of research samples that experienced MPS was more in adolescents who had excessive duration of playing video games (>2 hours / day) which was 45 samples (76.3%) than samples who had MPS with a normal duration of playing video games (<2 hours / day). The conclusion of this study is that there is a significant correlation (p = 0.000) between the duration of playing video games and MPS of the upper trapezius muscle in adolescents in Denpasar City.
... When the muscles in the body are in a static position, the muscles do not stretch for that period of time. If this condition continues for a long time, it will lead to myofascial pain syndrome [14]. ...
... 이는 '아시지법'에서 "以手按之, 病者快 8,9) . 방아쇠점은 골격근에서 과항진된 지점(hyperirritable spot)으 로 타우트 밴드(taut band)에서 촉지 가능한 노듈 등의 특징을 보 인다 10,11) . 1977년 ...
... Trigger points are specific sites in muscles, located within taut bands, which are discrete bands of contracture muscle fibers that can be palpated and visualized by particular imaging methods (for review, see Travell and Simons, 2013 [99]. They have greater than normal degree of stiffness than that of normal muscle tissue [100]. They develop most often due to muscle overload, i.e., when an applied load exceeds the capability of the muscle to respond adequately, particularly following unusual or excessive eccentric or concentric loading [101]. ...
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(1) Background and Objectives: The aim of this narrative review was to analyze the neuroanatomical and neurophysiological basis of cervicogenic pain in cervico-cranial pain syndromes, focusing particularly on cervico-orofacial syndromes as a background for the proper diagnosis and non-surgical treatment. Relevant literature on the topic from past 120 years has been surveyed. (2) Material and Methods: We surveyed all original papers, reviews, or short communications published in the English, Spanish, Czech or Slovak languages from 1900 to 2020 in major journals. (3) Results: The cervicogenic headache originates from the spinal trigeminal nucleus where axons from the C1–C3 cervical spinal nerves and three branches of the trigeminal nerve converge (trigeminocervical convergence) at the interneurons that mediate cranio-cervical nociceptive interactions. The role of the temporomandibular joint in the broad clinical picture is also important. Despite abundant available experimental and clinical data, cervicogenic orofacial pain may be challenging to diagnose and treat. Crucial non-surgical therapeutic approach is the orthopedic manual therapy focused on correction of body posture, proper alignment of cervical vertebra and restoration of normal function of temporomandibular joint and occlusion. In addition, two novel concepts for the functional synthesis of cervico-cranial interactions are the tricentric concept of mouth sensorimotor control and the concept of a cervicogenic origin of bruxism. (4) Conclusions: Understanding the basis of neuroanatomical and neurophysiological neuromuscular relations enables an effective therapeutic approach based principally on orthopedic manual and dental occlusal treatment.
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Prolonged overactivity of the upper trapezius muscle with myofascial trigger points might cause muscle fatigue and subsequently change scapular kinematics and associated muscular activities. Scapular kinematics and associated muscular activities were investigated in 17 overhead athletes with upper trapezius myofascial trigger points and 17 controls before and after a fatigue task. Participants performed a fatigue task requiring sustained isometric scapular elevation. The outcomes included scapular kinematics (upward/downward rotation, external/internal rotation, posterior/anterior tilt) that were tracked by the Polhemus FASTRAK (Polhemus Inc., Colchester, VT, USA) system with Motion Monitor software and muscular activities (upper trapezius, lower trapezius and serratus anterior) that were collected at 1000 Hz per channel using a 16-bit analog-to-digital converter (Model MP 150, Biopac systems Inc., CA, USA) with pairs of silver chloride circular surface electrodes (The Ludlow Company LP, Chocopee, MA) during arm elevation. Mixed ANOVAs were conducted to characterize the outcomes with and without a fatigue task in participants with myofascial trigger points. Decreased scapular posterior tipping during 90 degrees of arm raising/lowering (effect sizes of 0.51 and 0.59) was likely to be elicited by the scapular elevation fatigue task in the presence of myofascial trigger points. Activity of the lower trapezius was higher in the myofascial trigger point group (6.2%, p = 0.036) than in the control group. Following the fatigue task, both groups showed increased activity in the upper trapezius (9.0%, p = 0.009) during arm lowering and in the lower trapezius (2.7%, p < 0.01) during arm raising and lowering. Decreased scapular posterior tipping during 90 degrees of arm raising/lowering after a fatigue task may lead to impingement. We found that the presence of upper trapezius myofascial trigger points in amateur overhead athletes was related to impaired scapular kinematics and associated muscular activities during arm elevation after a fatigue task, especially the decreased scapular tipping during 90 degrees of raising/lowering.
