Myofascial pain injury is common among people with soft tissue injuries to muscles and surrounding connective tissue. President John F. Kennedy suffered from chronic myofascial pain injury from World War II. His White House physician, Dr. Janet Travell, wrote the first edition of a medical treatise, Myofascial Pain and Dysfunction: The Trigger Point Manual. We have represented many people with chronic myofascial pain resulting from injuries in a wide variety of accidents.
However, insurance claims people and defense lawyers tend to place little value on “soft tissue” injuries to muscles, tendons, and ligaments. They know that without objective, visual evidence, it is hard to persuade twelve jurors to overcome bias against soft tissue injuries. When claims of painful injuries are supported only by subjective complaints, the victims are subject to accusations of malingering, exaggerating, magnifying symptoms, or lying for money. The defense may contest the existence of the conditions as being based upon methodologically weak “junk science.” There have been enough cases of real malingering and exaggeration to feed such suspicion. While hard trigger points are nodules that an examiner may objectively feel, critics long claimed that only the “fingers of faith” could detect them on physical examination.
Certainly, many simple muscle strains do resolve within a few weeks. Acute, localized myofascial pain can resolve spontaneously or with simple treatments. However, when myofascial pain injury becomes chronic, lasting six months or more, with increased muscle stiffness and trigger points in muscles, it can be debilitating and life-altering. Your injury lawyer needs to understand the medicine of myofascial pain and how to prove that injury objectively.
Physical examinations of muscles with myofascial pain injury reveal trigger points, tiny. hard and extremely irritable knots located within a taut band of skeletal muscle or fascia. Trigger points can cause referred pain, local tenderness, and autonomic changes when compressed. They are painful to both touch and movement.
Myofascial pain injury involves microscopic damage to muscle tissues and can become a long-term “thorn in the flesh.” There are two types of myofascial pain trigger points: active and latent. Active trigger points are associated with pain without movement or palpation. If you are just walking around, you may have pain with every step from an active trigger point in a hip or leg muscle. Latent trigger points are painful only to palpation. Myofascial pain syndrome involves increased muscle stiffness and trigger points in muscles.
Exercise is vital to recovery from myofascial pain injury. Aerobic exercise can have an anti-inflammatory effect on muscles by increasing blood pressure, flow and oxygen saturation, allowing more blood and metabolic substrates to enter trigger points. However, as pain causes guarding of movement, physical activity may be self-limited. Therefore, low-impact forms of exercise such as swimming and water aerobics may be helpful. Adequate sleep and a healthy diet are essential for everyone, especially those with chronic pain.
Treatment for myofascial pain injury typically includes medications, trigger point injections, or physical therapy. Exercise is an integral part of any treatment program. A person who has always enjoyed recreational sports such as running or tennis may reluctantly reduce or give up such activity when it becomes painful due to injury. Chronic myofascial pain injury that naturally leads to reduced physical activity can have ripple effects of weight gain, leading to higher cholesterol levels, elevated blood pressure, and declining cardiovascular health. Additionally, chronic pain can adversely impede social interaction and sexual intimacy. Mental sharpness may also suffer s physical activity declines. Depression is a common companion of chronic pain. The overall quality of life can go into a downward spiral.
Medications used for myofascial pain injury include:
- Pain relievers. Over-the-counter pain relievers such as ibuprofen (Advil, Motrin IB, others) and naproxen sodium (Aleve) may help. A doctor may prescribe stronger pain relievers. Some pain relievers are available in patches to be worn.
- Antidepressants. For some people with myofascial pain syndrome, amitriptyline appears to reduce pain and improve sleep.
- Sedatives. When pain causes anxiety and poor sleep, a sedative such as Clonazepam (Klonopin) might help. However, it must be used carefully because it can cause excessive drowsiness and become habit-forming.
Home exercises and physical therapy can help relieve chronic myofascial pain injury. This may include:
- Gentle stretching exercises can help ease the pain in your affected muscle. If trigger point pain increases when stretching, a physical therapist may spray a numbing solution on the skin.
- Posture training. Improving your posture can help relieve myofascial pain.
- Massage along your muscle or placing pressure on specific areas of your muscle may provide myofascial release. A skillful neuromuscular massage specialist may provide great help. Rolling the affected body area on a foam roller, bumpy roller, a therapy ball similar to a lacrosse or tennis ball, or a massage stick may provide relief at home.
