More than five years after I felt my first symptoms, two years after I received my diagnosis of myofascial pain syndrome, and a year after I finally resolved my remaining pelvic pain, The Washington Post published my article on myofascial pain in the Health and Science section on June 18, 2013. Myofascial pain and the strange bladder symptoms it triggered had dominated my life for years, limiting my diet, my exercise, my work, my travel and my social life as I searched for answers about what was happening to my body. I wrote the article so that others don’t have to experience the confusion and frustration that I did. At only 1,500 words, it can’t describe every symptom that someone with myofascial pain – and in particular pelvic pain – experiences, or outline all the treatment options available. But I hope my article prompts perplexed patients and their practitioners to seek out more information and find answers quickly. As a starting point, I include some references below.
In particular, patients experiencing symptoms such as bladder pain and urinary frequency and urgency might be interested in Dr. David Wise’s book A Headache in the Pelvis, and his protocol for treatment described at http://www.pelvicpainhelp.com/. I attended Dr. Wise’s clinic in February 2012. By then, Dr. Timothy Taylor of Richmond VA had successfully treated the trigger points in my hips, thighs and backside with dry needling, taught me how to compress trigger points and stretch my muscles between treatments, and prescribed thyroid medication and vitamin D. With this treatment, most of my symptoms had disappeared or diminished, but the bladder irritation persisted. Dr. Wise’s protocol filled in the remaining gap. It focuses specifically on resolving trigger points in the pelvic floor that cause referred symptoms to the bladder, and includes a relaxation technique to help eliminate the clenching tendency that leads to chronic trigger points.
In the course of researching this article, I reviewed dozens of scientific papers on myofascial pain syndrome and pelvic pain and spoke with many experts. I’ve listed some of the scientific papers here for those interested in current understanding of the pathophysiology, diagnosis and treatment of myofascial pain. I hope to publish a longer magazine piece in coming months that tells more of the myofascial story, and why it’s so challenging to diagnose and treat this condition. In the meantime, my best wishes for successful healing to everyone who may be struggling with myofascial and pelvic pain.
References
American Physical Therapy Association. Description of Dry Needling.in Clinical Practice: An Educational Resource Paper. Produced by the APTA Public Policy, Practice and Professional Affairs Unit. February 2013.
Physical Therapists and the Performance of Dry Needling: An Educational Resource Paper. Produced by APTA Department of Practice and APTA State Government Affairs. January 2012.
Doggweiler, Ragi. Urologic myofascial pain syndromes. Current Pain and Headache Reports. Vol. 8:445-451. 2004.
Dommerholdt, Jan and Peter Huijbregts (eds). Myofascial Trigger Points: Pathophysiology and Evidence Informed Diagnosis and Management. Jones and Bartlett Publishers LLC, Sudbury Massachusetts. 2011.
Dommerholdt, Jan, Carel Bron, and Jo Frannsen. “Myofascial trigger points: an evidence informed review” in Myofascial Trigger Points: Pathophysiology and Evidence Informed Diagnosis and Management. Dommerholdt, Jan and Peter Huijbregts (eds). Jones and Bartlett Publishers LLC, Sudbury Massachusetts. 2011.
Fernandez-de-las-Peῇas, César, Lars Arendt-Nielson and David G. Simons. “Contributions of myofascial trigger points to chronic tension-type headache” in Myofascial Trigger Points: Pathophysiology and Evidence Informed Diagnosis and Management. Dommerholdt, Jan and Peter Huijbregts (eds). Jones and Bartlett Publishers LLC, Sudbury Massachusetts. 2011.
Gerwin, Robert D. “A review of myofascial pain and fibromyalgia – factors that promote their persistence.” Acupuncture in Medicine Vol. 23(3):121-134.2005.
Gerwin, Robert D. “Classification, epidemiology, and natural history of myofascial pain syndrome.” Current Pain and Headache Reports. Vol. 5:412-420.2001.
