Myofascial pain syndrome

Historical note and nomenclature
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By Charles Argoff MD and Howard Smith MD

Myofascial pain syndrome is also known as or subsumes Fibrositis, Myofascitis, Nonarticular rheumatism, and Tension myalgia. -ed.

It has been nearly a century since Sir William Gowers introduced the term fibrositis for a common, but idiopathic, localized form of muscular rheumatism that is now recognized as myofascial pain syndrome (Gowers 1904). Despite the intervening years, myofascial pain syndromes constitute the largest group of unrecognized and undertreated acute and chronic medical problems in clinical practice today, and these are among the most commonly overlooked causes of chronic pain and disability in medicine (Simons 1988).

Historical perspectives. As first defined by Gowers in 1904, the term “fibrositis” referred to the local tenderness and regions of palpable hardness in the muscle, which he attributed to inflammation of fibrous tissue. Though initially embraced in the literature, the concept of fibrositis as inflamed connective tissue fell into disfavor as subsequent biopsy data failed to substantiate inflammatory pathology. It was not until the late 1930s that the first physiologic-based evidence came with Kellgren's observations on the nature of pain originating from deep connective tissue structures (Kellgren 1938). Using hypertonic saline injections to irritate different anatomical areas including fascia, tendon, and muscle, he demonstrated that pain was produced that differed not only in quality but also in its specific referral pattern. Although the term "myofasciitis" was first introduced in 1927 by Albee, it was not until 1939, in a paper read on low back pain, that Steindler first used the terms "myofascial pain" and "trigger point" (Albee 1927; Steindler 1940). Travell and colleagues used the term trigger point in 1942 to describe the site from which pain was referred, and in 1952, adopted the expression "myofascial pain syndrome" (Travell et al 1942; Travell and Rinzler 1952). In 1954, Schwartz reported that inactivation of trigger points by procaine injection was often an important part of the management of pain in the temporomandibular joint region (Schwartz 1954). According to Travell, it was Good who recognized the pathognomonic trademark of myofascial pain syndrome, now called the “jump sign,” where a patient responded with a cry, grimace, or wince to palpation of the painful muscle focus (Travell 1983). Travell first published a paper describing the diagnostic criteria and treatment protocols for myofascial pain syndrome in 1942. This paper established the foundation for the modern approach to this syndrome. In 1953, Bonica published a text separating myofascial pain syndrome from fibrositis (Bonica 1953). Janet G Travell (1901 to 1997) relieved then-Senator John F Kennedy of disabling back pain using her trigger point management techniques in 1955. She was appointed as the White House physician during the presidencies of John F Kennedy as well as that of Lyndon B Johnson. The subsequent work of Travell and Simons elucidated trigger points and zones of radiating pain, as well as the taut bands of myofascial pain syndrome, codifying their locations in virtually every muscle of the body (Travell and Simon 1983; 1991). Using the classification of the International Association for the Study of Pain, such localized disease is now currently termed "specific myofascial pain syndrome" (Merskey and Bogduk 1994).

Controversies in nomenclature. A source of controversy relative to the acceptance of the concepts of myofascial pain and dysfunction has been the varied terminology used throughout the literature. The term “fibrositis,” in particular, has been used erroneously to include both myofascial pain syndrome and fibromyalgia, as well as almost any unexplained musculoskeletal pain problem. The confusion in nomenclature has been compounded by the widespread belief that these musculoskeletal pain syndromes are psychogenic in nature. As late as the 1970s, most major textbooks considered fibrositis to be a disease with strong psychogenic overtones (Rosen 1993). The terms nonarticular and psychogenic rheumatism, soft tissue disability, tension myalgia, and muscle contraction states also have remained in use, suggesting psychologic dysfunction as their primary cause as opposed to physical factors. Similarly, current terms, including overuse syndromes, repetitive trauma syndromes, and repetitive injury or strain syndromes fail to address the more critical issues regarding pathogenesis, with many of these overlapping disorders representing local forms of myofascial pain, which apparently have not been appreciated as such. Currently, no universally accepted terminology allows clinicians to more accurately codify the dysfunction seen in patients who present with musculoskeletal pain and dysfunction (Thompson 1990).