Upper Limb Myofascial Pain Evaluation and Treatment

Myofascial Pain Symptoms

The following symptoms are commonly associated with myofascial pain:[1]

• Pressure-sensitive pain points – mainly in the muscles
• Dull, aching, and nagging pain
• Deep muscle pain rather than joint pain
• Limbs may feel slightly weak heaviness and stiffness
• Pain that is primarily localized to a specific area and has a distinct epicenter
• Patients often want massage but find it only temporarily relieves symptoms
• Patients often find relief (at least for a short time) from hot showers and baths
• Patients often find that activity and exercise help reduce symptoms
• Pain does not correlate strongly with exercise
• No clear mechanism of injury, but symptoms are usually exacerbated by extreme postural movement or temperature
• Pain is mostly episodic, but each episode may last for a long time (ie weeks/months)
• Pain can even shift to the opposite side of the body – a less common trigger point symptom

Myofascial Treatment Techniques

1. Instrument Assisted Soft Tissue Mobilization (IASTM)
2. Trigger point release
3. Selective Functional Movement Assessment (SMFA)
4. Kinesiotaping
5. Dry needling
6. Foam Rolling
7. Exercises

1. Instrument-Assisted Soft Tissue Mobilization (IASTM)

Figure 1. Graston® technique.

Instrument-Assisted Soft Tissue Mobilization (IASTM) is a well known and accepted treatment for myofascial limitations. It uses specially designed instruments to loosen scar tissue and myofascial adhesions. [2] An example of IASTM is the Graston® technology (see Fig. 1).[2] Other tools/companies include: Técnica Gavilán® Hawk Grips® Functional and Kinetic Treatment and Rehab (FAKTR)® Adhesion Breakers® and Fascial Abrasion Technique™. [2]

These IASTM instruments have a mechanical advantage for the clinician, allowing them to penetrate further into the tissue. It has been suggested that the use of instruments to achieve soft tissue mobilization may increase vibrational perception for both therapist and client. [2] This may enhance The therapist’s ability to notice changes in tissue properties, such as tissue adhesions, also increases the client’s awareness of any sensory changes in their tissues. [2][3][4]

As summarized by Cheatham et al. [2] it is believed that IASTM can:

• Stimulation of connective tissue remodeling through resorption of hyperfibrosis
• Induces collagen repair and regeneration in response to fibroblast recruitment

This results in release and decomposition:

• Scar tissue
• Adhesions
• Fascial restrictions

Cheatham et al. [2] conducted a systematic review to assess the evidence for IASTM:

• Seven randomized controlled studies included in the review
• Five studies compared the effects of IASTM with control or alternative interventions in participants with musculoskeletal disorders
• Study showed no significant difference (p>.05) – i.e. same results for control and study groups
• Two studies found that IASTM resulted in significant (p<.05) short-term (i.e., up to 24 hours) gains in joint range of motion compared to control or alternative interventions [2]

The Graston® technique

As summarized by Cheatham et al. [2] the treatment protocol with the Graston® technique has several components:

• Examination
• Warm-up
• IASTM treatment (eg 30-60 seconds per lesion)
• Stretching post-treatment
• Strengthening
• Ice (when concerned with subacute inflammation)

According to the Graston Technique® website:[5]

The Graston Technique® (GT) is a unique evidence-based form of instrument-assisted soft tissue mobilization that enables clinicians to effectively and efficiently address soft tissue injuries and fascial limitations, resulting in improved patient outcomes. GT is made of specially designed stainless steel Instrument with unique treatment edges and angles for effective manual treatment. Using GT machines in conjunction with appropriate therapeutic exercises can restore pain-free movement and function. These instruments are also used for diagnostic evaluation Use the principle of regional interdependence to build dynamic chains in an efficient manner.

Effects of the Graston® technique

Based on the Graston® technique [5], there is empirical and anecdotal evidence that the technique has the following advantages:

• Isolates and breaks down collagen crosslinks and opens and stretches connective tissue and muscle fibers
• Facilitates reflex changes in chronic holding muscles (abnormal tone inhibition/guarding leading to pain relief through improved sensory input) .
• Modifies/inhibits spinal cord secretory activity (facilitated segment) .
• Increases local blood flow and regeneration (angiogenesis vs. immediate local increases in blood flow) .
• Increases cellular activity in the area, including fibroblasts and mast cells
• Increased histamine response secondary to mast cell activity

Conditions Treated with Graston® Technology

This list of conditions is available on the Graston® Technique website:[5]

• Achilles tendinitis/tendinosis
• Carpal tunnel syndrome
• Cervicothoracic sprain/strain
• Fibromyalgia
• Lateral epicondylitis/epicondylitis (tennis elbow)
• Lumbosacral sprain/strain
• Medial epicondylitis/epicondylitis (golfer’s elbow)
• Myofascial pain syndromes
• Patellofemoral disorders
• Plantar fasciitis/plantar heel pain
• Postoperative (depending on postoperative protocol)
• Rotator cuff tendinitis/tendinosis
• Scar tissue/post surgical wound (once closed) .
• Patients with central and/or peripheral sensitization (light stroking/brushing mode is used to aid desensitisation) .
• Shin splints
• Trigger finger
• Women’s health issues (e.g. post mastectomy and surgical wounds) .

