SCALENE MYOFASCIAL PAIN SYNDROME

Patient with Rt knee pain

26-years-old man

P I/M ache

Clinical reasoning
Area of symptoms suggest that the following
structure may be implicated.
The pain may due to the surgery complication
that he has underwent.

Relationship of symptoms
P1 occurs independently. The onset of each symptom is linked, which
suggests a single source of symptoms. C5
and C6 cervical spine nerve root may involve
base on dermatome. However patient does
not complain sharp or shooting pain that
indicate nerve root involvement (Magee
1997, Newham & Mills 1999). This patient
complain of constant dull ache and pulling
pain that indicate muscle involvement
(Magee 1997, Newham & Mills 1999).
Aggravating factors
 Writing on the whiteboard using left hand
for 30 min: P1 present follow by P2 after
10 min
 Fastening bra and comb hair using left
shoulder: P3 immediately
 Bilateral neck rotation: P3 present
 Untreated P1 and P2: P4 and P5 present
 irritability of muscles, leading to the
 Lying on left shoulder: no pain at left
shoulder.
 Elbow movements: no pain
 Supination/pronation: no pain
Severity
Writing on the whiteboard using left hand –
can continue after onset of P1 and P2.
– can continue even though presence of P3
and P4
Irritability
Put down left shoulder – P1 eases slowly
within 30 min.
24-hour behavior
 Constant pain on the day dependent on
activity.
 Difficulty to sleep with constant P1 and
P2.
Special question
History of present condition (HPC)
Gradual pain at P1 since past 1 year, and
symptoms become worse around 3 months
ago. Does not release the cause of pain.
Patient felt P1 first then follow by P2 after
Identifies source of symptoms as follows:
 Combination movement of left shoulder
flexion and neck extension show cervical
radiculopathy symptom.
 Rotator cuff muscle involvement
(muscular pain).
 Neck rotator muscle involvement such as
upper trapezius.
 Perpetuating factors can increase
propagation of TPs and increasing the
distribution and severity of pain. This
progression leads, in time, to the complex
disaster, chronic pain (Simons G, D.,
1987).
 Negates shoulder joint
 Negates elbow
 Negates elbow
Because of the positive relationship of
symptoms, the spine and muscle around
shoulder and neck must continue to be
suspected as a source of symptoms.
Moderate, as the patient can continue do her
activity.
Irritable, as the symptom ease slowly and will
increase as they are reproduce for a
prolonged period of time.
 Although the pain is usually related to
muscle activity, it may be constant
(Alvarez and Rockwell, 2002).
 Pain can be worse at night, may be either
cervical spine radicular or pathognomonic
from TPs around shoulder and neck
muscle (Simons G, D., 1987).
Provides supporting evidence that all the
symptoms are related.
bear P1 one week. P3 and P4 present with
worsening of P1.
Past medical history
 History of muscular pain at neck and
shoulder already present for past 3 years.
 Patient develop sinus since childhood.
Special history
Work as teachers who required lot of
overhead activity, shoulder movement,
putting weight on shoulder and writing for 8
hours/day.
Still working.
Physical examination
Observation in sitting
Reduce cervical lordosis, retracted shoulder
girdle and tuck in chin.
 This is not first episode of pain, not good
prognosis.
 Hypertrophy of respiratory accessory
muscle may be present. Must be future
examined on respiratory assessor
muscle.
Area of pain that is produce by this patient is
common related to nature of her job.
Improper body mechanic that produce
repetitive stress on single or group of muscle
will cause chronic stress on muscle fiber that
leading to TPs (Alvarez and Rockwell, 2002).
Education about ergonomic intervention such
as writing position must be given to reduce
and prevent recurrent symptoms.
Plan of physical examination
The onset of each symptom is linked, which
suggests a single source of symptoms. The
symptoms shows cervical radiculopathy,
however there is no related single cervical
movement as aggravating factors. Therefore,
when examining the cervical spine it will be
necessary to use combined movements.
However patient does not complain sharp
or shooting pain that indicate nerve root
involvement (Magee 1997, Newham & Mills
1999). This patient complain of constant dull
ache and pulling pain that indicate muscle
involvement (Magee 1997, Newham & Mills
1999).
Since patient have history of respiratory
problem, respiratory assessor muscle must
be examine. The plan for day 1 is to examine
fully the muscular pain that giving same
symptoms as cervical radiculopathy such as
scalene, because TPs at scalene muscle also
will produce same pain pattern as cervical
radiculopathy (Petty 2012).
Clinical reasoning
Prolonged poor posture may leading to
increase strain on the neuromusculoskeletal
thus enhance microtrauma of the muscle.
Repetitive microtrauma may lead to the
development of TPs (Alvarez and Rockwell,
2002). Therefore, correction of posture is
 importance to maintain positive treatment
effect.
Cervical spine active movements
Flexion – no symptom produce Symptom reproduction, suggest muscular
Extension – no symptom produce pain, not radiculopathy. However, accessory
LLF and LLrot. – produce P3 movement of cervical need to be done to
RLF and RLrot. – produce P3 make sure this anatomy does not involve in
this condition.
Shoulder active movements
Flexion Symptom reproduction, suggest
Extension
Abduction
Adduction
External rot. – limited and produce P2
Internal rot. – limited and produce P2
Cervical spine accessory movements
In combined positions – no symptom produce Negates cervical spine
Shoulder accessory movements
Does not produce pain at end fell.
Passive lengthening of muscle
Left upper trapezius – reproduces P3
Left levator scapular – reproduces P3
Left supraspinatus – no symptom produce
Palpation of muscle
Left scalene – produce jump sign with Have reproducible TPs over scalene, upper
referred pain to the left shoulder and arm trapezius and rhomboid when gentle digital
side. pressure was given (Abdul Jalil, N. et al,
Bilateral upper trapezius – produce jump 2010).
sign. Provide evidence that TPs is present.
Left rhomboid – produce jump sign.
Scapular assisted

