Cervical myofascial pain is a type of myofascial pain syndrome that originates from neck muscle and surrounding fascia which becomes tight or damaged.
Cervical myofascial syndrome is characterized by
- Stiff neck with limited range of motion
- Tight painful neck muscles
- Pain that goes to surrounding parts like head or shoulder
- Trigger points- Sharp small knots in the neck/upper back which are painful on being pressed
Trigger points are hyperirritable areas located in a palpable, taut band of muscles.
Know more about trigger points.
Cervical myofascial pain is thought to occur following either overuse of or trauma to the muscles that support the shoulders and neck though it can also occur due to underlying issues like arthropathy.
Trapezius, levator scapulae, rhomboids, supraspinatus, and infraspinatus are the most commonly involved muscles.
Myofascial pain is common and constitutes about one-fifth of the OPD attendance. Its incidence increases with age till middle age whereafter it starts to decrease.
Causes
The following can be causes of cervical myofascial pain
- Overuse of muscles
- Repetitive injury
- Wrong posture- For example, high desk job with high keyboards stresses trapezius
- Trauma to neck muscles as in motor vehicle accident
- Underlying condition
- Arthritis of zygapophyseal or facet joint
- Annular tear in disc
Other risk factors which are thought to have a contributory role are
- Hormonal imbalance
- Chronic infections
- Poor nutrition
- Poor posture
- Stress
Pathophysiology
The pathophysiology of myofascial pain is not clear per se.
Taut bands within the muscles may develop in response to trauma. The trigger points can also develop in response to trauma.
An increase in acetylcholine levels leading to increased muscle tension and the formation of the taut bands has been theorized.
This leads to a decrease in tissue oxygen and activation of pain fibers and autonomic modulation.
This, in turn, causes a further increase in acetylcholine levels causing a vicious circle.
The location of the trigger points varies with the muscle involved. The region of the pain referred to depends on the location of the trigger points. A rough estimation is given below.
- Trapezius
- Neck
- Shoulder
- Temporal region
- Splenius capitis and cervicis
- Head
- Occiput, shoulder, and neck; vision may be blurred
- Posterior neck muscles, semispinalis capitis and cervici multitifidi
- Suboccipital area, neck, and shoulders
- Levator scapulae
- The angle of the neck
- Along the vertebral body of the border of the scapula
- Scalene Muscles
- Chest
- Upper-central border of the scapula
- Along the arm.
- Supraspinatus
- Posterior neck
- Suboccipital area of the deltoid
- Deep in the shoulder joint
- Front and lateral aspects of the arm.
Presentation
The patient may present with acute pain after the trauma though it is more common to have a pain that is insidious in origin.
A history of poor posture, repetitive works, and stress should be asked specifically.
There could be additional symptoms present
- Neck stiffness affecting the range of motion
- Painful knot or bump in one or more neck muscles [trigger points]
- Disturbed sleep due to pain
- Pain and paresthesiae in upper limb
On examination, the patient might have a poor posture [such as rounding of shoulders and protraction of scapula Palpation of the muscles esp trapezius, supraspinatus, infraspinatus, rhomboids, and levator scapulae muscles may reveal taut fibers and trigger points. It is a good idea to note down number and location of the trigger points.
The range of motion of the patient may be decreased.
Imaging
The diagnosis of myofascial pain is mainly clinical.
Imaging may be done to rule out and evaluate other diagnostic possibilities such as trauma. For example, x-rays may be done to rule out possible underlying conditions like cervical instability.
Magnetic resonance imaging may help to rule out problems in the cervical spine and spinal canal.
Differential Diagnoses of Cervical Myofascial Pain
Common differential diagnoses of cervical myofascial pain are
- Cervical Disc Disease
- Cervical Spondylosis
- Cervical sprain
- Fibromyalgia
- Rheumatoid Arthritis
- Thoracic Outlet Syndrome
Treatment of Cervical Myofascial Pain
Treatment of myofascial pain on the neck involves multiple approaches. The options include
- Physical therapy
- Myofascial release
- Exercises
- Heat therapy
- Stretch and spray
- Self massages
- Trigger point injection
- Dry needling
- Drugs
- Relaxation techniques
Physical Therapy
Physical therapy aims to diminish the pain and restore the balance between muscle units. The following processes are used to achieve this
For myofascial release is done by using gentle direct pressure and long stretching strokes on trigger points. Progress is depicted by increase in range of motion and ease of function.
