“Vitality shows in not only the ability to persist but the ability to start over.”
– Scott Fitzgerald

Myofascial Pain

Myofascial pain is one of the most overlooked and ignored causes of chronic pain.  Myofascial pain is defined as pain derived from muscle and/or fascia, including scar tissue. Fascia is a tough, fibrous, viscoelastic membranous sheet-like matrix formed from stiff fibers called collagen and elastic fibers called elastin.



See also:



This fascial matrix surrounds and connects every cell, tissue and structure in the body. As the primary component of our connective tissues that creates a thin gelatinous and friction-less interface between the skin and the body’s interior rigid structure. It is continuous throughout the body and is responsible for maintaining the stability of the form and structure of our body. Without fascia, our tissues would lack cohesiveness and our bodies would simply be a skin sack of guts with a skeletal core.

Although the extracellular fibrous matrix is predominant in fascia, there are also several cell populations within it including adipocytes (fat cells), endothelial cells of blood vessels, nerve terminals and various migrating white blood cells such as mast cells.


Myofascial Pain

Muscle and fascia both contain pain receptors that contribute to most if not all chronic, painful musculoskeletal conditions. They may be a primary, or independent, source of pain derived from an isolated injury or pathology of muscle or fascia or they may be secondary, related to another condition such as arthritis or spine injury. Myofascial pain is also believed to be a component of visceral pain conditions such as endometriosis, interstitial cystitis, irritable bowel syndrome, painful menstruation and prostatitis.

Myofascial pain is usually experienced as a hypersensitive spot in a tight band of a skeletal muscle that is painful when compressed, stretched or overloaded when using the muscle. The pain is nociceptive, mostly described as deep and aching, cramping or dull. In the presence of a trigger point (TrP), a localized source of myofascial pain, the pain can be referred to areas distant from its source and usually has a distinct referred pain pattern.


Because myofascial pain frequently accompanies most chronic musculoskeletal conditions, it is important to evaluate these conditions for the co-existing presence of TrPs. Left untreated, TrPs can be responsible for severe pain that seriously compromises function and quality of life. Worse, the referral patterns of TrPs can mislead clinicians toward incorrect diagnoses and inappropriate procedures, even surgery. An extensive review of trigger points, their causes, manifestations and their treatment is found on another page on this website.

See: Trigger Point Therapy


Myofascial Pain Syndrome

The Myofascial Pain Syndrome (MPS) may be defined as meeting the following four criteria:

1. Regional pain location not restricted to a dermatomal pattern characteristic of nerve root pain

2. Presence of either:

    • Trigger points with referred pain OR
    • Muscular tender points (without referral) in the presence of taut bands, nodules, or ropiness in muscle

3. Normal neurological examination

4. At least one of the following:

    • Pain described as dull, achy, or deep
    • Decreased range of motion (ROM)


Principles of Understanding Myofascial Pain Syndrome (MPS) and Treatment

In addition to pain, the myofascial pain syndrome (MPS) compromises individuals in other ways: it provokes muscle dysfunction, e.g. muscle weakness, muscle irritability, muscle cramps and spasm along with impaired range of motion of the spine and joints. As a consequence of muscle dysfunction, postural imbalances then occur, further contributing to neck, back and/or joint pain. These imbalances coupled with muscle weakness increase the risk for falls and further injury. In effect, MPS not only contributes to existing pain and functional impairment but also perpetuates underlying pain conditions and perpetuates itself.


Examples of Conditions that Contribute to MPS

Whiplash (motor vehicle accidents, slip & fall, sports, injuries etc.)

The abrupt movement from impact triggers muscle  to contract to maintain postural stabilization
. The inertial forces produce a whipping motion that coupled with muscle contractions (often asymmetirc or eccentric when head is turned at the time) causes muscle and connective tissue damage and dysfunction.


Overuse (typing, occupation, hobby, postural distortion, etc)

Constant contractions of muscles causes decrease blood circulation
 and metabolic waste increases along a with lack of oxygen and nutrients for muscle health. This results in tissue damage that includes disruption of the nerve receptors in the muscles and fascia and imbalances in neurotransmitters at the nerve-muscle junctions (acetylcholine and acetylcholine receptors), giving rise to muscle dysfunction including spasm and weakness. The long duration of postural distortion also leads to fascial distortion, further contributing to joint dysfunction.


Lack of use (bed rest, cast, splint, etc)

In the absence of adequate muscle movement, there is reduced production of fascial lubricant (glycosaminoglycans and mucopolysaccharides)
 generated by the fascia that facilitates and maintains normal muscle movement and range of motion. An additional consequence of lack of use is muscle atrophy
 as well as loss of motor “memory” that facilitates routine, repetitive motions resulting in muscle dysfunction.


