High prevalence of shoulder girdle muscles with myofascial trigger points in patients with shoulder pain

Carel Bron, Jan Dommerholt, Boudewijn Stegenga, Michel Wensing, Rob A B Oostendorp, Carel Bron, Jan Dommerholt, Boudewijn Stegenga, Michel Wensing, Rob A B Oostendorp

Abstract

Background: Shoulder pain is reported to be highly prevalent and tends to be recurrent or persistent despite medical treatment. The pathophysiological mechanisms of shoulder pain are poorly understood. Furthermore, there is little evidence supporting the effectiveness of current treatment protocols. Although myofascial trigger points (MTrPs) are rarely mentioned in relation to shoulder pain, they may present an alternative underlying mechanism, which would provide new treatment targets through MTrP inactivation. While previous research has demonstrated that trained physiotherapists can reliably identify MTrPs in patients with shoulder pain, the percentage of patients who actually have MTrPs remains unclear. The aim of this observational study was to assess the prevalence of muscles with MTrPs and the association between MTrPs and the severity of pain and functioning in patients with chronic non-traumatic unilateral shoulder pain.

Methods: An observational study was conducted. Subjects were recruited from patients participating in a controlled trial studying the effectiveness of physical therapy on patients with unilateral non-traumatic shoulder pain. Sociodemographic and patient-reported symptom scores, including the Disabilities of the Arm, Shoulder, and Hand (DASH) Questionnaire, and Visual Analogue Scales for Pain were compared with other studies. To test for differences in age, gender distribution, and education level between the current study population and the populations from Dutch shoulder studies, the one sample T-test was used. One observer examined all subjects (n = 72) for the presence of MTrPs. Frequency distributions, means, medians, standard deviations, and 95% confidence intervals were calculated for descriptive purposes. The Spearman's rank-order correlation (ρ) was used to test for association between variables.

Results: MTrPs were identified in all subjects. The median number of muscles with MTrPs per subject was 6 (active MTrPs) and 4 (latent MTrPs). Active MTrPs were most prevalent in the infraspinatus (77%) and the upper trapezius muscles (58%), whereas latent MTrPs were most prevalent in the teres major (49%) and anterior deltoid muscles (38%). The number of muscles with active MTrPs was only moderately correlated with the DASH score.

Conclusion: The prevalence of muscles containing active and latent MTrPs in a sample of patients with chronic non-traumatic shoulder pain was high.

Figures

Figure 1
Figure 1
Referred pain patterns (red) from the upper and lower trapezius muscle MTrPs (Xs), according to Simons et al. Illustrations courtesy of LifeART/MEDICLIP, Manual Medicine 1, Version 1.0a, Lippincott, Williams & Wilkins, 1997.
Figure 2
Figure 2
Referred pain patterns (red) from the upper and middle trapezius muscle MTrPs (Xs), according to Simons et al. Illustrations courtesy of LifeART/MEDICLIP, Manual Medicine 1, Version 1.0a, Lippincott, Williams & Wilkins, 1997.
Figure 3
Figure 3
Referred pain patterns (red) from the anterior deltoid muscle MTrPs (Xs), according to Simons et al. Illustrations courtesy of LifeART/MEDICLIP, Manual Medicine 1, Version 1.0a, Lippincott, Williams & Wilkins, 1997.
Figure 4
Figure 4
Referred pain patterns (red) from the infraspinatus muscle MTrPs (Xs), according to Simons et al. Illustrations courtesy of LifeART/MEDICLIP, Manual Medicine 1, Version 1.0a, Lippincott, Williams & Wilkins, 1997.
Figure 5
Figure 5
Flow chart showing a schematic summary of patient participation in this study.
Figure 6
Figure 6
The number of active (black bar) and latent (grey bar) of MTrPs per subject. The X-axis shows the number of subjects, and the Y-axis shows the number of MTrPs per subject (n = 72).
Figure 7
Figure 7
The number of subjects with active (black bar) or latent MTrPs (gray bar) per muscle. The X-axis shows the muscles that were examined for identification of MTrPs, and the Y-axis shows the number of subjects with MTrPs (n = 72).
Figure 8
Figure 8
Scatterplot of DASH scores versus the number of muscles with active MTrPs. The regression line shows a weak positive correlation (r = 0.3), indicating that increasing numbers of active MTrPs have only a moderate effect on DASH scores.