Cervical stretch and stabilization exercises work to stretch the neck tissue and strengthen the muscle.
Postural retraining is important in cervical myofascial pain.
An ergonomic evaluation may be indicated if overuse in the work setting is contributing to the patient’s symptoms.
Aerobic exercises, such as biking, swimming, and walking are also recommended.
The patient can also do self or assisted massage at home.
Trigger Point Injection
Trigger point injection is performed by inserting the needle into the trigger point and insert a local anesthetic. This causes relaxation of trigger point and that allows an increase in movements.
Stretch and spray
A vapor coolant spray applied to the affected muscle after it has been placed in the passive stretch.
Dry Needling
Ischemic Compression
Ischemic compression involves the application of sustained pressure on the trigger point. It is done by pressing firmly on the trigger point with a thumb after the muscle is fully stretched. The pressure is lessened gradually as the pain decreases.
Drug Therapy
There are various drugs that can be used to address cervical myofascial pain.
Analgesics
Nonsteroidal anti-inflammatory drugs are the drugs of choice for the initial treatment of cervical myofascial pain. Ibuprofen, Indomethacin, naproxen, diclofenac, and ketoprofen are commonly used drugs.
Opioid analgesics like tramadol can also be used.
Tricyclic Antidepressants
Tricyclic antidepressants like amitriptyline are commonly used for chronic pain. They also help to treat associated insomnia.
Muscle Relaxants
Cyclobenzaprine, baclofen, carisoprodol, tizanidine are commonly used muscle relaxants.
Anticonvulsants
Gabapentin has been shown to be effective in treating myofascial and neuropathic pain.
Prognosis of Cervical Myofascial Pain
Cervical myofascial pain is a treatable condition but recurrence is a problem. With appropriate treatment, the prognosis is generally good. The early treatment produces better results.
References
- Touma J, May T, Isaacson AC. Cervical Myofascial Pain. StatPearls.
- Affaitati G, Costantini R, Tana C,et al. Effects of topical vs injection treatment of cervical myofascial trigger points on headache symptoms in migraine patients: a retrospective analysis. J Headache Pain. 2018 Nov 8. 19 (1):104.
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I identify myself as having many of the symptoms detailed here. I've suffered from what I have always labeled 'tension headaches' for ten years now, starting in my late teens, however the pain is not actually in my head at all. The tension begins at the bottom of my cranium, spreading through the back and sides of my neck and slightly under the ears, right down to the most tender points along the tops of my shoulders. I also have a great deal of tension at the top of my shoulder blades. I experience an episode every 10-14 days which generally last 2-3 days a time. 9 times out of 10 I actually wake up with pain having gone to bed ok. The only relief I get is by applying a heat pack but the pain returns within hours. I have been able to continue to attend work but with a great deal of discomfort. I have had both physio and osteopathy treatment over the years where I have experienced some relief with soft tissue massage and adjustments but the muscle tension returns again within days.
I have had countless eye/dental tests, changed my pillows/matresses, changed my birth control and cut possible food triggers out of my diet. All to no avail. I have not suffered any trauma to my neck and do not suffer from stress or depression. I try not to take pain relief medication as I do not want to become addicted or develop rebound headaches. I have been taking magnesium phosphate tablets for six months but have not noticed any improvement.
I can only assume that the cause is either my sleeping position itself or my posture so I am working on improving this. My doctor has simply advised that I need to explore what the causes of my 'tension' are by myself.
Can anyone offer any suggestions or shed any light on what else I should explore? My chiropractor has mentioned fybromyalgia but from what I've read this appears to be a more severe pain and much wider spreading muscle issue throughout the body than I experience.
Thank you in advance for any feedback you are able to offer.
@C.O'Halloran,
Has your neck been examined and investigated?
This information is very helpful and I work at Ortho and sports medicine practice I know lots of MSK issues but this is still good information I can use for myself, I have been dealing with cervical myofascial issues since 2 years and sometimes it is very frustrating. Thank you!
Thanks for your appreciation and I am glad you found it useful.