- Heat. Applying heat, via a hot pack, hot shower or hot bath, can help relieve muscle tension and reduce pain. If you have access to a whirlpool tub, myofascial pain is a great reason to use it. Using a therapy ball under the affected area while in a hot tub can be helpful.
- Ultrasound therapy uses sound waves to increase blood circulation and warmth, which may promote healing in muscles affected by myofascial pain syndrome.
- Needle procedures may involve either injections or dry needles. A physician
may inject Injecting a numbing agent or a steroid into a trigger point can help relieve pain. A doctor or physical therapist may insert dry needles in and around trigger points. No numbing agent may be needed if the clinician is sufficiently skilled in locating the trigger points. Dry needling may be combined with electrical stimulation. Chiropractic treatment and acupuncture may also provide symptomatic relief for some people who have myofascial pain syndrome.
If myofascial pain injury becomes chronic — lasting more than six months — it may affect the quality of life for a long time. The average duration of symptoms of chronic myofascial pain in one study was 63 months. The range was between 6 and 180 months. If the underlying medical condition is not corrected, myofascial pain may become recalcitrant, intractable, and out of control.
Permanent impairment ratings based upon chronic myofascial pain injury present a difficult analysis. The American Medical Association Guides to Evaluation of Permanent Impairment, 6th Edition, outlines the following criteria:
- Use of prescription drugs beyond the recommended duration and/or abuse of or dependence on prescription drugs or other substances.
- Excessive dependence on health care providers, spouse, or family.
- Secondary physical deconditioning due to disuse and or fear-avoidance of physical activity due to pain.
- Withdrawal from social milieu, including work, recreation, or other social contracts.
- Failure to restore pre-injury function after a period of disability, such that the physical capacity is insufficient to pursue work, family or recreational needs.
- Development of psychosocial sequelae after the initial incident, including anxiety, fear-avoidance, depression, or nonorganic illness behaviors.
These criteria may be individually applied to people suffering from chronic myofascial pain injury which may cause debilitating pain for 5 to 15 years, or longer, with a ripple effect on other aspects of physical and mental health.
So how can a personal injury lawyer prove the severe reality of a chronic myofascial pain injury?
Ultrasound imaging technology is a cost-effective way to objectively visualizing trigger points related to chronic myofascial pain injury. As ultrasound equipment is common within medical offices, it is more accessible and economical that some alternatives. While primarily used for diagnosis and to guide needling treatment, the images can be invaluable as medical evidence.
Magnetic resonance imaging (MRI) can demonstrate a chronic myofascial pain injury by revealing changes in signal intensity and sites of bleeding inside muscles hematomas. It can visualize soft tissues with excellent contrast, resolution and multiplanar assessment of muscles, especially in cases where traumatic lesions are clinically suspected. In addition, magnetic resonance elastography (MRE) can potentially improve the detection of skeletal muscle stiffness. Diffusion tensor imaging (DTI) provides a potentially excellent way to study injury to muscle structure in injured people. In the future, diffusion kurtosis imaging (DKI) and high angular resolution diffusion imaging (HARDI), could prove even better than DRI used. However, neither is yet used in clinical practice. MRI and ultrasound can detect and demonstrate tendon and ligament injuries due to disruption of the patterns of collagen and water content in the tissues.
Any such images to document a chronic myofascial pain injury can be difficult for lay people, either lawyers or jurors, to interpret. Therefore, it is advisable to supplement them with colorization of the radiology images and superb medical illustrations that a treating physician may in testimony to explain the situation clearly. Experienced trial advocates should work with top-quality medical illustrators to maximize effectiveness without exceeding the bounds of credibility and good taste.
In addition, it is crucial to marshal evidence of practical ways a chronic myofascial pain injury affects the quality of life of the injured person. It is best to find people outside the family who have observed pain behavior when the injured person did not know they were being observed.
If you or a loved one has a chronic myofascial pain injury caused by another’s negligence, call us at 404-254-7862.
Johnson & Ward has been a leading personal injury and wrongful death specialty law firm in Atlanta since 1949.
Ken Shigley, senior counsel at Johnson & Ward, is a former president of the State Bar of Georgia (2011-12). He was the first Georgia lawyer to earn three board certifications from the National Board of Trial Advocacy (Civil Trial Advocacy, Civil Pretrial Advocacy, and Truck Accident Law). In 2019, he received the Traditions of Excellence Award for lifetime achievement. Mr. Shigley was lead author of eleven editions of Georgia Law of Torts: Trial Preparation and Practice (Thomson Reuters, 2010-21). He graduated from Furman University and Emory University Law School.