What is the approach to diagnosing and treating myofacial pain?

Diagnosing and Treating Myofascial Pain

Myofascial pain syndrome (MPS) is characterized by trigger points - hyperirritable spots within taut bands of muscle fibers that cause both localized and referred pain, requiring a thorough diagnostic approach and multimodal treatment plan for optimal outcomes. 1

Diagnostic Approach

History and Physical Examination

• Obtain detailed pain history including timing (onset, duration, periodicity), location, quality, severity, and factors that relieve or aggravate the pain 2
• Identify associated factors such as bruxism habits, jaw clicking/locking, altered sensation, and other pain conditions (headaches, fibromyalgia) 2
• Assess impact of pain on sleep, mood, concentration, fatigue, and quality of life 2

Physical Examination Components

• Perform extraoral examination of head and neck region, looking for:

  • Visual inspection for color changes, swellings, and skin lesions 2
  • Palpation of muscles of mastication and head/neck muscles for tenderness and trigger points 2
  • Assessment of muscle hypertrophy and temporomandibular joint movement including crepitus 2
  • Cranial nerve examination 2

• Conduct intraoral examination:

  • Evaluate teeth for decay, mobility, excessive wear facets (indicating bruxism) 2
  • Check occlusion and ability to open mouth 2
  • Examine oral mucosa for soft tissue lesions 2

Diagnostic Testing

• Use validated pain assessment questionnaires such as Brief Pain Inventory, Beck Depression Inventory, or McGill Pain Questionnaire 2, 3
• Order imaging studies only when indicated by specific clinical findings 3
• Consider dental panoramic tomographs for bony lesions or cysts 2
• MRI or CT scans may be indicated in some conditions but should not be routine 2, 3

Red Flags to Consider

• Giant cell arteritis must be distinguished from temporomandibular disorders, especially in patients over 50 years 2
• Progressive neuropathic pain may indicate cancer 2
• Lack of diagnosis can significantly impact sufferers' daily lives 2, 3

Treatment Approach

First-Line Treatments

• Manual physical therapy techniques should be the initial approach, including:

  • Maneuvers to resolve muscular trigger points 4
  • Techniques to lengthen muscle contractures 4
  • Release of painful scars and connective tissue restrictions 4
  • Myofascial release to facilitate participation in exercise programs 4, 5

• Physical therapy interventions:

  • Low-resistance exercise to improve joint stability by increasing muscle tone 4
  • Ischemic compression therapy 5
  • Transcutaneous electrical nerve stimulation (TENS) 5
  • Spray and stretch techniques 5

Pharmacological Options

• NSAIDs for symptomatic relief of myofascial pain 4, 5
• Consider topical treatments including:
  • Lidocaine patches 4, 5
  • Diclofenac patches 4, 5
  • Capsaicin 4
• For persistent pain, consider:
  • Tricyclic antidepressants 4
  • Serotonin-norepinephrine reuptake inhibitors (SNRIs) 4
  • Anticonvulsants (gabapentin, pregabalin) for refractory cases 4

Injection Therapies

• Trigger point injections with local anesthetics show sufficient evidence for effectiveness 1, 5
• Dry needling may be effective compared to sham or placebo 1
• Botulinum toxin injections have insufficient evidence for routine use 1

Adjunctive Approaches

• Cognitive behavioral therapy for patients with psychological components 4
• Relaxation techniques and breathing exercises 4
• Heat and cold therapy applications 4
• Acupuncture may provide relief for some patients 1, 6

Clinical Pitfalls and Caveats

• MPS often remains underrecognized due to symptom overlap with other pain disorders such as fibromyalgia, neuropathic pain, and joint disorders 1
• Avoid overreliance on diagnostic testing without appropriate clinical correlation 3
• Focus on treating underlying pathologies including spinal conditions, postural abnormalities, and behavioral issues 5
• Recognize that MPS can significantly impact quality of life, physical and social functioning, and emotional well-being 6
• Consider that MPS is frequently associated with other chronic pain disorders and conditions such as anxiety 6