Myofascial Pain Patterns for Head and Neck Disorders - American ...

Myofascial Pain Patterns for 

Head and Neck Disorders 

Sajid A. Surve, D.O. 

UMDNJ School of Osteopathic Medicine 

NeuroMusculoskeletal Institute

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Myofascial Pain Patterns 

Head & Neck Disorders- 

Surve 

Learning Objectives 

By the end of this presentation, participants will 

be able to: 

• Correctly distinguish between referred pain 

patterns of different origins 

• Appropriately refer patients to interventional 

pain management or perform injections on 

affected structures in myofascial pain 

• Recognize the indications for Osteopathic 

Manipulative Treatment in myofascial pain

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Disclosures 

• I have no relevant financial disclosures with 

regard to this presentation.

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Outline 

• Introduction 

• Myotomic patterns 

• Dermatomic patterns 

• Sclerotomic patterns 

• Conclusion

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Introduction 

• 45-year old male presents 

with 6 year history of 

headache following motor 

vehicle accident 

• Restrained driver of sedan 

travelling 15-20 mph, rearended 

by another sedan 

travelling 25-30 mph

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Introduction 

• Rates pain VAS 4/10 during 

flare-ups which occur 3-4 

times per month. Otherwise 

pain-free 

• Describes as throbbing, achy 

pain with no other associated 

symptoms

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Introduction 

• Saw PCP, has been taking 

prescription naproxen 

intermittently, which helps 

• Within 6 months of accident 

had x-rays and MRI of c- 

spine which were both 

negative

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Introduction 

• Remainder of history is 

unremarkable 

• On physical exam, patient 

has tenderness to palpation 

of cervical spine and 

restricted range of motion 

x 

x 

x

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Introduction 

• What do we think about this 

case 

• What is the treatment plan 

for this patient 

▫ OMT 

▫ Trigger point injection 

▫ Spray and stretch 

▫ Botox 

▫ Something else 

x 

x 

x

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Myotomic Pain Patterns

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Myotomic Pain Patterns 

• Originally described by Travell, Simons, and 

Simons in 1942 

• 80 years later, still debate about exact diagnostic 

criteria 

• General consensus describes trigger points as 

derangement of muscle or fascial tissue 

hallmarked by referral of pain in a predictable 

pattern upon direct palpation 

Myburgh et al. A systematic, critical review of manual palpation for identifying myofascial trigger 

points: evidence and clinical significance.Arch Phys Med Rehabil. 2008 Jun ;89(6):1169-76.

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• New imaging techniques are giving us greater 

insight into underlying pathology 

• Diagnosis is still made from history and physical 

exam findings 

• Number of treatment options have been 

considered, although few have solid evidence 

Chen Q, Bensamoun S, Basford JR, Thompson JM, An K-N. Identification and quantification of myofascial 

taut bands with magnetic resonance elastography. Arch Phys Med Rehabil 2007;88:1658-61.

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Evidence-based beneficial treatments: 

• OMT 

• Trigger Point Injection / Dry Needling / 

Acupuncture 

• TENS 

• Iontophoresis with indomethacin 

• Spray and Stretch 

Annaswamy TM et al. Emerging concepts in the treatment of myofascial pain: a review of medications, 

modalities, and needle-based interventions.PM R. 2011 Oct ;3(10):940-61.

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Botox is not considered an effective modality for 

myofascial pain 

Soares A, Andriolo RB, Atallah ÁN, da Silva EMK, da Silva EMK. Botulinum toxin for myofascial pain 

syndromes in adults. Cochrane Database of Systematic Reviews 2012, Issue 4. Art. No.: CD007533. DOI: 

10.1002/14651858.CD007533.pub2

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Trapezius 

Images courtesy of http://www.triggerpoints.net

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Sternocleidomastoid 


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Splenius Capitis/Cervicis 


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Suboccipitalis 


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Frontalis (A) / Occipitalis (B) 


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Temporalis 


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Lateral Pterygoid 


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Medial Pterygoid 


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Dermatomic Pain Patterns

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Dermatomic Pain Patterns 

• Neuropathic radicular pain related to 

entrapment of either nerve roots or peripheral 

nerves 

• May be caused by canal stenosis, disc disease, or 

external pressure (peripheral nerves only) 

• OMT indicated primarily as adjunct, HVLA 

contraindicated at level of entrapment 

Chila et al. Foundations of Osteopathic Medicine, 3 rd edition. LWW 2011. pp. 524

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• NSAIDs and TCAs indicated in cervical 

radiculopathy 

• Opiates generally indicated through WHO 

guidelines 

• Oral corticosteroids not well studied for 

radicular pain 

Carette S, Fehlings M. Cervical radiculopathy. N Engl J Med. 2005;353:392–399.

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• Low level evidence for cervical immobilization, 

traction, physical therapy in radiculopathy 

• Acupuncture is recommended for both acute and 

chronic radiculopathy 

Carette S, Fehlings M. Cervical radiculopathy. N Engl J Med. 2005;353:392–399. 

Council of Acupuncture and Oriental Medicine Associations. Acupuncture and electroacupuncture: 

evidence-based treatment guidelines. National Guideline Clearinghouse. Available at 

http://guideline.gov/summary/summary.aspxdoc_id=9343.

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• Moderate to high level evidence for cervical 

epidural steroid injection and selective nerve 

root blocks 

• Moderate to high level evidence for peripheral 

nerve blockade in peripheral nerve entrapment 

Manchikanti L et al. Comprehensive evidence-based guidelines for interventional techniques in the 

management of chronic spinal pain.Pain Physician. 2009 Jul-Aug ;12(4):699-802.

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Segmental Nerve Patterns

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Peripheral Nerve Patterns

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Sclerotomic Pain Patterns

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Sclerotomic Pain Patterns 

• Cervical facets are innervated by medial branch

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• In cervical facet disease (i.e. spondylosis) bony 

hypertrophy and sclerosis can produce referred 

pain which is independent from all other referral 

patterns 

• OMT of limited use for improving referred pain, 

although indicated for compensatory changes

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• Moderate to high level evidence for diagnostic 

cervical facet injections 

• Moderate to high level evidence for 

radiofrequency ablation to medial branch 

Manchikanti L et al. Comprehensive evidence-based guidelines for interventional techniques in the 

management of chronic spinal pain.Pain Physician. 2009 Jul-Aug ;12(4):699-802.

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Sclerotomic Pain Patterns

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Conclusion

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Conclusion 

• Different structures have different referral 

patterns 

• Being cognizant of pain patterns will help to 

guide interventions 

• OMT has indications for many causes of cervical 

myofascial pain

Myofascial Pain Patterns for Head and Neck Disorders - American ...

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