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Fibromyalgia (FMS) and
Chronic Myofascial Pain (CMP)
For Doctors and 
Other Health Care Providers

with Devin Starlanyl

 

 

Devin’s Diagnostic: Update 2009

 

[Note:  I thank readers for their patience in waiting for this.  As I worked on it, the realization came that a full list with diagrams requires another book.  This will happen.  For now, this will help.  DJS]

 

Symptoms from fibromyalgia (FM) and myofascial trigger points (TrPs) are often the source of diagnostic confusion.  This is compounded since many FM research articles have failed to take into account co-existing TrPs that may be contributing to or causing described symptoms.  The sensitization of the central nervous system (CNS) that is part of FM can be initiated by many different things, such as infections, trauma, or a multitude of other stressors.  There may be a genetic component that gives some of us a more easily rattled CNS.  In others, the stressors are just too strong or last too long for their CNS to endure without sensitization.  Pain from several TrPs or other peripheral sources, such as arthritis, can do this.  Once central sensitization occurs, sleep, posture and dietary and exercise patterns are disrupted.  Multiple biochemical responses may begin, leading to further imbalances in the body.

Localized pain is NOT part of FM.  Trigger points are NOT part of FM.  Myofascial pain is NOT part of FM.  Some people have tried to “simplify” by lumping these conditions together, resulting in mass confusion.  Perpetuating factors and many good treatment options have been missed, and needless testing and even surgical procedures have been performed.  You have what you have, and you need to understand what that is so that you can get those things under control.

Many doctors and patients have mentioned difficulty discerning whether symptoms are due to FM or TrPs.  Some symptoms may have components of both, or may be due to other causes, such as medication side-effects.  Other chronic illness often has TrP and/or FM components.  For example, many cases of arthritis may include treatable pain from TrPs, and even many symptoms of old age, such as stiffness and decreased range of motion, may be aggravated or even caused by TrPs and can be treated successfully.

 TrPs are most commonly associated with specific referred pain patterns, and familiarity with the complete pain patterns is required for efficient diagnosis and treatment.  While multiple muscle TrPs may cause or contribute to a symptom, the specific pain pattern helps to distinguish which TrPs are involved.  There may be multiple TrPs, with overlapping pain and other symptom patterns.  TrPs can cause many more symptoms besides (or instead of) pain.  They can cause muscle dysfunction such as weakness and restriction of range of motion even before pain is noticed.  In addition, they may be accompanied by autonomic symptoms such as sweating, goosebumps or blanching of the skin, by or proprioception symptoms such as inability to judge the weight of an object in the hand, or dizziness.  Your teeth may bite the inside of your cheek or the tongue because one part of the body can’t tell where the others are in relation to it.  The buccinator muscle (cheek and tongue biting) and genioglossus (tongue biting) TrPs can be especially associated with this.  This can add insult to injury, or just add more injury.  We stumble and fall over our feet, and we spill things and wind up wearing our food.  We’re not clumsy.  We are proprioceptively impaired.  Here is a listing of some symptoms that can be caused by TrPs.  It is not comprehensive, but will give you an idea of the trouble TrPs can cause and of the misery that could be relieved if they were adequately diagnosed and treated.  If you already have multiple TrPs, check for more if a symptom occurs and the cause cannot be found.   Always be sure that there are no organic causes.  If a symptom recurs after treatment, either there are uncontrolled perpetuating factors, or the treatment is not properly done or adequate to the task.  The same symptoms should not be treated again and again with the same therapy endlessly.  This is a sign that there are perpetuating factors (including other TrPs) that must be discovered and brought under control if possible.  TrPs can occur in any part of any muscle and in many layers of each muscle.  Perpetuating factors often have their own perpetuating factors.  For example, throat and nasopharyngeal TrPs may be aggravated by rhinitis and post nasal drip, which may be aggravated by allergies and TrPs in the pterygoid, etc.  Each myofascial TrP has its own distinct referral pattern, but TrPs can occur in any place in any layer of any muscle, and also can occur in other tissues.

List of some confusing and often missed symptoms associated with TrPs:

Muscle contracture: sustained intrinsic muscle shortening (tension, tight muscle) in the absence of motor unit action potentials.  This is different than shortening due to spasm or fibrosis.  It is the type caused by TrPs.

Some trapezius TrPs can cause steady burning or superficial burning feeling in their specific TrP patterns along the shoulder blade.

Burning, prickling or lightning-like jabbing pain can come from TrPs in scar tissue.  The scars may be internal, such as those from surgery.

Difficulty breathing can be due to activation of any respiratory muscle TrPs, including TrPs in the diaphragm.  These TrPs can cause air hunger, shortness of breath and/or panting respiration.

Sinus congestion may be caused by sternocleidomastoid TrPs.

Impotence can be caused by TrPs, especially those entrapping blood vessels and nerves.

Nausea may be due to abdominal TrPs and some back TrPs along the spine.

Dizziness can be caused by several TrPs, including sternocleidomastoid.

Heartburn/abdominal fullness/bloating/indigestion can be associated with upper abdominal external oblique and upper rectus abdominus paraxphoid TrPs.

Nasopharyngitis can be part of multiple head, neck and throat TrPs.

Vomiting can be caused by several abdominal TrPs.

