Rapid Diagnosis

By John Lowe, MA, DC

Myofascial therapy is not for acute care only;1 nevertheless, it is the best method for rapidly diagnosing and relieving your patients' acute myofascial pain. You can diagnose the source of most patients' pain quickly and accurately in two steps. First, use your patient's pain pattern as a guide to the muscle that's referring the pain. Secondly, palpate the suspected muscle to isolate taut, tender bands that contain trigger points (TPs).

To illustrate this process, consider a patient (we will call her Gail) who recently came to me for a persistent headache. My first step with Gail was to get a description of her pain. In most cases, myofascial pain is a deep, dull aching that's persistent, poorly localized, and almost impossible to ignore. Gail affirmed that these were the qualities of her pain. This made it likely that her problem was myofascial in origin. I now needed her to precisely describe the distribution of her pain. "Show me where you hurt," I stated. She pointed to her right temple.

"Is that the only place it hurts?"

"Not exactly," she said. "It hurts sort of over here, too." She swished her finger over to the top of her right ear. "It kind of fades away from my temple back here." Then, as though it were an afterthought, she said, "It hurts across my forehead."

"Show me with your finger exactly how far the pain travels across your forehead."

"It's just on the right," she said. "But not much; it fades out right about here." She fingered a spot at about mid-eyebrow. She waved her finger back and forth, indicating that the margin of the pain was nebulous.

I pondered the possible muscles that could be referring her pain and remembered four cervical muscles that typically refer patterns similar to hers. There might be others I didn't recall, but if I found through palpation that none of the four were referring her pain, I could check pain pattern charts to see which other muscles might be responsible.

For a more precise description, I questioned her further. "Is there any pain around your right eye?" I asked, making a crescent shape with my fingers above and lateral to my eye.

"Yes, there is; it hurts a little here." She drew an imaginary line just lateral to her right eye. With this addition to her description, it seemed likely that her right sternocleidomastoid (SCM) muscle housed the referring lesion.

When I talk with some patients, they veer from the subject with such vigor that I don't carry my questioning this far. I may find it more expedient to stop talking and pinpoint their problem muscle by palpating all the possible ones. But in this case, Gail communicated quickly and accurately. "Do you hurt anywhere else?" I asked. When she answered no, I decided to palpate the muscles that could be referring, starting with the most likely one, the right SCM.

I found a referring lesion in this muscle. But, before I found it, I palpated the muscle at several points along its length. I pressed my thumb and middle finger deeply into the tissues on both sides of the SCM and squeezed down, getting a good pincer grip. It resisted somewhat as though it were stuck to her neck with rubbery glue. I squeezed the bulk of the muscle and maintained the pressure as I let it slide between my digits back against her neck. At about the middle of the muscle's length, I felt a tense bundle of tissue slip past my fingers. I took another grip on this mass and squeezed it firmly. The tissue slid about, but I was able to squeeze the induration hard enough to provoke referred pain.

"That's it!" This is what most patients say with surprise when you locate the responsible TP and cause it to refer pain. I squeezed the muscle again to confirm the pain pattern. As with many patients, my squeezing the taut tissue didn't duplicate her pain exactly, but it was enough of a facsimile to justify a trial of specific myofascial treatment. I marked the skin overlying the taut band with a grease pencil so that my CA would know where and how to apply ultrasound.2

In spite of having found a source of her pain, I also palpated the other three muscles. I did so to make sure that her pain was coming solely from the SCM, and wasn't a composite pattern referred from two or more muscles. None of the other muscles, however, contained tender lesions.

To quickly and accurately diagnose myofascial pain, use the patient's pain pattern as a map to the possible referring muscles. Palpate to isolate the taut, tender lesion that upon sustained pressure refers pain to the area of complaint. Then with equal speed, neutralize the TP with therapeutic techniques.

In any type of chiropractic practice, there is often the need to relieve the patient's acute pain. When using these diagnostic steps, even the busiest DC can move quickly and give his patients the relief that comes only through myofascial therapy.

References

  1. Lowe, J.C. "Acute care only?" Dynamic Chiropractic, July 4, 1990, p. 32.
  2. Lowe, J.C. "Treatment-Principles and Physiotherapy," tape 9, The Purpose and Practice of Myofascial Therapy, (audio cassette album), Houston, McDowell Publishing Co., 1989.

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