Neck Myofascial Pain: Pathology, Physiotherapy Evaluation, and Rehabilitation Program

Introduction

Neck myofascial pain, often referred to as myofascial pain syndrome (MPS) in the cervical region, is a common musculoskeletal condition characterized by localized pain and tenderness in the neck muscles, often associated with myofascial trigger points (MTrPs). It affects up to 30–50% of individuals with chronic neck pain, with a higher prevalence in women and those engaged in repetitive or static postures.

Pathology of Neck Myofascial Pain

Myofascial pain syndrome arises from the presence of trigger points—hyperirritable spots within taut bands of skeletal muscle or fascia that elicit local or referred pain when compressed. In the neck, commonly affected muscles include the trapezius, levator scapulae, sternocleidomastoid, and cervical paraspinals.

Pathological Mechanisms

  1. Myofascial Trigger Points (MTrPs):
    • Active Trigger Points: Cause spontaneous pain at rest or with movement, often referring pain to distant sites (e.g., trapezius MTrPs referring pain to the shoulder or head).
    • Latent Trigger Points: Painful only when palpated, contributing to muscle stiffness and restricted movement.
    • MTrPs are associated with localized muscle fiber contraction, reduced blood flow, and accumulation of metabolites like lactate, leading to pain and dysfunction.
  2. Pathophysiology:
    • Muscle Overuse or Trauma: Repetitive strain (e.g., prolonged computer use), poor posture, or acute injury (e.g., whiplash) can initiate MTrPs by causing sustained muscle contraction or microtrauma.
    • Central Sensitization: Chronic MTrPs may lead to heightened pain sensitivity via central nervous system changes, amplifying pain perception.
    • Neurogenic Inflammation: Release of neuropeptides (e.g., substance P) in the muscle tissue contributes to local inflammation and pain.
  3. Contributing Factors:
    • Postural Dysfunction: Forward head posture or rounded shoulders increase stress on cervical muscles, promoting MTrP formation.
    • Psychosocial Factors: Stress, anxiety, or poor sleep can exacerbate muscle tension and pain, as supported by a PubMed study linking psychological stress to MPS severity.
    • Biomechanical Factors: Joint dysfunction (e.g., cervical facet irritation) or muscle imbalances may perpetuate MTrPs.
  4. Histological Changes: Research indicates MTrPs exhibit abnormal sarcomere shortening, increased inflammatory markers, and reduced oxygenation, contributing to a self-sustaining pain cycle.

Clinical Presentation

Patients with neck myofascial pain typically present with:

Physiotherapy Evaluation

A thorough physiotherapy evaluation is critical to identify MTrPs, assess functional impairments, and guide treatment. The evaluation includes subjective and objective components tailored to the patient’s presentation.

Subjective Assessment

Objective Assessment

  1. Postural Analysis: Observe for forward head posture, rounded shoulders, or scapular winging, which may indicate muscle imbalances or stress on cervical muscles.
  2. Range of Motion (ROM): Measure cervical flexion, extension, lateral flexion, and rotation using a goniometer or inclinometer. Restrictions suggest muscle tightness or joint dysfunction.
  3. Palpation:
    • Identify MTrPs by palpating for taut bands, tenderness, or referred pain in muscles like the trapezius, levator scapulae, or sternocleidomastoid.
    • Assess for local twitch responses (a muscle contraction elicited by snapping palpation of an MTrP).
  4. Muscle Strength Testing: Evaluate strength in cervical and shoulder girdle muscles (e.g., deep cervical flexors, scapular stabilizers) to identify weaknesses contributing to pain.
  5. Special Tests:
    • Cervical Compression/Distraction Test: To differentiate myofascial pain from radiculopathy or disc-related pain.
    • Spurling’s Test: To rule out nerve root compression if radicular symptoms are reported.
  6. Functional Testing: Assess movement patterns during tasks like reaching, lifting, or head turning to identify compensatory strategies or functional limitations.

Imaging and Correlation

Imaging is rarely needed for neck myofascial pain, as it is a soft tissue condition. However, if red flags or neurological symptoms are present, MRI or X-rays may be used to rule out cervical disc herniation or other pathologies. A PubMed review notes that ultrasound imaging can detect MTrPs by visualizing taut bands, but clinical palpation remains the gold standard.

Rehabilitation Program

Conservative management, centered on physiotherapy, is the primary treatment for neck myofascial pain, aiming to deactivate MTrPs, restore function, and prevent recurrence. The following program is evidence-based, supported by PubMed literature where applicable.

Phase 1: Pain Relief and Trigger Point Deactivation (0–4 Weeks)

Goals: Reduce pain, deactivate MTrPs, and educate the patient.

Phase 2: Mobility and Muscle Re-Education (4–8 Weeks)

Goals: Restore cervical ROM, improve muscle flexibility, and enhance strength.

Phase 3: Functional Restoration and Maintenance (8+ Weeks)

Goals: Enhance functional capacity, prevent MTrP recurrence, and promote long-term neck health.

Special Considerations

Conclusion

Neck myofascial pain is a prevalent condition driven by myofascial trigger points, muscle overuse, and postural dysfunction, with significant impacts on quality of life. Physiotherapy evaluation, combining subjective history, objective testing, and MTrP identification, guides effective conservative management. A structured rehabilitation program, emphasizing pain relief, trigger point deactivation, and functional restoration, is effective for most patients, supported by PubMed evidence. By addressing biomechanical and psychosocial factors, physiotherapy plays a central role in improving outcomes and preventing recurrence in neck myofascial pain.