Gerwin, Robert D. “Myofascial pain syndrome: unresolved issues and future directions” in Myofascial Trigger Points: Pathophysiology and Evidence Informed Diagnosis and Management. Dommerholdt, Jan and Peter Huijbregts (eds). Jones and Bartlett Publishers LLC, Sudbury Massachusetts. 2011.
Gerwin, Robert D. “Myofascial and visceral pain syndromes: visceral-somatic pain representations.” Journal of Musculoskeletal Pain [The Haworth Medical Press, an imprint of The Haworth Press, Inc.] Vol. 10 (1/2):165-175. 2002.
Gerwin, Robert D., Jan Dommerholt, and Jay P. Shah. “An expansion of Simons’ integrated hypothesis of trigger point formation.” Current Pain and Headache Reports. 8:468–475. 2004.
Gerwin, Robert D., Steven Shannon, Chang-Zern Hong, David Hubbard, Richard Gevirtz. “Interrater reliability in myofascial trigger point examination.” Pain. Vol. 69:65–73. 1997.
Harden, R. Norman, Stephen P. Bruehl, Suzanne Gass, Claudia Miemiec, Brian Barbick. “Signs and symptoms of the myofascial pain syndrome: a national survey of pain management providers.” Clinical Journal of Pain. Vol. 16: 64-72. 2000.
Lucas, Nicholas, Petra Macaskil, Les Irwig, Robert Moran, Nikolai Bogduk. “Reliability of physical examination for diagnosis of myofascial trigger points: a systematic review of the literature. Clinical Journal of Pain. 2009. 25(1):80-89.
McEvoy, Johnson and Peter Huijbregts. “Reliability of myofascial trigger point palpation: a systematic review” in Myofascial Trigger Points: Pathophysiology and Evidence Informed Diagnosis and Management. Dommerholdt, Jan and Peter Huijbregts (eds). Jones and Bartlett Publishers LLC, Sudbury Massachusetts. 2011.
McPartland, John M. and David G. Simons. “Myofascial trigger points: translating molecular theory into manual rherapy” in Myofascial Trigger Points: Pathophysiology and Evidence Informed Diagnosis and Management. Dommerholdt, Jan and Peter Huijbregts (eds). Jones and Bartlett Publishers LLC. Sudbury Massachusetts. 2011.
Shah, Jay P. and Elizabeth A. Gilliams. Uncovering the biochemical milieu of myofascial trigger points using in vivo microdialysis: An application of muscle pain concepts to myofascial pain syndrome. Journal of Body Work and Movement Therapies. Vol. 12: 371-384. 2008.
Shah, Jay P., Terry M. Phillips, Jerome V. Danoff and Lynn H. Gerber. An in vivo microanalytical technique for measuring the local biochemical milieu of human skeletal muscle. J Appl Physiol 99: 1977–1984. 2005.
Sikdar, Siddartha, Jay. P. Shah, Tadesse Gebreah, Ru-Huey Yen, Elizabeth Gilliams, Jerome Danoff, Lynn H. Gerber. Novel Applications of Ultrasound to Visualize and Characterize Myofascial Trigger Points and Surrounding Soft Tissue. Arch Phys Med Rehabil Vol 90: 1829 -1838. 2009.
Skootsky SA, Jaeger B, Oye RK. “Prevalence of myofascial pain in general internal medicine practice.” Western Journal of Medicine. Vol. 151:157–160. 1989.
Tough, E.A, A.R. White, T.M. Cummings, S.H. Richards, J.L. Campbell.Acupuncture and dry needling in the management of myofascial trigger point pain: a systematic review and meta-analysis of randomised controlled trials. European Journal of Pain. Jan;13(1):3-10. 2009.
Wise, David and Rodney Anderson. A Headache in the Pelvis: A new understanding and treatment for chronic pelvic pain syndromes. Sixth Edition. National Center for Pelvic Pain Research. Occidental CA. 2011.