References

    1. Picavet HSJ, Schouten JSAG. Musculoskeletal pain in the Netherlands: prevalences, consequences and risk groups, the DMC3-study. Pain. 2003;102(1):167–178. doi: 10.1016/s0304-3959(02)00372-x.
    1. Kuijpers T, van Tulder MW, van der Heijden GJ, Bouter LM, van der Windt DA. Costs of shoulder pain in primary care consulters: a prospective cohort study in The Netherlands. BMC Musculoskelet Disord. 2006;7:83. doi: 10.1186/1471-2474-7-83.
    1. Feleus A, Bierma-Zeinstra SM, Miedema HS, Verhaar JA, Koes BW. Management in non-traumatic arm, neck and shoulder complaints: differences between diagnostic groups. Eur Spine J. 2008;17(9):1218–1229. doi: 10.1007/s00586-008-0710-1.
    1. Macfarlane GJ, Hunt IM, Silman AJ. Predictors of chronic shoulder pain: a population based prospective study. J Rheumatol. 1998;25(8):1612–1615.
    1. Reilingh ML, Kuijpers T, Tanja-Harfterkamp AM, van der Windt DA. Course and prognosis of shoulder symptoms in general practice. Rheumatology (Oxford) 2008;47(5):724–730. doi: 10.1093/rheumatology/ken044.
    1. Schellingerhout J, Verhagen A, Thomas S, Koes B. Lack of uniformity in diagnostic labeling of shoulder pain: Time for a different approach. Man Ther. 2008. p. 6.
    1. Neer CS. Anterior acromioplasty for the chronic impingement syndrome in the shoulder: a preliminary report. J Bone Joint Surg Am. 1972;54(1):41–50.
    1. Hawkins RJ, Hobeika PE. Impingement syndrome in the athletic shoulder. Clin Sports Med. 1983;2(2):391–405.
    1. Needell SD, Zlatkin MB, Sher JS, Murphy BJ, Uribe JW. MR imaging of the rotator cuff: peritendinous and bone abnormalities in an asymptomatic population. AJR Am J Roentgenol. 1996;166(4):863–867.
    1. Schibany, Zehetgruber H, Kainberger F, Wurnig C, Ba-Ssalamah A, Herneth AM, Lang T, Gruber D, Breitenseher MJ. Rotator cuff tears in asymptomatic individuals: a clinical and ultrasonographic screening study. Eur J Radiol. 2004;51(15294335):263–268.
    1. Naranjo A, Marrero-Pulido T, Ojeda S, Francisco F, Erausquin C, Rua-Figueroa I, Rodriguez-Lozano C, Hernandez-Socorro CR. Abnormal sonographic findings in the asymptomatic arthritic shoulder. Scand J Rheumatol. 2002;31(1):17–21. doi: 10.1080/030097402317255318.
    1. Neumann CH, Holt RG, Steinbach LS, Jahnke AH Jr, Petersen SA. MR imaging of the shoulder: appearance of the supraspinatus tendon in asymptomatic volunteers. AJR Am J Roentgenol. 1992;158(6):1281–1287.
    1. Park HB, Yokota A, Gill HS, El Rassi G. Diagnostic Accuracy of Clinical Tests for the Different Degrees of Subacromial Impingement Syndrome. The Journal of Bone and Joint Surgery. 2005. (3057332520020642814)
    1. MacDonald PB, Clark P, Sutherland K. An analysis of the diagnostic accuracy of the Hawkins and Neer subacromial impingement signs. J Shoulder Elbow Surg. 2000;9(4):299–301. doi: 10.1067/mse.2000.106918.
    1. McFarland EG, Selhi HS, Keyurapan E. Clinical evaluation of impingement: what to do and what works. Instr Course Lect. 2006;55:3–16.
    1. Bonsell S, Pearsall AWt, Heitman RJ, Helms CA, Major NM, Speer KP. The relationship of age, gender, and degenerative changes observed on radiographs of the shoulder in asymptomatic individuals. J Bone Joint Surg Br. 2000;82(8):1135–1139. doi: 10.1302/0301-620X.82B8.10631.
