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Myofascial pain is a common sequela of traumatic musculoskeletal injuries. It is characterized by pain and tenderness in the muscles and surrounding connective tissue (fascia). The pain often originates from hyperirritable spots within taut bands of skeletal muscle known as myofascial trigger points (MTrPs). MTrPs can develop due to acute muscle overload, repetitive microtrauma, poor posture, or after injuries like strains, contusions, or whiplash.
A multimodal treatment approach is most effective for managing post-traumatic myofascial pain. Key components include:
– Rest and activity modification
– Oral medications like NSAIDs and muscle relaxants
– Topical analgesics
– Physical therapy and manual trigger point release
– Psychological support
This report will focus on the benefits of rest, oral NSAIDs and muscle relaxants like cyclobenzaprine (Flexeril), and topical medications in the management of myofascial pain after trauma.
Rest is a critical first-line treatment in the acute phase after a musculoskeletal injury. Benefits of rest include:
– Prevents further damage to injured muscles and soft tissues
– Reduces metabolic demands on healing tissues
– Helps limit extent of inflammation
– Provides pain relief
– Facilitates tissue healing and repair
In the first 24-72 hours after an acute muscle injury, the RICE protocol should be followed:
– Rest – limit use of injured area
– Ice – apply cold packs for 15-20 min every 1-2 hrs
– Compression – use elastic bandage to reduce swelling
– Elevation – raise injured limb above heart
After the acute phase, rest should be balanced with early mobilization and a gradual return to activities. Complete immobilization for prolonged periods can lead to deconditioning, muscle atrophy, and joint stiffness. Low-impact aerobic exercise and pain-free range of motion exercises can be started a few days after injury.
Work and recreational activities may need to be modified to avoid overuse and re-injury of healing muscles. Ergonomic adjustments and frequent rest breaks are important. The patient should be advised to stop any activity that causes pain. A graded return to regular activities should occur over a period of weeks to months depending on the severity of the initial injury.
Oral nonsteroidal anti-inflammatory drugs (NSAIDs) are a mainstay of treatment for myofascial pain and other soft tissue injuries. Commonly used oral NSAIDs include:
– Ibuprofen (Advil, Motrin)
– Naproxen (Aleve, Naprosyn)
– Diclofenac (Voltaren)
– Celecoxib (Celebrex)
Oral NSAIDs provide multiple benefits in the management of myofascial pain:
– Analgesia (pain relief)
– Anti-inflammatory effects
– Reduction of swelling
– Improvement in mobility
NSAIDs work by inhibiting cyclooxygenase (COX) enzymes involved in prostaglandin synthesis. Prostaglandins mediate pain, inflammation, and fever. By blocking their production, NSAIDs help reduce pain and inflammation at the site of injury.
Pain relief from NSAIDs allows patients to participate more comfortably in rehabilitation and resume daily activities. This is important for preventing deconditioning and muscle atrophy. The anti-inflammatory effects of NSAIDs also help limit the extent of tissue damage and swelling after an injury. This may promote faster healing.
Compared to opioids, NSAIDs provide comparable pain relief for musculoskeletal injuries without the risks of dependence, tolerance, and other adverse effects. NSAIDs are generally well-tolerated but can cause gastrointestinal side effects like dyspepsia, ulcers, and bleeding. They may also increase cardiovascular risk with prolonged use. Renal and hepatic function should be monitored. NSAIDs should be used at the lowest effective dose for the shortest duration needed.
Muscle relaxants are frequently prescribed in combination with NSAIDs for acute musculoskeletal pain. The most common oral muscle relaxant used is cyclobenzaprine (Flexeril). Others include methocarbamol (Robaxin), tizanidine (Zanaflex), and baclofen (Lioresal).
Potential benefits of muscle relaxants for myofascial pain include:
– Reduction in muscle spasm and tightness
– Relief of pain caused by muscle tension
– Improved range of motion
– Facilitation of stretching and manual therapy techniques
– Promotion of restful sleep
Cyclobenzaprine is well-studied for use in acute musculoskeletal injuries. It has been shown to be more effective than placebo for providing short-term pain relief, reducing tenderness, and improving mobility. Effects are seen as early as the first 1-3 days of treatment.
The mechanism of action of cyclobenzaprine is not fully understood. It is structurally similar to tricyclic antidepressants and likely acts centrally to reduce tonic somatic motor activity and spasms. It may also have analgesic effects through modulation of serotonergic and noradrenergic transmission.
Cyclobenzaprine is typically dosed at 5-10 mg three times daily. The most common side effects are drowsiness, dizziness, and dry mouth. It can potentiate the effects of alcohol and other CNS depressants. Tolerance and dependence are rare when used as directed. Cyclobenzaprine should be used cautiously in the elderly and those with cardiac conduction disturbances, heart failure, and arrhythmias.
Topical medications are applied directly to the skin over painful muscles. Potential benefits of topicals for myofascial pain include:
– Targeted pain relief with minimal systemic absorption
– Avoidance of systemic side effects
– Convenience of use
– Adjunctive analgesia when combined with oral meds
Commonly used topical agents for musculoskeletal pain include:
– Menthol – counterirritant that stimulates cold receptors
– Methyl salicylate (oil of wintergreen) – counterirritant and salicylate analgesic
– Capsaicin – depletes substance P from sensory neurons
– Lidocaine – local anesthetic
– Diclofenac – topical NSAID
Topical menthol, methyl salicylate, and capsaicin are available over-the-counter. They work as counterirritants, which stimulate sensory nerve endings in the skin to provide a sensation of warmth or coolness. This increases local blood flow and creates a temporary analgesic effect by masking underlying pain signals.
Topical lidocaine blocks nerve impulses involved in pain transmission. It is available as a patch or gel. The 5% lidocaine patch can provide localized pain relief for up to 12 hours. Systemic absorption is minimal, so side effects are rare. Topical lidocaine is most effective for superficial, localized myofascial pain.
Topical NSAIDs like diclofenac have the same anti-inflammatory and analgesic effects as oral NSAIDs but with less systemic absorption. This reduces the risk of gastrointestinal, cardiovascular, and renal adverse effects. Topical diclofenac is available as a 1% gel and as a medicated patch. It has been shown to effectively relieve pain and tenderness in acute ankle sprains, knee osteoarthritis, and other superficial soft tissue injuries.
Topicals are generally well-tolerated but can occasionally cause local skin irritation, rash, or burning sensations. They should not be applied to broken skin or open wounds. Hands should be washed after application to avoid contact with eyes or mucous membranes. Topicals can be used alone or in combination with oral analgesics for optimal pain control.
Myofascial pain is a common problem after traumatic musculoskeletal injuries. A comprehensive treatment plan should include rest, activity modification, oral and topical medications, physical therapy, and psychological support.
In the acute phase, rest is essential to unload injured tissues and allow healing to occur. NSAIDs are the first-line oral medication for providing pain relief and reducing inflammation. Muscle relaxants like cyclobenzaprine can be added to relieve painful muscle spasms and facilitate rehabilitation. Topical agents provide targeted pain relief with minimal systemic side effects.
The goals of treatment are to relieve pain, prevent chronic MTrPs from developing, restore function, and improve quality of life. With proper multidisciplinary care, most patients with myofascial pain after trauma can achieve good long-term outcomes. Patience and a graded return to activities are key to avoiding re-injury and ensuring optimal recovery.
©2025 Dr Frank McCormick All Rights Reserved.
©2025 Dr Frank McCormick All Rights Reserved.