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Amy — I believe your article has led me to a possible explanation of an experience I have had periodically. I have had UTIs fairly regularly since I was 18 (I’m now 71), and have come to understand that my bladder is lacking a mechanism which prevents bacteria from attaching to its walls and causing infection. I have managed it in various ways, with the help of my physicians and urologists — mostly by taking a low dose of antibiotics with intercourse, washing before and after intercourse, drinking lots of water etc. But sometimes I develop referred pain in the pelvic area and in my lower back which does not immediately resolve even when a culture shows no infection. It eventually goes away, but it is very troublesome. You mention several physicians in your article — to which one would you suggest that I go? I live in DC.
Thanks, Pam
Hi Pam, I also had the UT symptoms on and off for years with this (although I was never treated with antibiotics because there was no sign of infection). The treatment that finally made the difference for me was reading A Headache in the Pelvis and attending Dr. Wise’s clinic in Santa Rosa CA where they show you how to use an internal wand to release trigger points on the pelvic floor that can cause (at least in my case) the urgency and frequency feelings.
In the DC area, I also got a lot of help with pelvic floor tightness and pain from Ann Udofia, a very gentle PT who does internal pelvic floor release (at least she did at the time). She has now opened her own practice. I don’t know if she is still doing the internal pelvic floor work, but you can check out her website at: http://www.wellness.com/dir/2615781/physical-therapist/va/arlington/ann-udofia-body-connect-physical-therapy-dpt
best of luck, Amy
I read your article in today’s Washington Post. Through your accurate description of the etiology of trigger-point referred pain, and the frustrations associated with getting a proper diagnosis, you have provided much-needed direction and hope for others afflicted with this syndrome. Thank you for a well-written and enlightening article.
Hi,
I found your article in the Post really interesting. I just wanted to share a potentially related issue – pelvic organ prolapse. I am 35 and experienced this after my first child was born (most women experience prolapse after menopause). I did a lot of research and the most effective and least invasive way to manage my symptoms has been changing posture. I thought you might find this website interesting — I owe a lot to this woman! http://wholewoman.com/
Best,
Leslie
I have read Headache in the Pelvis books, studied/tried myofascial release, trigger point therapy, massage, dry needling, ART, Graston, stretching, spent 5 years with 10 different pelvic floor therapists, multiple surgeries and STILL I have tight pelvic floor muscles and severe pain. Most people cannot travel to CA, especially from the east coast with IC/pudendal nerve pain, not being able to sit or able to afford the 4-5 thousand dollars, Dr. Wise’s facility charges for his treatment or the home care work that involves having a partner to participate in doing the internal work.
Can you please describe the relaxation technique that Dr. Wise prescribes. Why is this such a deep secret? Do they make you sign an agreement not to disclose this piece of information?
Hi L,
The thing I actually found most useful about the Wise clinic was the internal wand. David Wise has designed a smoothly curved tool that anyone can use themselves to apply pressure on trigger points on their pelvic floor and release them. You can do it yourself at home as needed. It received FDA approval last fall. You don’t need a partner to do this.
They don’t make you sign an agreement not to talk about the relaxation technique, but it is a challenging practice and I think he wants to make sure that people do it correctly so that they don’t get frustrated and give up on it. In my experience, it takes a lot of practice (much like meditation) to shut down the thoughts and pathways that cause me to (pretty much reflexively) clench my pelvic floor muscles (often in response to stress, which is pretty much all the time for many of us in modern life). I’m still working on this.
The cost is definitely a challenge. You might try calling Dr. Wise and talking with him about your situation and see what he says. I did that when I was considering going and he called me right back and we spoke for a half hour or so.
The most important part of Myofascial Trigger Point Therapy is identifying the Perpetuating Factors (what’s actually causing the pain) If your postures…hip height..Morton’s toe..diet are not looked at, it will most likely be a temporary fix. I had migraines and back pain for over 20 yrs. I’ve been pain free now for the last 12 yrs of my life. I am now a Trigger Point Therpaist who closely follows Dr.Janet Travell’s protocol. Too many people try to go right to the trigger point right away. I do not work on my patient on the first visit. I find the “why” of their pain and have them make the changes that are necessary to relax the tight shortened muscles. After they have corrected the perpetuating factors I can then release the trigger points and they have a much greater chance of staying pain free. I try to see my patients typically 2 to 6 times depending on how long they’ve had their pain. If you get a minute…Google “the chronic pain center, springfield, va” That’s the name of my business and I enjoy helping others get pain free. I’ve been there myself with the pain. I was on 80 pain pills a week 12 yrs ago……no more….Thank God. I’m here if anyone has any questions.
