Myofascial Pain and Trigger Points

AuthorSamuel D. Hodge, Jr./Jack E. Hubbard
ProfessionSkilled litigator, is chair of the department of legal studies at Temple University/Professor of Neurology at the University of Minnesota
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
musculoskeletal aches
and pains of mankind.
Janet Travell, MD
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.
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

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