Cervical Myofascial Pain- Causes, Symptoms and Treatment

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

1. Touma J, May T, Isaacson AC. Cervical Myofascial Pain. StatPearls.
2. 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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