    1. Bradley MP, Tung G, Green A. Overutilization of shoulder magnetic resonance imaging as a diagnostic screening tool in patients with chronic shoulder pain. J Shoulder Elbow Surg. 2005;14(3):233–237. doi: 10.1016/j.jse.2004.08.002.
    1. Ekeberg OM, Bautz-Holter E, Tveita EK, Juel NG, Kvalheim S, Brox JI. Subacromial ultrasound guided or systemic steroid injection for rotator cuff disease: randomised double blind study. BMJ. 2009;338:a3112. doi: 10.1136/bmj.a3112.
    1. Desmeules F, Cote CH, Fremont P. Therapeutic exercise and orthopedic manual therapy for impingement syndrome: a systematic review. Clin J Sport Med. 2003;13(3):176–182. doi: 10.1097/00042752-200305000-00009.
    1. Dorrestijn O, Stevens M, Winters JC, van der Meer K, Diercks RL. Conservative or surgical treatment for subacromial impingement syndrome? A systematic review. J Shoulder Elbow Surg. 2009;18(4):652–660. doi: 10.1016/j.jse.2009.01.010.
    1. Buchbinder R, Green S, Youd JM. Corticosteroid injections for shoulder pain. Cochrane Database Syst Rev. 2003. p. CD004016.
    1. Green S, Buchbinder R, Hetrick S. Physiotherapy interventions for shoulder pain. Cochrane Database Syst Rev. 2003. p. CD004258.
    1. Green S, Buchbinder R, Glazier R, Forbes A. Interventions for shoulder pain. Cochrane Database Syst Rev. 2000. p. CD001156.
    1. Cummins CA, Sasso LM, Nicholson D. Impingement syndrome: temporal outcomes of nonoperative treatment. J Shoulder Elbow Surg. 2009;18(2):172–177. doi: 10.1016/j.jse.2008.09.005.
    1. Gerwin RD, Dommerholt J, Shah JP. An expansion of Simons' integrated hypothesis of trigger point formation. Curr Pain Headache Rep. 2004;8(6):468–475. doi: 10.1007/s11916-004-0069-x.
    1. Simons DG, Travell JG, Simons LS. Myofascial Pain and Dysfunction. The trigger point manual. Upper half of body. second. I. Baltimore, MD: Lippincott, Williams and Wilkins; 1999.
    1. Shah JP, Danoff JV, Desai MJ, Parikh S, Nakamura LY, Phillips TM, Gerber LH. Biochemicals associated with pain and inflammation are elevated in sites near to and remote from active myofascial trigger points. Arch Phys Med Rehabil. 2008;89(1):16–23. doi: 10.1016/j.apmr.2007.10.018.
    1. Shah JP, Phillips TM, Danoff JV, Gerber LH. An in vivo microanalytical technique for measuring the local biochemical milieu of human skeletal muscle. J Appl Physiol. 2005;99(5):1977–1984. doi: 10.1152/japplphysiol.00419.2005.
    1. Chen Q, Bensamoun S, Basford JR, Thompson JM, An KN. Identification and quantification of myofascial taut bands with magnetic resonance elastography. Arch Phys Med Rehabil. 2007;88(12):1658–1661. doi: 10.1016/j.apmr.2007.07.020.
    1. Sikdar S, Shah J, Gebreab, Yen R, Gilliams E, Danoff JV, Gerber L. Novel Applications of Ultrasound Technology to Visualize and Characterize Myofascial Trigger Points and Surrounding Soft Tissue. Arch Phys Med Rehabil. 2009;90:1829–1838. doi: 10.1016/j.apmr.2009.04.015.
    1. Zhang Y, Ge HY, Yue SW, Kimura Y, Arendt-Nielsen L. Attenuated skin blood flow response to nociceptive stimulation of latent myofascial trigger points. Arch Phys Med Rehabil. 2009;90(2):325–332. doi: 10.1016/j.apmr.2008.06.037.
    1. Ge HY, Fernandez-De-Las-Penas C, Arendt-Nielsen L. Sympathetic facilitation of hyperalgesia evoked from myofascial tender and trigger points in patients with unilateral shoulder pain. Clinical Neurophysiology. 2006;117(7):1545–1550. doi: 10.1016/j.clinph.2006.03.026.