I agree completely about perpetuating factors – that has been my experience. In my case, poor posture and constant clenching of abdominal, pelvic floor, and hip seem to be the cause of my pain. And so I am now constantly aware of how I’m holding my body, so I can minimize recurrence. Trigger points do recur if I’m not careful (which often happens during times of stress). But I now know what’s causing the trigger points, and I know how to treat the trigger points once they form, and so I can manage my MPS without major disruption in my life.
“Metabolic” factors can also be an issue. Dr. Taylor ran extensive blood tests when I first consulted him, because some deficiencies are believed to contribute to myofascial pain. My thyroid and vitamin D levels were low, and so we treated those as part of my treatment.
I enjoyed your article in the Post and it has so much more relevance than just what happens in the pelvic region. Some of the techniques you mention to deal with the trigger points are really some sort of deep tissue massage and I was curious why you didn’t mention massage as a treatment for these muscle knots? As a competitive racquetball and street hockey player, I did extensive research when I experienced debilitating pain in my calf that kept me from playing my sports. The doctors sent me a vein doctor to ensure I didn’t have a blood clot, but then couldn’t figure out what was wrong. During the course of my own research, I came across the web site of Julie Donnelly – http://www.julstro.com. She does a fantastic job of describing what happens in the muscles, what trigger points are, and why simple stretching is NOT the answer when you’re dealing with muscle knots. She lays out a wonderful way for you to treat yourself when you experience muscle pain. I’ve even visited her twice to get treatment for various muscle-related issues. I now make it a point to get deep tissue massage locally once a month to ensure I get to keep playing my sports.
You did some wonderful research and provided some very helpful advice for dealing with trigger point issues. I just wanted to add that deep tissue massage could be another tool to help deal with the issue.
I was helped tremendously during all of this by a manual therapist who did deep tissue work on me weekly for more than a year (externally) and a PT who used the Barnes method of release on me internally. The problem was that the trigger points kept coming back. Dr. Taylor was the first one to run blood tests for metabolic conditions that were likely contributing to that (low vitamin D and hypothyroidism), adjust my posture to reduce recurrence, do extensive dry needling repeatedly on each muscle to remove the worst of the trigger points, and direct me to David Wise’s protocol, which includes deep relaxation to reduce recurrence and an internal wand to self treat my internal points. For me, it took multiple therapies over a period of months to get significant, meaningful relief. I still get trigger points, but I can keep it manageable and treat it myself now.
Thanks for sharing your experience.
WOW! Your description of your symptoms matched my problems very closely. I had just about given up hope of ever finding out what was wrong with me. I was dx with interstitial cystitis over a year ago and have stopped eating many foods and hardly ever leave the house because I am always hurting and riding in a car just makes it that much worse. Even though, I am taking elmiron for IC, I still hurt all over. It seems as though my pain is spreading more and more. I also have been to many doctors. Your article made me realize that what I am feeling is real.
I tried to make an appointment with Timothy Taylor of Pain Relief Home, Richmond, VA, but the phone number listed online for him is no longer in use. 804-320-1128 at 1702 Homestead Ct. Richmond, VA 23235. Do you know of another phone number for him? Thanks again for your very supportive article!
Hi Pat,
I had the same food situation – I went on the IC diet when I was misdiagnosed and found that following it strictly reduced my bladder symptoms substantially. And so I stuck with it even though it made a social life impossible (it’s amazing how much of our interaction with other people is over food and drink – and I couldn’t eat most foods or drink anything other than plain water or chamomile tea) and I missed food with flavor desperately. The other symptoms emerged in the months after that. I assumed they were a totally separate problem, and that somehow I was having a terrible string of bad (health) luck. It took a long time before I realized they were connected. But trigger points in the pelvic floor can cause the bladder pain and urgency and frequency symptoms. Treating those trigger points has made a huge huge difference in my life.
