Muscle Pain Treatment and Myofascial Pain Syndrome

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Muscle Pain Vs. Myofascial Pain

In order to understand muscle pain we first need to define the function of skeletal muscle. Most patients, doctors and therapist would describe muscle as an organ, which moves bones. This however is only a portion of function of muscle as an organ. Muscle is not only a mover but also is a sensory organ as well as an organ of pain.


Is Muscle Pain the Same as Myofascial Pain?

Not really. Muscle pain could be any kind of pain triggered by different mechanisms of over stimulation of pain receptors located in the in the muscle fibers. The term myofascial pain is often used loosely to say that the origin of pain is somewhere in the muscle.

Myofascial pain on the contrary is a very specific phenomenon in which local painful muscle knot (trigger point) gives rice to nonciceptor (pain) activity. A trigger point is a contracture of a sacromere (a functional muscle unit). The pathophysiology of a trigger point could be explained by endplate dysfunction. So what is end plate and what happens at end plate to cause pain?

An endplate is a junction of the nerve ending and a muscle fiber. The local energy crisis (ischemia) at the endplate causes release of pain sensitizing substance. This substance inhibits reuptake of calcium back into the muscle fiber cells, which results in vicious circle of pain-spasm-pain.


What Causes Myofascial Pain?


Trigger points are found in most people, however painful trigger points are more common to people who engage little in physical activity throughout the day, but have occasional intervals of muscular low grade strain.

The most common cause of trigger points is sprain and strain, particularly repetatative postural strain. Other causes of myofascial pain include:

Biomechanical insufficiency
Nerve interference
Internal disease
Nutritional deficit
Hormonal disorders
Psychological and psychiatric disorders
Latent response to trauma
Lack of sleep

Also trigger points are concomitant to almost all disorders of musculoskeletal system such as radiculopathy, disc disorders, osteoarthritis, nerve compression syndromes, postural anomalies, complex pain syndromes and other trigger points.

What Kind of Pain Is Caused by Trigger Points?

Trigger points can cause local or referred pain. Since trigger point pain is often coupled with joint or nerve pain it could be felt as deep or superficial depending on location.

Is Trigger Point Pain Harmless?

Most often when no underlying cause such as herniated disc or pinched nerve is found the myofascial pain is dismissed as non serious. This however is big mistake as there is a long term sequela if trigger point pain persists for longer then six month. This trigger point pain can turn into irreversible muscle tissue damage, which becomes very resistant to treatment.

How Is Myofascial Pain Diagnosed?

In the past majority of doctors did not believe that myofascial pain exists. If you cannot see it, it does not exist. Fortunately, with development of technology myofascail trigger points could be visualized on high- end ultrasound machines. However, these machines are not yet affordable for an average clinician. Besides, the scanning technique is quite cumbersome. The good news is that you don’t need a high- end technology to diagnose existence of trigger points. A good clinical palpation skill and knowledge of myofascial anatomy is all that is required. At DNR we supplement palpation skills with ESWT (extracorporeal shockwave therapy) devise for diagnosis of trigger points, which are located deep inside the muscular tissues.


What Is the Best Treatment for Myofascial Pain?

The best treatment always starts with elimination of causative factors whether they are structural like herniated disc or functional such as postural disorder or emotional such as in the case of stress.


What Treatments Do We Use at DNR?

To be successful myofascial therapy must be comprehensive and diagnostically precise. We have come a long way from the original concept of manually release by mere pressure. At DNR we use a combination of: ESWT (extracorporeal shockwave therapy) and manual therapy. But most importantly we begin with a thorough diagnosis to establish the underlying pathology. We use diagnostic ultrasonography and elastography to localize deep trigger points as well as tendinopathies and enthesiopathies without which the trigger point therapy would never be effective. Fascial component of the treatment is provided by radial shockwave and manual facial therapy.

Lev Kalika Clinical Director and DC, RMSK

Dr.Kalika revolutionized foot and ankle care by using high resolution diagnostic ultrasonography for structural diagnosis, combined with with gait and motion analysis technology. Dr.Kalika’s motion and gait analysis lab is the only private lab in the US that features research-grade technology found only at top research universities, made available to patients in his private clinic.

Our Specialists

HyunJu YOO, PT, MPT, DPT, CPI (Licensed Physical Therapist)
Dr. Christina Pekar DC
Dr. Michelle Agyakwah DC
Dr. Mikhail Bernshteyn MD (Internist)

Research at NYDNRehab

Conference paper. 12th World Congress of the International Society of Physical and Rehabilitation Medicine (ISPRM 2018), At Paris, France. DRY NEEDLING UNDER ULTRASOUND GUIDANCE DECREASE NEUROPATHIC COMPONENT AND INCREASE LEVEL OF MOTION IN PATIENT WITH LOW BACK PAIN.
Conference paper. 12th World Congress of the International Society of Physical and Rehabilitation Medicine (ISPRM 2018), At Paris, France. DRY NEEDLING TRIGGER POINTS IN RECTUS AND OBLIQUUS CAPITIS INFERIOR MUSCLES UNDER ULTRASOUND GUIDANCE IS EFFECTIVE FOR CHRONIC HEADACHE.
Conference paper. 12th World Congress of the International Society of Physical and Rehabilitation Medicine (ISPRM 2018), At Paris, France. TREATMENT OF HAND PAIN AND CARPAL TUNNEL SYNDROME USING PRECISE DRY NEEDLING UNDER ULTRASOUND GUIDANCE – RELEVANCE OF SUPINATOR SYNDROME.
Conference paper. 12th World Congress of the International Society of Physical and Rehabilitation Medicine (ISPRM 2018), At Paris, France. MULTILEVEL EVALUATION OF MOTION AND POSTURE PATTERNS IN LOWER EXTREMITY AND SPINE USING DYNAMIC ULTRASOUND.
Conference paper. 21st European Congress of Physical and Rehabilitation Medicine, At Vilnius, Lithuania, 1-6 May, 2018. EFFICACY OF DRY NEEDLING UNDER ULTRASOUND GUIDANCE FOR NEUROPATHIC PAIN TREATMENT.
[R.Ya. Abdullaev, R.V. Bubnov, V.I. Tsymbalyuk, O.I. Grechanyk, L. Kalika, Z. Pilecki], Fact, 2017.pp. 150-163 Book chapter: “Novel approaches of physical therapy and pain management.” in Ultrasound of the spine, peripheral nerves and for pain management

In this instance, an athlete was originally diagnosed with minor quadriceps muscle strain and was treated for four weeks, with unsatisfactory results. When he came to our clinic, the muscle was not healing, and the patients’ muscle tissue had already begun to atrophy.

Upon examination using MSUS, we discovered that he had a full muscle thickness tear that had been overlooked by his previous provider. To mitigate damage and promote healing, surgery should have been performed immediately after the injury occurred. Because of misdiagnosis and inappropriate treatment, the patient now has permanent damage that cannot be corrected.

The most important advantage of Ultrasound over MRI imaging is its ability to zero in on the symptomatic region and obtain imaging, with active participation and feedback from the patient. Using dynamic MSUS, we can see what happens when patients contract their muscles, something that cannot be done with MRI. From a diagnostic perspective, this interaction is invaluable.

Dynamic ultrasonography examination demonstrating
the full thickness tear and already occurring muscle atrophy
due to misdiagnosis and not referring the patient
to proper diagnostic workup

Demonstration of how very small muscle defect is made and revealed
to be a complete tear with muscle contraction
under diagnostic sonography (not possible with MRI)


Complete tear of rectus femoris
with large hematoma (blood)


Separation of muscle ends due to tear elicited
on dynamic sonography examination

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