2. Trigger Point Release

Primary vs Secondary Trigger Points

1. Primary or central trigger points: trigger points in the center of the muscle belly where the motor endplate enters the muscle.[6] They are caused by acute or chronic overload of the involved muscles. They are not activated due to the activity of other muscles.[7]
2. Secondary or satellite trigger points: A trigger point that arises in response to primary trigger points in the surrounding tissue.[7] They usually settle when the central trigger point runs out but can form clusters.

Trigger Point Types

1. Active trigger points: Points that cause tenderness or referred pain on palpation / direct pressure. Pain persists and muscle stiffness / weakness decreases.[7] Most central and satellite trigger points work. Trigger point irritability determines pain intensity and expansion.[7]
2. Passive or latent triggers: Trigger-like lesions / muscles.[6] They have the same features with active trigger points but are less intense. The pain is not constant but occurs (e.g. on touch).[7] They are described as foci of hyperirritability in the taut band of muscle and is often associated with tenderness with a local twitch response and/or referred pain upon palpation.[8] Latent trigger points can be activated and become active trigger points.[8]
3. Diffuse Trigger Points: Common in individuals with severe postural disabilities and when all four sides of the body are involved.[6] Secondary trigger points are recorded as diffuse trigger points when there are multiple satellite trigger points that occur in response to a central trigger points.[6]
4. Factors Stimulating Attachment: Tendo-osseous junctions are often very fragile. Left untreated, these can lead to degeneration or acceleration of an adjacent joint.[6]
5. Ligamentous Trigger Points: Evidence suggests that trigger points can also occur in ligaments. For example it has been found that areas of stimulation in the anterior longitudinal muscles of the spine can cause neck instability.[6] Similarly they are dealing with trigger points in the patella ligament and fibular collateral ligament may be useful for knee pain.[6]

Indications of Trigger Point Therapy

1. Repetitive / acute micro-trauma
2. Vitamin deficiencies
3. Poor posture
4. Sleep disturbances
5. Joint problems
6. Chronic stress on nerve fibers or psychological stress
7. Chronic infections
8. Radiculopathy
9. Depression
10. Hypothyroidism
11. Hyperuricemia
12. Hypoglycemia[9]

Contraindications to Trigger Point Therapy

1. Epilepsy
2. Asthma
3. Pregnancy
4. Hypertension
5. Patient pain tolerance
6. Anxiety and stress
7. Acute stage of healing or open wound burn
8. Medical conditions such as pneumonia kidney liver or respiratory failure
9. Diabetes with gangrene
10. Bleeding conditions and use of anticoagulants
11. Severe atherosclerosis
12. Unstable hypertension
13. Shock
14. Contagious diseases[9]

Interventions for Trigger Point Therapy

1. Change or eliminate everyday micro stressors
2. Discipline and posture training comprehensive patient education about lifestyle (ergonomics) .
3. Passive stretching techniques and/or foam roller stretching a few times a day
4. Self-massage a few times a day especially Deep Stroking Massage which is done rhythmically and in only one direction
5. Strength: initially only isometric and then isotonic exercises
6. Taping technique
7. Spray and spread by using ethyl chloride spray
8. Manual lymphatic drainage (MLD) because the presence of stimulating areas can be an obstruction to lymphatic flow
9. Other proprioceptive neuromuscular mechanisms: Reciprocal Inhibition (RI) Post-Isometric Relaxation (PIR) Contract-Relax/Hold-Relax (CRHR) Contract-Relax/Antagonist Contract (CRAC);

3. Selective Functional Movement Assessment (SMFA) .

The Selective Functional Movement Assessment (SFMA) was developed by Gray Cook et al.[10] The Functional Movement Systems were also developed.[11] The SFMA is a clinical model that aims to identify movement pattern dysfunction and thus contribute to the diagnosis and management of musculoskeletal disorders events.[12]

The SFMA is an assessment program only available to physicians. The SFMA analysis is divided into seven high-level tests. Each test result is assigned one of the following points:[13]

1. Function/Pain (FP): The patient completes the movement but feels pain
2. Dysfunctional/ Non-painful (DN): The patient cannot complete movement but does not have pain
3. Dysfunctional/ Painful (DP): The patient is unable to complete the movement and is in pain
4. Functional/Non-painful (FN): The patient completes the movement without pain

SFMA patterns for assessment:[13][14]