Dr. Taylor is no longer practicing. However, Dr. Robert Gerwin in Bethesda treated Dr. Taylor for his myofascial pain, and he and his partner Jan Dommerholt trained Dr. Taylor to treat others. Dr. Gerwin’s practice is called Pain and Rehabilitation Medicine. Their website is: http://www.painpoints.com/. I also strongly encourage you to check out Dr. David Wise’s website and book, which I mention in my blog post above. Ultimately the only way I got real relief from the bladder symptoms was treating the trigger points internally using Dr. Wise’s techniques. If you think these techniques will help you, call him and talk about your symptoms. I called him after I read his book and spoke with him about my symptoms. I decided to attend his clinic after speaking with him. It is expensive, but it has helped me get my life back.
Good luck and be persistent. This takes time.
best wishes, Amy
Hi Amy
I am also down to drinking only water or chamomile tea. I like chamomile tea, but I am so tire all the time that I don’t drink it very often. I can’t even watch one hour long TV show without falling asleep. I also felt that my other symptoms were not related to my IC. I even make my own bread to keep chemicals out of my diet.
Thanks for getting back to me so quickly. I went to the Pains Points web site. There was so much information that I printed out the articles so that I can sit down and read them that way I can highlight points of interest. I also have a copy of Doctor Wise ‘s book which I will read again. I will also call Doctor Robert Gerwin about scheduling an appointment. I finally have some hope after months of no hope. How did we get so lucky to get this problem? Take care Pat
Hi Amy–
I have been meaning to write you for some time regarding your excellent Post article on myofascial pain. I am a patient of Dr. Gerwin, and have found his therapies most helpful but temporary. What I have found most effective are the recommendations of Dr. John Sarno, particularly in his books “Healing Back Pain” and “The Mind-Body Prescription.” My daughter gave me his first book and I knew upon reading it that this was the answer for me.
While most physicians regard his views as focusing on “psychosomatic” disorders, I believe they have real relevance, particularly his view that most muscle pain is caused by stress, tension, and repressed anger. Following his advice has given me the only sustained relief in more than seven years of neck and back pain.
You may want to explore his ideas, which I believe are largely ignored by mainstream medicine.
Many thanks again for your article.
Stan, thank you for writing. I agree that for some of us, the pain starts with our thinking. In my case, I found Dr. David Wise’s book and clinic (mentioned in the blog post) really hit the nail on the head for me as the ultimate source of my pain. Dr. Wise has found that many people with pelvic pain chronically clench their pelvic floor muscles and abdomen in response to stress and as a protective mechanism. This chronic response to stress fatigues the muscles and leads to trigger points. His therapy includes something he calls paradoxical relaxation, to help people recognize and release this tendency. I’m still trying to master paradoxical relaxation, but I can see now how my tendency to respond to stress this way creates new trigger points. I agree, to resolve these problems, many of us need to address the thought patterns that lead to muscle tension and pain need to be addressed.
Hello Amy Mathews Amos, I tracked you down from a FB post and your WP article that is about my mission, which are Trigger Points. I am a F.P. doctor in Dallas and have spent the last 15 yrs researching, studying, practicing and experimenting with the causes and dynamics of muscles, tissue and fascia pain and malfunction syndromes. I also have found in many old dusty textbooks written by a few Masters of Medicine, the answers needed to defeat this disease. These Master of Medicine collective wisdom can be seamlessly blended into a profound treatment recipe. (Your reference list is only half of the Masters of the pain syndromes) This treatment recipe is holistic, natural, safe, nontoxic and can be done by any primary care provider, be they a nurse, Physician Assistant, Physical Therapist and even the patients themselves.
NO need for complex technology, medications or surgery.
If you care to know more just email me, find me on FB or the web.
