Myofascial pain disorders can be challenging to diagnose and they frequently overlap. With this in mind, this author reviews common signs and symptoms of conditions ranging from bursitis and plantar fasciitis to fibromyalgia, and offers pertinent treatment pearls as well.

When it comes to managing common soft tissue myofascial pain disorders, a key principle is correctly identifying the involved anatomical structures. In order to ensure an accurate diagnosis, one must perform a complete physical exam and obtain a thorough patient history. Within that history, clinicians must identify precipitating and aggravating events to the presenting complaint, and ascertain the patient’s work history as well.

Is there a problem from a single injury or from repetitive activities? Are multiple soft tissue myofascial pain disorders occurring simultaneously? This is often the case.

The author notes he often sees cases in which multiple soft tissue myofascial pain disorders occur simultaneously. For example, he often sees patients with neck pain who also have shoulder pain.

I often see patients with neck pain who also have shoulder pain or patients with low back pain as well as hip pain from osteoarthritis. The challenge is trying to sort out how much of the patient’s pain is from one source or the other. To effectively treat the patient, it is imperative to sort out the source of a patient’s pain, ascertain which site is causing a majority of your patient’s symptoms and then focus the treatment efforts on the most symptomatic site first. Once one has established the diagnosis, the clinician can proceed to outline a specific treatment plan.

Key Considerations For Bursitis
Treatment for bursitis depends of course on the site of the bursa. There are approximately 150 sites for bursae in humans. Clinicians treat most bursae with local heat or ice, stretching, nonsteroidal antiinflammatory drugs (NSAIDS) and protection of the area from trauma. One may also tailor a specific exercise program for any area affected by bursitis. Clinicians may choose to refer the patient to a physical therapist to help facilitate care for these patients.

Bear in mind that some bursae may be resistant to the aforementioned conservative treatments. Anserine, ischial, trochanteric, olecranon or subacromial bursae are especially suited for corticosteroid injections, which one may utilize to help reduce inflammation. However, clinicians should not inject an Achilles or patellar tendon for tendonitis or bursitis as the corticosteroids weaken the tendon structure and increase the likelihood of tendon rupture.

Identifying And Treating Tendonitis And Enthesitis
Tendonitis is another common complaint of many patients presenting to primary care or rheumatology offices. In these cases, clinicians will note pain, erythema and occasionally swelling over the site of the tendonitis. There may be “triggering” of a finger secondary to stenosing tenosynovitis and you can palpate a mass in the tendon.

When it comes to conservative care for tendonitis, one may emphasize relative rest, NSAIDs and judicious use of corticosteroid injections. In a more extreme case, clinicians may opt for splinting and bracing of the affected limb in order to facilitate a period of rest for the patient. One may also consider referral for surgical debridement (synovectomy) and tenovaginotomy (trigger finger release) in those cases that do not respond to conservative measures.

Enthesitis is defined as inflammation of an insertion of a tendon or ligament into a bone. There is magnetic resonance imaging (MRI) evidence of inflammatory changes at these sites. When one targets specific treatment to the enthesitis, the patients do respond. With a careful physical exam, clinicians can isolate the site of tenderness. If there are many diffuse sites of enthesitis, you should suspect an inflammatory spondylitis and investigate with appropriate testing such as an HLA-B-27 gene test.

To treat enthesitis, you may utilize local heat or ice therapy, stretching exercises and NSAIDs. Practitioners may employ physical therapy to assist in decreasing the patient’s pain level and stiffness. A physical therapist can also assist in teaching the patient a home exercise program. Judicious use of corticosteroid injections may help in reducing the pain and inflammation of enthesitis. As noted earlier, avoid using steroid injections around the Achilles or patellar tendons. This prevents weakening and rupture of the tendon that occurs with overuse of corticosteroid injections in or around the tendon.

Keys To Treating Plantar Fasciitis
Fasciitis involves pain in the heel. We see this malady commonly in our practice. Usually patients come in to the office and tell me they have pain in their foot from a “heel spur.” Most studies confirm that the pain is caused by inflammation of the plantar fascia and that the spur is merely an incidental finding on the X-rays. I have even treated this problem without getting X-rays during the first visit. Indeed, I often have to reeducate the patients and family regarding the incidence of asymptomatic heel spurs in multiple studies. I believe the pain on the plantar region of the foot is caused by the plantar fasciitis and that the spur is meaningless in this regard.

When it comes to conservative care for tendonitis, clinicians may opt for judicious use of corticosteroid injections, NSAIDs and emphasize relative rest for these patients.

The treatment modalities for plantar fasciitis include stretching exercises, local heat or ice, NSAIDs, stretching exercises, night splints, emphasizing good shoe fit, stretching exercises, casting and the judicious use of corticosteroid injections. Stretching exercises are the mainstay of treatment for plantar fasciitis. To assist my patients in their ice treatments, I advise them to use a frozen juice can and roll it on the floor with the sole of their foot for 10 to 15 minutes after they perform their stretching exercises.

If all of these modalities fail, you may choose to refer the patient to a surgeon for plantar fascial release. This procedure will usually relieve even the most intractable cases of plantar fasciitis.

How To Recognize Fibromyalgia
I cannot write about the treatment of myofascial pain without mentioning fibromyalgia syndrome (FMS). Fibromyalgia syndrome is a regional pain disorder that is frequently misunderstood and frequently misdiagnosed as there is a major overlap with multiple other diagnoses.

