Myofascial Pain and Trigger Points

• Author: Samuel D. Hodge, Jr./Jack E. Hubbard
• Profession: Skilled litigator, is chair of the department of legal studies at Temple University/Professor of Neurology at the University of Minnesota
• Pages: 561-588

Myofascial Pain

and Trigger Points

Samuel D. Hodge Jr., Jack E. Hubbard, and Daniel Mitsakos

Myofascial trigger

points are a frequently

overlooked and

misunderstood source

of the distressingly

ubiquitous

musculoskeletal aches

and pains of mankind.

Janet Travell, MD

1983

11

A young woman who was involved in a motor vehicle accident complained of discomfort

in her neck, left shoulder, and lower back.1 She had a series of chiropractic treatments,

and a neurologist opined that she suffered from posttraumatic myofascial pain, or myo-

fascitis. An MRI, however, revealed no abnormalities. Eighteen months after the incident,

the woman was still complaining of localized pain in her spine as well as headaches. At

trial, the medical expert for the defense disagreed with the diagnosis, claiming that the

myofascitis would have been visible on the MRI as either inflammation or swelling. The

jury disagreed and concluded that the plaintiff had sustained a permanent soft-tissue

injury, and awarded $400,000 in damages. On appeal, the defense argued that the plain-

tiff’s myofascial pain was not verified by objective medical evidence and was inadequate

to prove a permanent condition as required under the no-fault law of the state. The

appellate court was not impressed with this position and allowed the verdict to stand.2

Welcome to the world of myofascial pain and trigger points in a personal injury setting,

a source of continuing controversy.

Introduction

Whiplash, sprains and strains, herniated disks, fibromyalgia, and even complex regional

pain syndrome are fairly well-known conditions that have become part of an attorney’s

vocabulary. But what is myofascial pain, a term that is showing up with more and more

frequency in the medical reports of personal injury and disability claimants? This chapter

explores the medical and legal implications of this condition, including an examination

of how the problem is diagnosed and treated and a review of how the diagnosis has been

viewed by the courts.

Analyzing the name given to this diagnosis is an appropriate first step. Myo- is the

prefix for muscle, and fascia refers to the protective covering surrounding a muscle. Myo-

fascial pain, therefore, is a disorder, of a muscle and its covering, that is responsible for

many patient visits to the doctor’s office. Myofascial pain is a localized condition that

can affect any skeletal muscle and can cause such manifestations as tenderness, local or

referred pain, stiffness, and muscle weakness without atrophy.3 Discomfort arises from

referred pain and muscle dysfunction caused by trigger points, which are tight bands of

skeletal muscle with palpable nodes.4 In nonmedical terms, region of abnormal muscle is

known as a “muscle knot.”5

Although the diagnosis may be alien to some attorneys, it is well known in the medical

community. In fact, myofascial trigger points, or MFTPs, were first described by Travell

and colleagues in 19426 and have been recognized as a common cause of chronic neck

562 ◆ CHAPTER 11

and back pain.7 Less well known is the fact that MFTPs can also cause a wide spectrum

of associated symptoms. For example, in one survey of patients with this malady, neuro-

logical, gastrointestinal, musculoskeletal, and otological symptoms occurred in 10 to 40

percent of the cases.8 In a litigation setting, a court described the problem in the follow-

ing way:

Unlike the generic problem of “back strain” myofascial pain syndrome is a chronic

form of muscle pain, which unlike normal muscle pain, does not resolve in a few days.

The pain is centered around sensitive muscle points called trigger points, which are

painful when touched; locations of the trigger points include the jaw, neck, low back,

pelvis and extremities.9

As discussed in prior chapters, all levels of the spine are controlled by multiple muscu-

lar layers that extend up and down the vertebral column. Because MFTPs are a common

cause of pain originating from the spine, it is important to examine this problem from

both medical and legal standpoints.

Myofascial Trigger Points

Myofascial trigger points are localized segments of muscle that have been subjected to

trauma either by acute injury or by microtrauma from repetitive stress and in some cases

can be the result of a systemic illness.10 Any skeletal muscle can develop MFTPs, which

can be identified by a careful examination of the affected muscle groups for “knots” 2 to

5 mm in diameter and tight bands that are painful when palpated.11 Unlike a spasm that

affects the entire muscle, similar to a charley horse or cramp, a trigger point is a small

patch of a tightly contracted muscle, or a more isolated spasm affecting just a small seg-

ment of muscle tissue.12 Figure 11-1. In turn, a collection of painful trigger points is called

myofascial pain syndrome or MPS.13

FIGURE 11-1.

Myofascial trigger points.

Side view of the neck revealing

the sternocleidomastoid muscle

containing several trigger points

(arrows) as revealed in the micro-

scopic view of the muscles fibers.

Trigger points are easily palpated

during an examination of that

muscle.