Strain-Sprain (unaccustomed overload, eccentric or excessive stretching of the joint, etc)

The “strains” that occurs during whiplash, falls or near-falls, forceful overloads etc. result in tears of muscle and fascia structural proteins
. In “sprains” there is damage to the ligament caused by stretching beyond the elastic limit of that ligament which introduces an inflammatory response.  Local pain signals from these injuries produce functional muscle splinting, or impaired contractions.


Understanding the Mechanisms of Myofascial Pain

Pain felt at the source of pain is termed “local pain” or “primary pain,” whereas pain felt in a region away from the source of pain is termed “referred pain.” Referred pain can be perceived in any region of the body, but the size of the referred pain area is variable.


Local Myofascial Pain

Muscle pain is associated with the activation of muscle pain receptors (nociceptors) by a variety of local substances, including neuropeptides and inflammatory mediators that have been triggered by injury. Studies have confirmed the presence of multiple biochemical substances in the immediate proximity of TrP. It is believed that peripheral sensitization occurs, described as a reduction in the pain threshold and an increase in responsiveness of the peripheral nociceptors, leading to heightened perception of pain in the area of TrPs. Local myofascial pain is typically described as deep, dull and achy, characteristic of nociceptive pain.

Nociceptive pain, and especially muscle stiffness, tends to be very responsive to NSAIDs and low potency opioids. Massage is also a very effective means of reducing local myofascial pain. Trigger points, however, require more vigorous manipulation of the tissues than afforded by gentle, Swedish massage, to obtain resolution of the pain. Deep tissue massage along with more forceful passive stretching is often required after initiating treatment of trigger points with dry needling. (See: Trigger Point Therapy).


Referred Myofascial Pain

The mechanisms of referred myofascial pain/TrPs is a combination of peripheral sensitization and central sensitization. The intensity of referred pain and the size of the referred pain area are positively correlated with central nervous system excitability and it is believed that muscle referred pain is a central sensitization process mediated by a peripheral sensitization phenomenon, with additional sympathetic activity facilitation and dysfunctional descending pain inhibition.


According to current theory, referred pain occurs in the spinal cord at the dorsal horn level and is the result of activation, by means of peripheral and central sensitization mechanisms, of inactive nerve connections between nerve fibers. The referred pain triggered by a TrP is a central phenomenon initiated, activated, and maintained by peripheral sensitization. Peripheral nociceptive input can sensitize previously silent dorsal horn neurons.


Central sensitization processes are also involved in the development of spreading pain, because larger referred pain areas in patients with chronic pain are a consequence of higher central neural plasticity. Maintenance of referred pain is dependent on ongoing nociceptive input from the site of primary muscle pain. It remains uncertain which sensitization mechanism, peripheral or central, is more dominant in the development of referred pain. These mechaisms, however, are consistent with a neuropathic basis for the referred pain of TrPs. Characteristic findings of neuropathic pain, hyperalgesia and allodynia, are associated with the hypersensitivity of TrPs and is another argument for a neuropathic pain component to myofascial pain syndrome. Neuromodulators including the gabapentinoids and other agents effective for nerve pain have been found to offer benefit is many patients with MPS.

See: Central Sensitization


Treatment of Myofascial Pain

Local myofascial pain, typically described as deep, dull and achy, often responds well to direct action on the effected muscles through the use of hot soaks, especially with epsom salts added to the water. Infrared treatment can also be helpful along with electrical stimulation therapy.


Massage and Tissue Manipulation

Massage is also a very effective means of reducing local myofascial pain. Trigger points, however, require more vigorous manipulation of the tissues than afforded by gentle, Swedish massage, to obtain resolution of the pain. Deep tissue massage along with more forceful passive stretching is often required especially after initiating treatment of trigger points with dry needling. (See: Trigger Point Therapy).



The use of topical medications can be very effective for myofascial pain. Muscle pain, and especially muscle stiffness, tends to be very responsive to topical as well as oral NSAIDs. Once limited to prescription availability only, topical diclofenac gel (Volaren gel) is often very useful and is available in 1-3% strengths. Other over-the-counter (OTC) topical medications have mild benefit such as those with menthol and other herbal products.

With the recent availability of marijuana products, research and common experience has demonstrated that OTC topical lotions containing CBD (cannabidiol) and BCP (β-caryophyllene), a terpene found in various plants including cannabis and black pepper, can be very effective for myofascial pain as well as joint pain. The addition of THC topically has also been reported by some as providing additional benefit. The recent discovery of the presence of CB1 and CB2 receptors, components of the endocannabinoid system, in fascia tissue supports the benefit of these agents for myofascial pain.