Some of the other diagnoses that overlap with FMS include but are not limited to: depression, chronic fatigue, interstitial cystitis and irritable bowel syndrome. It is difficult to ascertain a concrete diagnosis for FMS. There are no lab tests to confirm our diagnosis. There are no firm X-ray or imaging studies to hang our hats on when our diagnostic acumen is brought to task. Some may place too much emphasis on “trigger points” and almost demand that there be tenderness in 11 out of 18 specific trigger points in order for one to make the FMS diagnosis.1 There are also major and minor diagnostic criteria lists for the diagnosis of FMS.2

However, I believe that if you work long enough in a rheumatology clinic, you can make a diagnosis of FMS with fewer than 11 of the 18 trigger points and less that two out of four major criteria.2

You can tell when a patient is depressed, has interstitial cystitis, has irritable bowel syndrome and sleep disturbances. You can tell when this person hurts most of the time and the lab work is normal or only has minimal changes that are nonspecific. If you have worked long enough in the clinic, you can make the diagnosis of FMS clinically and with a lot of certainty.

We also know that the disease of FMS can wax and wane just like other diseases. One day, the patient may feel better yet feel much worse the very next day. Trigger points may be apparent one day and not too apparent the next day. This is just the nature of the disease.

While the cause of FMS is unknown, there is an increase in substance P and a brain fMRI scan can show increased activity in areas known to process the pain response in patients who have been diagnosed with fibromyalgia.4

Pertinent Pearls For Managing FMS
We also know there are ways of “dialing down” the pain volume of the brain in patients with FMS. One is by having the patient get enough restful sleep. You have to question these patients about their sleep patterns and if they wake up feeling rested in the morning. If the patient states that he or she is constantly waking up during the night, tosses and turns all night or wakes up feeling just as fatigued as when he or she went to bed, the patient is not getting restful sleep. Sleep studies are in order for these patients. Sleep apnea and periodic limb movement are common problems that one should rule out.

You should also discuss possible changes to a patient’s sleep habits. Some ways to help patients get the sleep they need may include warm baths, reading, no late meals, a comfortable room temperature and quiet, dark rooms. However, further research is needed on proper sleeping habits for patients who have difficulty sleeping.

There are also several good sleep medications available that are non-habit forming. While the following drugs are not approved by the Food And Drug Administration (FDA) for the treatment of FMS, one may prescribe these medications off-label for these patients.

Some examples of pharmacotherapy that I prefer to use include: tricyclic antidepressants, usually amitriptyline (Elavil) and cyclobenzaprine (Flexeril), a muscle relaxer related to the tricyclics. Both have had favorable double-blind studies in the treatment of disorders like FMS.5

Depression and chronic fatigue are two of the diagnoses that overlap with fibromyalgia syndrome (FMS). Other overlapping diagnoses include interstitial cystitis and irritable bowel syndrome.

Another class of antidepressants that I have found promising are the norepinephrine and serotonin reuptake inhibitors (NSRIs), specifically duloxetine (Cymbalta, Eli Lilly). I have had a few patients who have experinced marked relief of their pain and depression, as well as improvement of their sleep habits. At our clinic, we also use gabapentin (Neurontin, Pfizer) for the pain of FMS. There have also been anecdotal reports of pain improvement with this medication. Pregabalin (Lyrica, Pfizer) may also have a place in the treatment of FMS pain.

Clinicians may also utilize analgesics to treat FMS. In our clinic, Tramadol (Ultram) is our first choice among the opioid class of drugs. We also combine Tramadol with acetaminophen to obtain the synergistic effects that the two drugs have with each other (Ultracet). However, be certain to counsel your patients regarding the amount of acetaminophen that they are ingesting. Carefully review their current OTC and prescribed medications to see how much contains acetaminophen.

If the patient still requires stronger analgesic medications, we will at times use hydrocodone, darvocet, methadone, fentanyl transdermal or other opiates for select patients. We do require a pain contract on these patients and the patients are required to adhere to the contract.

As noted previously, none of the drugs are specifically FDA-approved for managing FMS. We use them off-label to help treat those with FMS.

Another approach to help make an impact on FMS pain is encouraging patients to get enough aerobic exercise. Daily aerobic exercise that lasts about 30 minutes each day has proven to reduce the pain in FMS patients.6 Walking, swimming, elliptical exercise devices, bicycles or any aquatic exercises offer quality aerobic exercises that are not hard on muscles or joints that may be painful. When it comes to patients with FMS, the hardest part of the exercise is getting the patient to start. When a patient first starts exercising, he or she frequently has more pain in muscles and joints that have not been exercised for some time. This often frustrates these patient and tempts them to stop exercising again.

All other treatment modalities — NSAIDs, antidepressants, analgesics, ice, heat, massage, sleep aids, physical therapy, acupuncture, etc. — are all geared to allowing the FMS patient to get more restful sleep and be more comfortable with aerobic exercise. When the patient can rest and exercise, he or she will have less pain and become less dependent on the medications to assist with sleep and exercises.

In Conclusion
The treatment is very similar for most of these painful disorders. Relative rest, heat, ice, NSAIDs, exercises with stretching, physical therapy and corticosteroid injections are the main components of our treatment regimens. It is all very simple if you break it down into its main components.

However, the art of treating our patients is to gain their confidence and trust during the treatment process. The practitioner must have empathy for the patient and try to understand what the patient is attempting to relate about his or her disease to us. As providers, we must obtain a thorough history and perform a good physical exam so we understand what the patient is feeling in terms of pain. Gaining the trust and confidence of a patient can go a long way toward facilitating an effective treatment plan. Once you have this bond with the patient, the rest of the treatment is easier although not always easy.

Another challenge is identifying the appropriate candidates for the current and emerging drugs. One may advocate for those patients with their insurance companies, and monitor the patients for appropriate response and possible side effects over time. We should also remain vigilant to new therapies on the horizon that may become available and could be of benefit for our patients. Indeed, we always need to remember that the patient comes first.