The use of acupuncture and dry needling has been widely debated, and the main point of contention is whether dry needling has been derived from acupuncture. This chapter comprehensively discusses the two aspects of basic theory, diagnosis and treatment of traditional acupuncture, meridian, acupoints, and myofascial trigger points (MTrPs). Except the difference between the two theories, many aspects are highly similar in terms of treatment action, applicable disease, and physiological experiments. Therefore, MTrP theory is considered a basis for modern acupuncture, which is different from traditional acupuncture theory. MTrP is also easily accepted and learned by individuals either with a background in modern medicine or that with knowledge in traditional acupuncture. Hence, MTrPs may be the precise acupoints in traditional Chinese medicine under modern scientific research, and meridian involves the paths of synthesis of center sensitization, nerves, vessels, and fascia mechanics. The scientific basis of Chinese and Western acupuncture should be uniformity, although the origin of these two theories varies because of the distinctiveness of the identity between ancient and modern knowledge. Therefore, the final goals of the two theories will go the same, and their results are highly similar. One theory should not belong to the other one. Meanwhile, human behavior or thinking is essential for acupuncture development. It is normal that a person often attempts either to experience nostalgia based on ancient knowledge or to develop new appropriate theory along with modern experiment technology.
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Repetitive neuromuscular magnetic stimulation (rNMS) for pediatric headache disorders is feasible, safe, and alleviates headache symptoms. This study assesses muscular effects and factors affecting response to rNMS. A retrospective chart review included children with headaches receiving six rNMS sessions targeting the upper trapezius muscles. Pressure pain thresholds (PPT) were measured before and after rNMS, and at 3-month follow-up (FU). Mean headache frequency, duration, and intensity within the last 3 months were documented. In 20 patients (14.1 ± 2.7 years), PPT significantly increased from pre- to post-treatment (p < 0.001) sustaining until FU. PPT changes significantly differed between primary headache and post-traumatic headache (PTH) (p = 0.019–0.026). Change in headache frequency was significantly higher in patients with than without neck pain (p = 0.032). A total of 60% of patients with neck pain responded to rNMS (≥25%), while 20% of patients without neck pain responded (p = 0.048). 60% of patients receiving rNMS twice a week were responders, while 33% of patients receiving rNMS less or more frequently responded to treatment, respectively. Alleviation of muscular hyperalgesia was demonstrated sustaining for 3 months, which was emphasized in PTH. The rNMS sessions may positively modulate headache symptoms regardless of headache diagnosis. Patients with neck pain profit explicitly well. Two rNMS sessions per week led to the highest reduction in headache frequency.
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To evaluate the effect of wet needling (related to acupuncture) and home stretching exercises on myofascial trigger points (MTrPs) in abdominal muscles for the treatment of dysmenorrhoea. The effect of wet needing of MTrPs in abdominal muscles, supplemented by home stretching exercises, was observed in 65 patients with moderate and severe primary dysmenorrhoea. The MTrPs in the abdominal region were localised and repeatedly needled with lidocaine injection. Menstrual pain was evaluated with a Visual Analogue Scale (VAS) score after every treatment, with the final evaluation made at a 1-year follow-up. Treatment was stopped when the VAS pain score reduced to ≤3. Symptoms scores were analysed with one-way analysis of variance. The mean VAS pain score before treatment was 7.49±1.16. After a single wet needling session, 41 patients had a reduction in their VAS pain score to <3 during their following menstrual cycle, with a mean of 1.63±0.49. Twenty-four patients who needed two treatments showed a reduction in menstrual pain scores to 0.58±0.50. After 1 year, the mean VAS pain score among all patients was 0.28±0.45, with a response rate of 100%. Primary dysmenorrhoea was significantly reduced 1 year after wet needling to MTrPs in the abdominal region and home stretching exercises, justifying further research with controlled trials.
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Low back pain is a common condition that is encountered by both primary care physicians as well as various specialists, which include: orthopedic surgeons, physical medicine and rehabilitation specialists, neurologists, rheumatologists, and pain management specialists. Associated muscular pain is very common and often a reactive response from nociception from other structures. Myofascial pain may arise, which is characterized by the presence of myofascial trigger points (MTrPs) that are located in fascia, tendons, and/or muscle. This article reviews the current evidence regarding the pathophysiology, assessment, and recommended treatment options for myofascial low back pain.
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Myofascial trigger points (MTrP), or muscle "contraction knots," of the pelvic floor may be identified in as many as 85 % of patients suffering from urological, colorectal and gynecological pelvic pain syndromes; and can be responsible for some, if not all, symptoms related to these syndromes. Identification and conservative treatment of MTrPs in these populations has often been associated with impressive clinical improvements. In refractory cases, more "aggressive" therapy with varied trigger point needling techniques, including dry needling, anesthetic injections, or onabotulinumtoxinA injections, may be used, in combination with conservative therapies.
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Myofascial trigger points (MTrPs) are hyperirritable points located within a taut band of skeletal muscle or fascia, which cause referred pain, local tenderness and autonomic changes when compressed. There are fundamental differences between the effects produced by the two basic types of MTrPs (active and latent). Active trigger points (ATrPs) usually produce referred pain and tenderness. In contrast, latent trigger points (LTrPs) are foci of hyperirritability in a taut band of muscle, which are clinically associated with a local twitch response, tenderness and/or referred pain upon manual examination. LTrPs may be found in many pain-free skeletal muscles and may be "activated" and converted to ATrPs by continuous detrimental stimuli. ATrPs can be inactivated by different treatment strategies; however, they never fully disappear but rather convert to the latent form. Therefore, the diagnosis and treatment of LTrPs is important. This review highlights the clinical implication of LTrPs.