I have lower lumbar degenerative disk disease and history of doing martial arts (including break falls) onto legs and buttocks. At age 57 got a Myofascial pain syndrome involving tension in Lower back, glutes, down into hamstrings, too. Trigger points were a part of this. I tried everything along with self diagnosis. Myofascial pain and stiffness followed after a bout of what appeared to be a brief case of reactive arthritis. Regarding pain and stiffness: Electrical stimulation helps somewhat (look for chiropractors; get a tens/ems unit for self treatment with large pads, too). What helped most was a massage therapist who used intense ultrasound with active release stretching during treatment along with my stretching and weightlifting and Pilates reformer exercises (aeropilates 700 from amazon or get a nicer one if you can afford it) and TRX suspension core exercises and use of an inversion table.
I believe the pain signals are sent via the spinal nerves which interface with other nerves (big nerve plexus in psoas (lumbosachral plexus) and psoas stretches and quadratus lumborum stretches (done in a door frame; lean hip hard to one side) help me get rid of ALL back pain (google quadratus lumborum syndrome for a list of back pain and related symptoms that come from those tight lower back muscles (there is even a psoas syndrome, too) that I had for YEARS. In addition deep breathing (part of Pilates) will help to relax the psoas during stretches (psoas connects with diaphragm). Between lower back and hips is so innervated that it often all connects in a bad way with these pain syndromes (mentioned by Wise & Anderson in “headache in the pelvis”). As they mention, many people have digestive issues, too (try ibs probiotics and Heather’s tummy tamers).
I believe that most to all of my pain is ALL from muscles clamping on nerves and nerve pain from the tension. I have found stretching and exercise is key to minimizing pain and minimizing trigger points, too (mine don’t all go away easily as the DDD and muscle tension are the “perpetuating factors” – but things are much, much better. You’re going to have to be a “do it yourselfer” as well as get treatment where you can find help for a lot of this if you have a complex case. The “stiffness” and the pain is NOT arthritis and can be made to go away. The longer it stays, the harder to get rid of, so I read.
Rich, thanks for your comments. I agree – I’ve found that so much pain is caused by tight muscles and the ripple effects of that. I fear most people don’t recognize this. As my husband and i get older, and he gets more aches and pains, I’ve convinced him that it’s probably due to tightness and massage and stretching will help. I wonder how many people are on addictive pain killers when much of their problem could be resolved by focusing on the muscles. Thanks for sharing your experience. -Amy
Hi Amy,
I’m so glad I’ve stumbled upon your WP article after recently finding out that this is the problem I’ve been suffering with for 2 years. I’ve unfortunately developed several trigger points throughout my body now (it originated in my jaw/neck) so it won’t be a quick fix. I’m currently seeing a manual trigger point therapist who does myofascial release as well and I’m going to start dry needling in a couple of weeks. Just wondering what treatments have you undergone and how long it took you to find relief, and whether you took medication for pain. Thanks very much for spreading awareness about this!
Best,
Seif
Hi there,
i’m glad you’re getting the help you need! My problem started in my pelvic floor and then spread down my legs to my knees. i did manual therapy all over my body (everything really is connected – I truly know that after this experience) as well as concentrated therapy with a specialist who worked internally in me to release trigger points. Eventually I found a treatment and a tool that let me release my pelvic floor trigger points myself (for others reading this who have pelvic floor trigger points, I went to Dr. David Wise’s clinic.). And of course I did the dry needling with someone who really knew how to do it well. (I’ve found that dry needling can be useless if not done properly and the differences in how people practice it appear subtle, but make a big difference.) Regarding medication: this whole process of discovering the cause of my problem and effective treatments to resolve it took about 5 years. In that time, the only time I took medication was early in the process when my pelvic floor trigger points manifested themselves through referred pain to my bladder. I was misdiagnosed with a bladder condition called interstitial cystitis – which basically feels like a constant bladder or urinary tract infection. For several weeks I tried various pain medications to cope with that, but they didn’t really help much. I soon found that restricting my diet helped completely, and I stopped medication and stuck to that until I eventually figured out the true problem and sought out effective treatment. So the short answer is no, I took no pain medication through most of my journey. Best of luck! -Amy