    1. Kimura Y, Ge HY, Zhang Y, Kimura M, Sumikura H, Arendt-Nielsen L. Evaluation of sympathetic vasoconstrictor response following nociceptive stimulation of latent myofascial trigger points in humans. Acta Physiologica. 2009;196(4):411–417. doi: 10.1111/j.1748-1716.2009.01960.x.
    1. Hubbard DR, Berkoff GM. Myofascial trigger points show spontaneous needle EMG activity. Spine (Phila Pa 1976) 1993;18(13):1803–1807. doi: 10.1097/00007632-199310000-00015.
    1. Bron C, Franssen J, Wensing M, Oostendorp RA. Interrater reliability of palpation of myofascial trigger points in three shoulder muscles. J Man Manip Ther. 2007;15(4):203–215. doi: 10.1179/106698107790819477.
    1. Ettlin T, Schuster C, Stoffel R, Bruderlin A, Kischka U. A distinct pattern of myofascial findings in patients after whiplash injury. Arch Phys Med Rehabil. 2008;89(7):1290–1293. doi: 10.1016/j.apmr.2007.11.041.
    1. Skootsky SA, Jaeger B, Oye RK. Prevalence of myofascial pain in general internal medicine practice. West J Med. 1989;151(2):157–160.
    1. Fishbain DA, Goldberg M, Meagher BR, Steele R, Rosomoff H. Male and female chronic pain patients categorized by DSM-III psychiatric diagnostic criteria. Pain. 1986;26(2):181–197. doi: 10.1016/0304-3959(86)90074-6.
    1. Gerwin R. A study of 96 subjects examined both for fibromylagia and myofascial pain. J Musculoskeletal Pain. 1995;3(supple 1)
    1. Fricton JR, Kroening R, Haley D, Siegert R. Myofascial pain syndrome of the head and neck: a review of clinical characteristics of 164 patients. Oral Surg Oral Med Oral Pathol. 1985;60(6):615–623. doi: 10.1016/0030-4220(85)90364-0.
    1. Sola AE, Kuitert JH. Myofascial trigger point pain in the neck and shoulder girdle; report of 100 cases treated by injection of normal saline. Northwest Med. 1955;54(9):980–984.
    1. Fleckenstein J, Zaps D, Ruger LJ, Lehmeyer L, Freiberg F, Lang PM, Irnich D. Discrepancy between prevalence and perceived effectiveness of treatment methods in myofascial pain syndrome: Results of a cross-sectional, nationwide survey. BMC Musculoskelet Disord. 2010;11(1):32. doi: 10.1186/1471-2474-11-32.
    1. Bron C, Franssen JLM, de Valk BGM. A post-traumatic Shoulder Complaint without apparent injury. (Een posttraumatische schouderklacht zonder aanwijsbaar letsel) Ned Tijdschrift v Fysiotherapie. 2001;111(4):97–102.
    1. Ge HY, Fernandez-de-Las-Penas C, Madeleine P, Arendt-Nielsen L. Topographical mapping and mechanical pain sensitivity of myofascial trigger points in the infraspinatus muscle. Eur J Pain. 2008;12(7):859–865. doi: 10.1016/j.ejpain.2007.12.005.
    1. Reynolds MD. Myofascial trigger points in persistent posttraumatic shoulder pain. South Med J. 1984;77(10):1277–1280. doi: 10.1097/00007611-198410000-00018.
    1. Abate M, Gravare-Silbernagel K, Siljeholm C, Di Iorio A, De Amicis D, Salini V, Werner S, Paganelli R. Pathogenesis of tendinopathies: inflammation or degeneration? Arthritis Res Ther. 2009;11(3):235. doi: 10.1186/ar2723.
    1. Falla D, Farina D, Graven-Nielsen T. Experimental muscle pain results in reorganization of coordination among trapezius muscle subdivisions during repetitive shoulder flexion. Exp Brain Res. 2007;178(3):385–393. doi: 10.1007/s00221-006-0746-6.