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Although acupuncture theory is a fundamental part of the Huangdi Neijing, the clinical application of the needle therapy in ancient China was always a limited one. From early times there have been warnings that acupuncture might do harm. In books like Zhang Zhongjing's Shanghanlun it plays only a marginal role. Among the 400 emperors in Chinese history, acupuncture was hardly ever applied. After Xu Dachun called acupuncture a "lost tradition" in 1757, the abolition of acupuncture and moxibustion from the Imperial Medical Academy in 1822 was a radical, but consequent act. When traditional Chinese medicine was revived after 1954, the "New Acupuncture" was completely different from what it had been in ancient China. The conclusion, however, is a positive one: The best time acupuncture ever had was not the Song dynasty or Yuan dynasty, but is now - and the future of acupuncture does not lie in old scripts, but in ourselves.
As one half of a comprehensive two-volume publication that covers every angle of muscle pain and is edited by two of the leading figures in the field, this volume details the basic mechanisms of chronic muscle pain syndromes. It provides the practitioner with a deeper understanding of the physical processes involved in these often misunderstood conditions, and in clarifying the nature of muscle pain enables health care professionals to provide more effective treatment.
To investigate the difference in the presence of trigger points (TrPs) between patients with chronic nonspecific low back pain (LBP) and healthy people, and to determine the relationship of TrPs with the intensity of ongoing pain, disability, and sleep quality. A cross-sectional study. The role of TrPs in LBP has not been determined. Forty-two patients with nonspecific LBP (50% women), aged 23-55 years old, and 42 age- and sex-matched controls participated. TrPs were bilaterally explored within the quadratus lumborum, iliocostalis lumborum, psoas, piriformis, gluteus minimus, and gluteus medius muscles in a blinded design. TrPs were considered active if the subject recognized the local and referred pain as familiar symptoms, and TrPs were considered latent if the pain was not recognized as a familiar symptom. Pain measures were collected with a numerical pain rate scale, disability was assessed with the Roland-Morris questionnaire, and sleep quality was determined with the Pittsburgh Sleep Quality Index. Patients with nonspecific LBP exhibited a greater disability and worse sleep quality than healthy controls (P < 0.001). Patients with nonspecific LBP exhibited a mean of 3.5 ± 2.3 active TrPs. Further, patients with nonspecific LBP showed a greater (P < 0.001) number of latent TrPs (mean: 2.0 ± 1.5) than healthy controls (mean: 1.0 ± 1.5). Active TrPs in the quadratus lumborum, iliocostalis lumborum, and gluteus medius muscles were the most prevalent in patients with nonspecific LBP. A greater number of active TrPs was associated with higher pain intensity (rs = 0.602; P < 0.001) and worse sleep quality (rs = 0.338; P = 0.03). The local and referred pain elicited by active TrPs in the back and hip muscles contributes to pain symptoms in nonspecific LBP. Patients had higher disability and worse sleep quality than controls. The number of active TrPs was associated with pain intensity and sleep quality. It is possible that a complex interaction among these factors is present in patients with nonspecific LBP.
To determine whether standard evaluations of pain distinguish subjects with no pain from those with myofascial pain syndromes (MPS) and active trigger points (MTrPs); and to assess whether self-reports of mood, function and health-related quality of life differ between these groups. Prospective, descriptive study. University PATIENTS: Adults with and without neck pain METHODS: We evaluated adults with MPS and active (painful) MTrPs and those without pain. Subjects in the "Active" ('A') group had at least one active MTrP with spontaneous pain which was persistent, lasted more than 3 months and had characteristic pain on palpation. Subjects in the "No pain" ('Np') group had no spontaneous pain. However, some had discomfort on MTrP palpation (latent MTrP) while others in the Np group had no discomfort on palpation of nodules or had no nodules. Each participant underwent range of motion (ROM) measurement, 10-point manual muscle test, and manual and algometric palpation. The latter determined the pain/pressure threshold using an algometer of 4 pre-determined anatomical sites along the upper trapezius. Participants rated pain using a verbal analogue scale (0-10); completed the Brief Pain Inventory and Oswestry Disability Scale (ODS), which included a sleep sub-scale; Short Form 36(SF36) and the Profile of Mood States (POMS). There were 24 in the 'A' group (mean 36yrs, 16 women) and 26 in the 'Np' group (mean 26yrs, 12 women). Subjects in group 'A' differed from 'Np' in number of latent MTrPs (p=.0062); asymmetrical cervical ROM (p=.01 side bending and p=.002 rotation); in all pain reports (p<.0001); algometry (p<.03); POMS (p<.038); SF36 (p<.01) and ODS (p<.0001). A systematic musculoskeletal evaluation of people with MPS reliably distinguishes them from subjects with no pain. The two groups are significantly different in their physical findings and self-reports of pain, sleep disturbance, disability, health status and mood. These findings support the view that a "local" pain syndrome has significant associations with mood, health-related quality of life and function.