Special test
 Spurling test  Negative radiculopathy involvement.
Negates cervical spine.
 Distraction test  Negative radiculopathy involvement.
Negates cervical spine.
 Empty can test  Positive rotator cuff involvement.
 Speed test  Positive rotator cuff involvement.
Impression
During taking data on subjective, the
symptoms that shown by this patient can be
said as cervical radiculopathy. However,
result from physical examination negates a
cervical as a source of symptom. From the
special test that has been done, rotator cuff
pathology may involve, however there is
evidence that suggest TPs at scalene is
cause of this patient symptom that leading to
Myofascial Pain Syndrome (MPS).

Treatment day 1
1) Treat MPS of scalene by:
 Heat therapy
 TPs release
 Ultrasound therapy
2) Active stretching exercise for scalene
muscle.
Day 2
Patient report on pain reducing at P1 and P2.
Now able to comb hair and fastening bra.
Shoulder active movements
External rot. – AFROM and does not produce
P2
Internal rot. – AFROM and does not produce
P2
Palpation
Tenderness at:
 Left scalene (does not produce jump sign
with no referred pain to the left shoulder
and arm side).
 Bilateral upper trapezius (produce jump
sign).
 Left rhomboid (produce jump sign).
Treatment
1) Continue same pain management but
focus to upper trapezius and rhomboid
muscle.
2) Active stretching exercise for upper
trapezius and rhomboid muscle.
3) Posture correction on increase cervical
lordosis.
4) Ergonomic intervention on writing.
MPS is chronic regional pain syndrome
that presents with hyperirritable spots known
as TPs that arise from taut bands (TB) in the
skeletal muscle (Abdul Jalil, N. et al, 2010).
MPS is often accompanied by a bizarre
referred pain pattern. MPS of scalene usually
presents with unilateral neck and anterior,
lateral, and posterior shoulder-girdle regions
as well as down the length of the upper
extremity to the index finger (Simons G, D.,
1987).
Functionally, MPS causes the muscle to
become weak and stiff, leading to reductions
in range of movement. In this case, TPs at
scalene will lead limited range of surrounding
area such as shoulder. End up, MPS become
cause of morbidity, with a significant impact
on daily activity, function and quality of life.
There is strong evidence that show MPS of
scalene is the causes of this patient
symptoms. This was technique that been
choice because it most suitable for this
patient.
Good prognosis
Good prognosis for TPs pain reducing of
scalene muscle. However TPs at upper
trapezius and rhomboid remain same
because this is active TPs. That is why
patient still show symptom of dull ache at P1
and P2.
Shows improvement with pain treatment that
was given at scalene muscle. Now focus to
reducing active TPs pain. Add on posture
correction, ergonomic intervention and HEP
to maintain positive treatment effect.
5) HEP
Reassessment
No jump sign for upper trapezius and This suggest that latent TPs can cause active
rhomboid muscle. TPs to others muscle.