In more severe cases, low potency opioids are sometimes used successfully in controlling myofascial pain.


Moving Beyond

Treating MPS is not just about treating trigger points; it is about addressing the perpetuating factors that maintain the MPS, including the changes in the fascia and the joint dysfunction. Perpetuating factors can be physical:  leg length inequalities, joint or extremity deformities etc; or behavioral: repetitive work activities or poor ergonomics in the home or workplace. 


Successful management of MPS includes identifying and correcting all perpetuating factors – postural, structural, ergonomic, endocrine, metabolic, nutritional, infectious and psychological aspects. Management includes movement rehabilitation based in physical therapy, exercise training, yoga or other stretching techniques and massage. It often requires a multidisciplinary approach to address stress-related contributions to MPS. Anxiety and stress result in increased muscle tone and chronic muscle contractions that further the MPS. Learning effective techniques for coping with stress can be coupled with techniques specifically directed at reducing muscle tension. Meditative techniques, mindful exercises and self-hypnosis training are proven methods of reducing the impact of stress and anxiety on muscle dysfunction.

See Using the Mind


The Physiology of Muscle and Fascial Pain

Both muscle and the surrounding fascia harbor pain receptors that contribute to the experience of muscle pain. That being said, the pain receptors in the fascia may be underappreciated, at least as a target for treating muscle pain. Outside of physical interventions, muscle pain has traditionally been approached with use of topical medications, including creams, lotions, gels and patches both over the counter and prescription including individualized compounded topical medications with multiple components in different formulations.

Topical medications, however, tend to have limited effectiveness in part at least due to inability to penetrate into muscle tissue. However, recent success with topical cannabinoids suggests their effectiveness may be related to their effect on fascial tissue which is more accessible to topical penetration. Both CB1 and CB2 cannabinoid receptors are found in fascia and in the fascial fibroblasts which build and maintain the fascia. Activation of these cannabinoid receptors suppresses proinflammatory cytokines such as IL-1 and TNF-alpha and increases anti-inflammatory cytokines.

Fibromyalgia is a condition associated with severe myofascial pain.  It has been shown there is a link with fibromyalgia to endocannabinoid deficiency and studies have demonstrated that cannabinoids can be an effective treatment for fibromyalgia symptoms.



Myofascial Pain, Fascia – New Publications for Review

  1. Pathophysiological and Therapeutic Roles of Fascial Hyaluronan in Obesity-Related Myofascial Disease – 2022
  2. Response to Mechanical Properties and Physiological Challenges of Fascia: Diagnosis and Rehabilitative Therapeutic Intervention for Myofascial System Disorders – 2023
  3. Anatomy, Fascia – PubMed Anatomy, Fascia – StatPearls – NCBI Bookshelf
  4. Hyaluronan within fascia in the etiology of myofascial pain – PubMed – 2011
  5. Fascia A missing link in our understanding of the pathology of fibromyalgia – PubMed 2010
  6. “Long COVID-19” and viral “fibromyalgia-ness”: Suggesting a mechanistic role for fascial myofibroblasts (Nineveh, the shadow is in the fascia)
  7. Review of Fibromyalgia (FM) Syndrome Treatments – 2022
  8. Efficacy of manual lymph drainage and myofascial therapy in patients with fibromyalgia A systematic review – PubMed – 2021
  9. Efficacy of Manual Therapy on Pain, Impact of Disease, and Quality of Life in the Treatment of Fibromyalgia – A Systematic Review – 2020
  10. Effectiveness of different styles of massage therapy in fibromyalgia a systematic review and meta-analysis – PubMed – 2015
  11. Comparative Study of the Efficacy of Hyaluronic Acid, Dry Needling and Combined Treatment in Patellar Osteoarthritis—Single-Blind Randomized Clinical Trial – 2022
  12. Hyaluronic Acid: Molecular Mechanisms and Therapeutic Trajectory. – 2019pdf
  13. Beta-caryophyllene enhances wound healing through multiple routes PLOS ONE – 2019
  14. Expression of the Endocannabinoid Receptors in Human Fascial Tissue – 2016
  15. Sensitivity of the Fasciae to the Endocannabinoid System: Production of Hyaluronan-Rich Vesicles and
  16. Potential Peripheral Effects of Cannabinoids in Fascial Tissue – 2020
  17. Fascial preadipocytes: another missing piece of the puzzle to understand fibromyalgia? – 2018pdf
  18. The Role of Nutrient Supplementation in the Management of Chronic Pain in Fibromyalgia – A Narrative Review – 2021
  19. A comparison of the clinical manifestation and pathophysiology of myofascial pain syndrome and fibromyalgia: implications for differential diagnosis and management – 2018
  20. Intraepidermal Nerve Fiber Density as Measured by Skin Punch Biopsy as a Marker for Small Fiber Neuropathy: Application in Patients with Fibromyalgia – 2021
  21. Fibromyalgia – StatPearls – NCBI Bookshelf The gadolinium hypothesis for fibromyalgia and unexplained widespread chronic pain – PubMed 2019
  22. Understanding Fibroblasts in Order to Comprehend the Osteopathic Treatment of the Fascia – 2014
  23. Clinical and symptomatological reflections: the fascial system – 2014
  24. A pilot study of myofascial release therapy compared to Swedish massage in Fibromyalgia – 2014
  25. Benefits of Massage-Myofascial Release Therapy on Pain, Anxiety, Quality of Sleep, Depression, and Quality of Life in Patients with Fibromyalgia. – 2010pdf
  26. Hyaluronan and the Fascial Frontier – 2021
  27. Pilot study assessing the effect of Fascial Manipulation on fascial densifications and associated pain – 2022pdf
  28. Hyaluronan homeostasis and its role in pain and muscle stiffness – 2022pdf
  29. Fascia Lata Alterations in Hip Osteoarthritis: An Observational Cross-Sectional Study – 2021
  30. Diabetic Foot: The Role of Fasciae, a Narrative Review – 2021


