Myofascial pain syndrome

Medical Information

Muscles and fascia are well-innervated and are frequently the cause of acute and chronic pain. Consequently, myofascial tissue must be specifically examined in musculoskeletal conditions and accounted for in classification (according to ICD-10). A myofascial trigger point (MTrP) is a circumscribed structure within the muscle or connective tissue that triggers pain and is involved in a musculoskeletal pain process.

Due to their precise application even in deep tissue layers, focused shockwaves are utilized in both the diagnosis and therapy of myofascial conditions and trigger points.

Muscles and fascia represent an anatomical and functional unit, which is also treated collectively.

ESWT is also indicated for connective tissue disorders.

Classification

ICD-10: M79.1 for myofascial pain syndrome, and additional local or regional pain, e.g., lumbar-sciatica M54.4

Synonyms

Myofascial pain syndrome, myogelosis, muscle contracture, muscle trigger points, myofascial trigger points, fascial shortening, fascial dysfunction.

Etiology

• Acute and chronic skeletal muscle injuries

• Acute and chronic overload, overstretching, direct trauma, non-physiological loading of the musculoskeletal system

• In combination with enthesopathies, incorrect loading (e.g., poor statics, muscular imbalances), radiculopathies, arthrogenic dysfunctions and irritations, internal organ diseases, endocrine diseases, psychosomatic reactive changes

Symptoms

Localized pain with involvement of the musculoskeletal system, localized hypersensitivity, referred pain (frequent pseudoradicular diffusion), dysesthesia, pain upon tension and stretching, joint pain, tendon pain, regional pain (e.g., headaches), muscle shortening, muscle hardening, reduced strength, coordination disturbances, vegetative symptoms.

Diagnosis

Basic diagnosis: clinical neurological-orthopedic examination.

Clinical examination: mobility, sensorimotor function, specific stretching tests.

Palpation is the gold standard in the clinical examination of muscles and fascia, including the diagnosis of trigger points.

Diagnosis with ESWT:

With feedback and according to diagnostic criteria (e.g., “recognition”, “referred pain”).

Diagnostic imaging:

If necessary, orientative ultrasound at the treatment site for local diagnosis. Ultrasound elastography diagnosis is possible (to date without clinical relevance), high-resolution MRI (used in scientific studies, without current clinical relevance).

Differential diagnoses:

Differential diagnosis of myalgia and musculoskeletal system diseases. Muscle and soft tissue tumors, primary and secondary myopathies, systemic neurological diseases, neurogenic dysfunctions, rheumatic diseases, hormonal disorders (e.g., hyperparathyroidism, hypothyroidism), medication side effects (e.g., lipid-lowering agents).

Conservative Therapies

Dry needling, ischemic compression, acupuncture, stretching, electrotherapy, fascial release techniques, fascial therapies, infiltrations, muscle relaxation techniques, physiotherapy according to IMTT standards, thermotherapy (“Stretch and Spray”).

Shockwave Therapy

Indication:

Indicated by a specialist physician.

Before therapy:

• Spatial requirements: Certification criteria for a medical practice, e.g., hygiene plan, emergency management available according to DIN standards.

• Patient preparation: Positioning in a pain-free posture, structures to be treated must be easily accessible.

• Information: Therapeutic pain also after treatment (in approximately 20–30%, similar to "muscle soreness"), if necessary, NSAID medication. Possible vegetative reaction (e.g., sweating, circulatory reactions).

Physician and assistant staff:

ESWT must be performed personally by a qualified physician with specialized expertise.

Contraindication:

Malignant tumor in the application area.

Therapy implementation:

• Principle: Exact treatment of the myofascial trigger point at the point of pain with an intensity adapted to the pain (energy).

• Documentation: Refer to the preamble. Specify the exact application of extracorporeal shockwave (ESW) therapy with anatomical localization (e.g., treated muscle or anatomical structure).

• Criteria: Name the diagnostic criteria triggered during shockwave therapy: local pain, “recognition”, “referred pain” (feedback) and, where applicable, muscle twitch response.

• Parameters: Specify the shockwave source, the number of impulses applied, and the intensity (EFD).

Post-treatment care:

Individual adjustment of loading, continuation of conservative therapies, stretching exercises and autonomous fascial treatment, physiotherapy.

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