Urinary incontinence/frequency/retention may be part of abdominal and pelvic TrPs.  Suspect them in cases of bedwetting in older children, especially of the child has TrPs or “growing pains.”

Urinary frequency can belong to TrPs along upper rim of the pubis.

Ringing in the ears can be due to lateral pterygoid TrPs and/or deep masseter TrPs.

Restricted rotation of thoracic spine may be from intercostal TrPs.

Blurred vision and/or visual disturbance may stem from eye muscle TrPs, sternocleidomastoid TrPs; upper trapezius TrPs, and/or orbicularis oculi TrPs.

Deep “bone” pain can be due to deep paraspinal muscles.

“Visceral” abdominal pain can be caused by TrPs along the spinal column in the upper lumbar area.

Difficulty climbing stairs may be part of longissimus TrPs.

Diarrhea may be caused by TrPs in the lower abdominal area.

Diffuse abdominal/gynecological pain can come from TrPs in the right lower rectus abdominus or high adductor magnus.

Prostatitis-type pain may be due to intrapelvic or high adductor magnus TrPs.

Urinary sphincter muscle spasm/ bladder sensitivity may be associated with TrPs directly above pubis.

Cystitis-type pain may be due to TrPs in the low rectus abdominus.

Dyspepsia and abdominal pain can be caused by TrPs in abdominal muscles.

Feeling drunk: “a swimmin’ in the head,” and unintentional veering may be part of sternocleidomastoid TrPs, as may loss of coordination; balance disorder.

Gait disturbances, so that you cannot walk normally, may be part of gluteus minimus TrPs.  Abnormal gait coordination and spatial disorientation may also be part of sternocleidomastoid TrPs.  Loss of positional sense in walking may be due to TrPs in the piriformis and other short lateral rotators.

Inability to sit still due to pain is often part of gluteus maximus TrPs symptoms.

Stuffiness of ear: medial pterygoid TrPs.

Abdominal cramping/colic may be caused by TrPs in the lateral periumbilical area.

Dysmenorrhea may be caused by TrPs in the lower rectus abdominus halfway between umbilicus and symphysis pubis. 

Cardiac arrhythmia can be associated with a pectoralis major TrP, between 5th and 6th ribs midway between nipple and sternum right side.

Heart attack type pain (can include pain referral down left arm) may be due to TrPs in the pectoralis major and/or sternalis.

Edema of breast may be caused by lymphatic entrapment by pectoralis major TrPs.

Nipple hypersensitivity/ intolerance to clothing may be due to TrPs in the pectoralis major.

Restriction of jaw opening may be due to many TrPs. The zygomaticus major alone may cause restriction of the opening by 10-20 mm.

Pharynx and throat pain may be caused by multiple facial and neck TrPs

Mouth pain, including tongue, pharynx and hard palate, may be caused by medial pterygoid TrPs.

Eye redness or swelling may be caused by sternocleidomastoid TrPs.

Gallbladder-type pain may be caused by TrPs in the oblique abdominals/lateral border rectus abdominus.

Appendicitis-like pain may be caused by TrPs in the iliopsoas, iliocostalis thoracis, and right rectus abdominus McBurney point TrP, rectus abdominus directly above umbilicus, or costal external oblique.

A lax, pendulous abdomen with gas is associated with TrPs in abdominal muscles.

Hyperasthesia/dysthesia/hypoesthesia in the cutaneous back may be due to paraspinal TrP nerve entrapment.

Renal colic-like referred pain to the loin, inguinal and scrotal regions may be caused by erector spinae TrPs.

Retraction of testicle may be due to TrPs in the erector spinae.

Testicle pain may be due to lower lateral abdominal wall TrPs.

Toothache pain may be due to sternocleidomastoid, trapezius, masseter, or temporalis TrPs.  This may include tooth cold and pressure sensitivity.

Sore throat and/or painful swallowing may be due to TrPs in the medial pterygoid, digastric, mylohyoid, stylohyoid or crico-arytenoid muscles.

TMJ pain may be caused by TrPs in the lateral pterygoid or deep masseter.

Stitch in the side may be due to TrPs in the serratus anterior and/or external oblique.

Elevated first rib may be caused by TrPs in the anterior scalene.  This can cause or contribute to costoclavicular syndrome.

Carpal tunnel pain may be caused by TrPs in the subscapularis.

Illegible handwriting and clumsy fingers; inability to button buttons, sew, paint or anything that can require a steady grip, weeder’s thumb” may be due to TrPs in the adductor and opponens pollicis or interosseous.

Foot slap gait irregularity may be caused by the long extensors of toes.

Difficulty raising arms above head may be caused by many TrPs including supraspinatus, biceps brachii and subscapularis.

Locked kneecap may be caused by TrPs in the vastus lateralis.

Buckling hip may be caused by a combination of TrPs in the rectus femoris and high vastus intermedius.

Buckling knee may be due to vastus medialis TrPs.

Buckling ankle may be due to peroneus TrPs.

Remember, if you already have TrPs and one or more of these symptoms develop, look for the pattern.  TrPs can cause or contribute to so many symptoms — not just pain.  If you have localized pain in specific patterns or a number of these symptoms, think about TrPs.  Try to find someone who can assess you for myofascial pain.  Please help to teach others about this common but often misdiagnosed condition.  Devin J. Starlanyl

 


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