Myofascial Pain and TrP – Overviews

  1. Myofascial Pain and Dysfunction: The Trigger Point Manual (2 vol. set, 2nd Ed.). Travell, Janet; Simons David; Simons Lois (1999). USA: Lippincott Williams & Williams.
  2. Treatment of myofascial pain syndrome with lidocaine injection and physical therapy, alone or in combination – 2016
  3. Identification and quantification of myofascial taut bands with magnetic resonance elastography. – PubMed – NCBI
  4. New views of myofascial trigger points: etiology and diagnosis. – PubMed – NCBI
  5. Comparison of lidocaine injection, botulinum toxin injection, and dry needling to trigger points in myofascial pain syndrome. – PubMed – NCBI
  6. Botulinum toxin for myofascial pain syndromes in adults. – PubMed – NCBI
  7. Needling therapy for myofascial pain – recommended technique with multiple rapid needle insertion – 2014
  8. Evaluation of the Sympathetic Skin Response to the Dry Needling Treatment in Female Myofascial Pain Syndrome Patients – 2016
  9. New Frontiers in the Pathophysiology of Myofascial Pain Enter the Matrix
  10. Alpha-2 Adrenergic Receptor Agonists – A Review of Current Clinical Applications – 2015
  11. Relating Chronic Pelvic Pain and Endometriosis to Signs of Sensitization and Myofascial Pain and Dysfunction – 2017
  12. Effectiveness of ultrasound therapy for myofascial pain syndrome – a systematic review and meta-analysis – 2017
  13. Efficacy of Deep Dry Needling on Latent Myofascial Trigger Points in Older Adults With Nonspecific Shoulder Pain – A Randomized, Controlled Clinical Trial Pilot Study – 2017
  14. The Possible Role of Meditation in Myofascial Pain Syndrome: A New Hypothesis – 2017
  15. Myofascial Pain Syndrome – A Treatment Review – 2013
  16. Tizanidine is effective in the treatment of myofascial pain syndrome. – 2002
  17. Comparison of two different techniques of electrotherapy on myofascial pain – PubMed 2002
  18. Expert consensus on the diagnosis and treatment of myofascial pain syndrome- 2021
  19. The Case for Comorbid Myofascial Pain—A Qualitative Review – 2020
  20. Myofascial Trigger Points Then and Now – A Historical and Scientific Perspective – 2015
  21. Trigger Points – An Anatomical Substratum – 2015
  22. A comparison of the clinical manifestation and pathophysiology of myofascial pain syndrome and fibromyalgia – implications for differential diagnosis and management – 2018
  23. Clinical implication of latent myofascial trigger point – PubMed -2013
  24. Effectiveness of Ultrasound Therapy on Myofascial Pain Syndrome of the Upper Trapezius – Randomized, Single-Blind, Placebo-Controlled Study – 2018
  25. Myofascial Pain Syndrome in the Elderly and Self-Exercise – A Single-Blind, Randomized, Controlled Trial – 2016
  26. Effect of Therapeutic Sequence of Hot Pack and Ultrasound on Physiological Response Over Trigger Point of Upper Trapezius – 2015
  27. Effectiveness of ultrasound therapy for myofascial pain syndrome – a systematic review and meta-analysis – 2017
  28. Randomized controlled study of the antinociceptive effect of ultrasound on trigger point sensitivity novel applications in myofascial therapy? – PubMed – 2007
  29. Expression of the Endocannabinoid Receptors in Human Fascial Tissue – 2016
  30. Injury triggers fascia fibroblast collective cell migration to drive scar formation through N-cadherin – 2020