1. Cervical spine patterns
   1. Flexion: Touch chin to chest
   2. Extension: Look up towards the ceiling
   3. Rotation with flexion: Touch chin to collar bone and repeat each side
2. Upper extremity patterns
   1. Abduction with external rotation: Put your arms around your head and try to touch the superior angle of the contralateral scapula
   2. Adduction with internal rotation: Reach back and try to touch the inferior face of the scapula
3. Multi-segmental Flexion: Reach down and touch the toes
4. Multi-segmental Extension: Reach your top and extend as wide as possible
5. Multi-segmental rotation: Rotate the body as far as possible and keep the legs flat on the floor
6. One-legged stance: Stand on one leg and hold the other leg in a 90-degree hip bend or greater for at least 10 seconds
7. Overhead deep squat: Raise your arms across your legs about shoulder width and squat as low as possible as you lower the legs

Example: Overhead squat and upper extremity program

• Upper extremity patterns – abduction/external rotation and adduction/internal rotation: Can be addressed by treating forearm and hindlimb ligaments[9][15]
• Back arm line (third tract):[14]
  1. Latissimus dorsi
  2. Thoracolumbar fascia
  3. Sacral fascia as opposed to thoracolumbar fascia
  4. Gluteus maximus in relation to thoracolumbar fascia
  5. Vastus lateralis
• Front arm line (third tract):[14]
  1. Pectoralis major
  2. External oblique
  3. Adductor longus opposite posterior oblique
  4. Gracilis as opposed to posterior oblique
  5. Pes anserine opposite oblique posteriorly
  6. Tibial periosteum opposite posterior oblique

The SFMA can be used in conjunction with tactile and eye tracking.[14] It is then necessary to evaluate and reassess the dysfunctional movement.[9] Please click here for more information on the upper myofascial chain.

4. Kinesiotaping

Zhang et al.[16] recently conducted a systematic review and meta-analysis to examine the evidence for kinesiotaping as an intervention for myofascial pain syndrome. 20 randomized trials with 959 participants were included. They found that:[16]

• Kinesiotaping was more effective in reducing pain intensity after intervention than other treatments
• Compared with other non-invasive techniques, kinesiotaping was superior in reducing pain intensity at follow-up
• No observed effects on disability / function were observed

Thus Zhang et al.[16] concluded that there is statistical evidence to support the use of kinesiotaping to reduce pain intensity and improve patients with myofascial pain syndrome in the post-intervention period.

5. Dry Needling

Charles et al.[17] conducted a systematic review to evaluate the effect of manual therapy techniques of dry cupping and dry needling on myofascial pain and triggers. Eight manual therapy studies 23 dry needling studies and two dry cupping studies reached the inclusion criteria. The authors found that that:[

• There were a sufficient number of randomized controlled trials to support the use of manual therapy
• Very low to moderate evidence for dry needling compared with control sham and other treatments
• There was a lack of data on dry cupping

6. Foam Rolling

Kalichman and David [18] performed a narrative review of the effects of self-myofascial release (SMFR) on muscle flexibility and strength in myofascial pain. They found that:[18]

• Therapists and fitness professionals have primarily used foam rolling to implement SMFR over the past 10 years as a treatment/maintenance tool
• Significantly increased range of motion with SMFR
• No reduction in muscle strength or changes in performance after SMFR treatment
• SMFR is widely used by health professionals to treat myofascial pain

However, the authors [18] noted that there are no clinical trials evaluating the effect of SMFR on myofascial pain.

Hughes and Ramer [19] conducted a systematic review to determine how long myofascial rolling should be applied to achieve optimal recovery and improvements in range of motion and performance. They found that:[19]

• The Most Evidence-Based Benefit of Myofascial Rolling Is Reduced Muscle Soreness
• Seven of eight studies found short-term reduction in pain/soreness
• Rolling each muscle for at least 90 seconds seems beneficial
• Ten of the 17 studies that looked at range of motion found strong improvements after rolling but with inconsistent results
• There was no significant effect on performance after post-rolling

The authors[19] therefore concluded that in order to achieve short-term pain/pain relief, patients should perform a minimum of 90 seconds of myofascial rolling per muscle group (with no upper time limit observed); . . . . But there are no studies linking myofascial rolling with longitudinal improvements in function or range of motion and current data are insufficient to make recommendations for acute changes in range of motion.[19]

7. Exercises

The following are some exercises that may help with upper extremity myofascial pain:[9]

1. Sit in a rolling chair: Place your palms down on the table in front of you. Slide your hips back until your elbows are almost straight. Keeping your feet on the floor, use your mid back and core to pull forward
   1. Advanced: Leaning on the inner side of the palm
   2. Take it a step further: Place palms on tennis ball and pull forward
2. Table or Wall Stretch: With palms down, roll hips out, keeping feet flat on floor, and rotate in opposite direction. Turn the neck in the same direction as the torso.
   1. Progression: as above, but face palm up
   2. Further Progression: As above, but with added wrist and finger extension