    1. Lucas KR, Rich PA, Polus BI. Muscle activation patterns in the scapular positioning muscles during loaded scapular plane elevation: the effects of Latent Myofascial Trigger Points. Clin Biomech. 2010;25(8):765–770. doi: 10.1016/j.clinbiomech.2010.05.006.
    1. Hidalgo-Lozano A, Fernandez-de-las-Penas C, Alonso-Blanco C, Ge HY, Arendt-Nielsen L, Arroyo-Morales M. Muscle trigger points and pressure pain hyperalgesia in the shoulder muscles in patients with unilateral shoulder impingement: a blinded, controlled study. Exp Brain Res. 2010;202(4):915–925. doi: 10.1007/s00221-010-2196-4.
    1. Bron C, Wensing M, Franssen JL, Oostendorp RA. Treatment of myofascial trigger points in common shoulder disorders by physical therapy: a randomized controlled trial [ISRCTN75722066] BMC Musculoskelet Disord. 2007;8:107. doi: 10.1186/1471-2474-8-107.
    1. Bergman GJ, Winters JC, Groenier KH, Pool JJ, Meyboom-de B Jong, Postema K, van der Heijden GJ. Manipulative therapy in addition to usual medical care for patients with shoulder dysfunction and pain: a randomized, controlled trial. Ann Intern Med. 2004;141(6):432–439.
    1. Bot SD, van der Waal JM, Terwee CB, van der Windt DA, Schellevis FG, Bouter LM, Dekker J. Incidence and prevalence of complaints of the neck and upper extremity in general practice. Ann Rheum Dis. 2005;64(1):118–123. doi: 10.1136/ard.2003.019349.
    1. de Winter AF, Jans MP, Scholten RJ, Deville W, van Schaardenburg D, Bouter LM. Diagnostic classification of shoulder disorders: interobserver agreement and determinants of disagreement. Ann Rheum Dis. 1999;58(5):272–277. doi: 10.1136/ard.58.5.272.
    1. Feleus A, Bierma-Zeinstra S, Miedema H, Verhaar J, Koes B. Management in non-traumatic arm, neck and shoulder complaints: differences between diagnostic groups. Eur Spine J. 2008;17(9):1218–1229. doi: 10.1007/s00586-008-0710-1.
    1. van der Windt DA, Koes BW, Boeke AJ, Deville W, De Jong BA, Bouter LM. Shoulder disorders in general practice: prognostic indicators of outcome. Br J Gen Pract. 1996;46(410):519–523.
    1. Geisser ME, Roth RS, Robinson ME. Assessing depression among persons with chronic pain using the Center for Epidemiological Studies-Depression Scale and the Beck Depression Inventory: a comparative analysis. Clin J Pain. 1997;13(2):163–170. doi: 10.1097/00002508-199706000-00011.
    1. Gerwin R, Shannon S. Interexaminer reliability and myofascial trigger points. Arch Phys Med Rehabil. 2000;81(9):1257–1258. doi: 10.1053/apmr.2000.18575.
    1. Al-Shenqiti AM, Oldham JA. Test-retest reliability of myofascial trigger point detection in patients with rotator cuff tendonitis. Clin Rehabil. 2005;19(5):482–487. doi: 10.1191/0269215505cr791oa.
    1. Solway S, Beaton D, McConnell S, Bombardier C. The DASH Outcome Measure User's Manual. second. Toronto: Institute for Work & Health; 2002.
    1. Bot SD, Terwee CB, van der Windt DA, Bouter LM, Dekker J, de Vet HC. Clinimetric evaluation of shoulder disability questionnaires: a systematic review of the literature. Ann Rheum Dis. 2004;63(4):335–341. doi: 10.1136/ard.2003.007724.
    1. McCormack HM, Horne DJ, Sheather S. Clinical applications of visual analogue scales: a critical review. Psychol Med. 1988;18(4):1007–1019. doi: 10.1017/S0033291700009934.
    1. Feinstein A. Clinimetrics. New York: Yale University Press; 1987.
    1. Roy JS, Macdermid JC, Woodhouse LJ. Measuring shoulder function: A systematic review of four questionnaires. Arthritis Care Res. 2009;61(5):623–632. doi: 10.1002/art.24396.