Myofascial Pain – Mechanisms of Pain

  1. The Discriminative Validity of “Nociceptive,” ” Peripheral Neuropathic,” and “Central Sensitization” as Mechanisms-based Classifications of Musculoskeletal Pain – 2011
  2. Clinical indicators of ‘nociceptive’, ‘peripheral neuropathic’ and ‘central’ mechanisms of musculoskeletal pain. A Delphi survey of expert clinicians – 2010
  3. Myofascial Trigger Points – Peripheral or Central Phenomenon? -2014


Myofascial Pain – Muscle Cramps

  1. Association Between Long-term Quinine Exposure and All-Cause Mortality – 2017
  2. Muscle Cramps Do Not Improve With Correction of Vitamin D Insufficiency – 2019
  3. Criteria in diagnosing nocturnal leg cramps – a systematic review – 2017
  4. Treatment of nocturnal leg cramps by blockade of the medial branch of the deep peroneal nerve after lumbar spine surgery – 2015
  5. Nocturnal Cramps in Patients with Lumbar Spinal Canal Stenosis Treated Conservatively – A Prospective Study – 2014
  6. Magnesium – Biochemistry, Nutrition, Detection, and Social Impact of Diseases Linked to Its Deficiency – 2021
  7. What is the role of magnesium for skeletal muscle cramps? A Cochrane Review summary with commentary – 2021
  8. Magnesium for skeletal muscle cramps – PubMed – 2020
  9. Non‐drug therapies for lower limb muscle cramps – 2012
  10. Non-drug therapies for the secondary prevention of lower limb muscle cramps – PubMed – 2021
  11. Nocturnal leg cramps in older people – 2002
  12. Assessment – symptomatic treatment for muscle cramps (an evidence-based review) report of the therapeutics and technology assessment subcommittee of the American academy of neurology – PubMed – 2010
  13. A scoping review to identify and map the multidimensional domains of pain in adults with advanced liver disease – 2020
  14. Randomized-controlled trial of methocarbamol as a novel treatment for muscle cramps in cirrhotic patients – PubMed – 2019
  15. Randomized placebo-controlled study of baclofen in the treatment of muscle cramps in patients with liver cirrhosis – PubMed – 2016
  16. Pilot study of orphenadrine as a novel treatment for muscle cramps in patients with liver cirrhosis – 2018


Myofascial Pain and TrP – Shoulder Pain

  1. Treatment-of-myofascial-trigger-points-in-patients-with-chronic-shoulder-pain-a-randomized-controlled-trial-2011
  2. High-prevalence-of-shoulder-girdle-muscles-with-myofascial-trigger-points-in-patients-with-shoulder-pain-2011
  3. chronic-shoulder-pain-of-myofascial-origin-a-randomized-clinical-trial-using-ischemic-compression-therapy-pubmed-ncbi


Emphasis on Education


Accurate Clinic promotes patient education as the foundation of it’s medical care. In Dr. Ehlenberger’s integrative approach to patient care, including conventional and complementary and alternative medical (CAM) treatments, he may encourage or provide advice about the use of supplements. However, the specifics of choice of supplement, dosing and duration of treatment should be individualized through discussion with Dr. Ehlenberger. The following information and reference articles are presented to provide the reader with some of the latest research to facilitate evidence-based, informed decisions regarding the use of conventional as well as CAM treatments.


For medical-legal reasons, access to these links is limited to patients enrolled in an Accurate Clinic medical program.


Should you wish more information regarding any of the subjects listed – or not listed –  here, please contact Dr. Ehlenberger. He has literally thousands of published articles to share on hundreds of topics associated with pain management, weight loss, nutrition, addiction recovery and emergency medicine. It would take years for you to read them, as it did him.


For more information, please contact Accurate Clinic.


Supplements recommended by Dr. Ehlenberger may be purchased commercially online or at Accurate Clinic.

Please read about our statement regarding the sale of products recommended by Dr. Ehlenberger.

Accurate Supplement Prices