    1. Gummesson C, Atroshi I, Ekdahl C. The disabilities of the arm, shoulder and hand (DASH) outcome questionnaire: longitudinal construct validity and measuring self-rated health change after surgery. BMC Musculoskelet Disord. 2003;4:11. doi: 10.1186/1471-2474-4-11.
    1. Schmitt JS, Di Fabio RP. Reliable change and minimum important difference (MID) proportions facilitated group responsiveness comparisons using individual threshold criteria. J Clin Epidemiol. 2004;57(10):1008–1018. doi: 10.1016/j.jclinepi.2004.02.007.
    1. Beaton DE, Katz JN, Fossel AH, Wright JG, Tarasuk V, Bombardier C. Measuring the whole or the parts? Validity, reliability, and responsiveness of the Disabilities of the Arm, Shoulder and Hand outcome measure in different regions of the upper extremity. J Hand Ther. 2001;14(2):128–146.
    1. Hunsaker FG, Cioffi DA, Amadio PC, Wright JG, Caughlin B. The American academy of orthopaedic surgeons outcomes instruments: normative values from the general population. J Bone Joint Surg Am. 2002;84-A(2):208–215.
    1. Diederichsen LP, Norregaard J, Dyhre-Poulsen P, Winther A, Tufekovic G, Bandholm T, Rasmussen LR, Krogsgaard M. The activity pattern of shoulder muscles in subjects with and without subacromial impingement. J Electromyogr Kinesiol. 2009;19(5):789–799. doi: 10.1016/j.jelekin.2008.08.006.
    1. Hess SA, Richardson C, Darnell R, Friis P, Lisle D, Myers P. Timing of rotator cuff activation during shoulder external rotation in throwers with and without symptoms of pain. J Orthop Sports Phys Ther. 2005;35(12):812–820.
    1. Gerwin R. Myofascial Pain Syndrome: Here we are, where must we go? J Musculoskeletal pain. 2010;18(4):18.
    1. Bron C, de Gast A, Dommerholt J, Stegenga B, Wensing M, Oostendorp RA. Treatment of myofascial trigger points in patients with chronic shoulder pain: a randomized, controlled trial. BMC Med. 2011;9:8. doi: 10.1186/1741-7015-9-8.
    1. DiMatteo MR. Evidence-based strategies to foster adherence and improve patient outcomes. JAAPA. 2004;17(11):18–21.
    1. DiMatteo MR. Variations in patients' adherence to medical recommendations: a quantitative review of 50 years of research. Med Care. 2004;42(3):200–209. doi: 10.1097/01.mlr.0000114908.90348.f9.
    1. Vecchiet L. Muscle Pain and Aging. Journal of Musculoskeletal Pain. 2002;10(1):5–22. doi: 10.1300/J094v10n01_02.
    1. Rollman GB, Lautenbacher S. Sex differences in musculoskeletal pain. Clin J Pain. 2001;17(1):20–24. doi: 10.1097/00002508-200103000-00004.
    1. Treaster DE, Burr D. Gender differences in prevalence of upper extremity musculoskeletal disorders. Ergonomics. 2004;47(5):495–526. doi: 10.1080/00140130310001638171.
    1. Ring D, Kadzielski J, Fabian L, Zurakowski D, Malhotra LR, Jupiter JB. Self-reported upper extremity health status correlates with depression. J Bone Joint Surg Am. 2006;88(9):1983–1988. doi: 10.2106/JBJS.E.00932.
    1. Fillingim RB, King CD, Ribeiro-Dasilva MC, Rahim-Williams B, Riley JL. Sex, gender, and pain: a review of recent clinical and experimental findings. J Pain. 2009;10(5):447–485. doi: 10.1016/j.jpain.2008.12.001.
    1. Beck AT, Brown G, Steer RA. Beck Depression Inventory II manual. San Antonio, TX: The Psychological Corporation; 1966.

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