Postgraduate Medicine

ISSN: 0032-5481 (Print) 1941-9260 (Online) Journal homepage: http://www.tandfonline.com/loi/ipgm20

The Myofascial Genesis of Pain

Janet Travell & Seymour H. Rinzler

To cite this article: Janet Travell & Seymour H. Rinzler (1952) The Myofascial Genesis of Pain,
Postgraduate Medicine, 11:5, 425-434, DOI: 10.1080/00325481.1952.11694280

To link to this article: http://dx.doi.org/10.1080/00325481.1952.11694280

Published online: 18 Apr 2016.

Submit your article to this journal

View related articles

Citing articles: 20 View citing articles

Full Terms & Conditions of access and use can be found at

http://www.tandfonline.com/action/journalInformation?journalCode=ipgm20

Download by: [RMIT University Library] Date: 04 May 2016, At: 02:51
 SCIENTIFIC EXHIBIT
THE MYOFASCIAL GENESIS OF PAIN
JANET TRAVELL AND SEYMOUR H. RINZLER*
Comell University Medical College and Beth Israel Hospital, New York
Trigger Areas in Myofascial Structures
Downloaded by [RMIT University Library] at 02:51 04 May 2016
Can Maintain Pain Cycles Indefinitely
THE TRIGGER AREA
Data are drawn from about 1000 patients with
(1) pain syndromes and (2) myofascial trigger
areas.
The trigger area is a small hypersensitive
region from which impulses bombard the cen-
tral nervous system and give rise to referred
pam.
Pain is set off whenever the trigger area is
stimulated by pressure, needling, extreme heat
or cold, or motion that stretches the structure
containing the trigger area.
The resistance to stretching leads to apparent
shortening of the affected muscle with limita-
tion of motion and weakness.
High-intensity discharges from a trigger area
•THE DEPARTMENT OF PHARMACOLOGY, COR-
NELL UNIVERSITY MEDICAL COLLEGE, AND THE
CARDIOVASCULAR RESEARCH UNIT, BETH ISRAEL
HOSPITAL, NEW YORK, NEW YORK,
ART WORK BY JULIUS F. KOCH AND MAISON C.
CLARKE.
THI~ INVESTIGATION WAS SUPPORTED BY A RE-
SEARCH GRANT FROM THE NATIONAL HEART
INSTITUTE, UNITED STATES PUBLIC
SERVICE, BETHESDA, MARYLAND.
THIS EXHIBIT WAS SHOWN AT THE
(ATLANTIC CITY) SESSION OF THE
MEDICAL ASSOCIATION, 1951.
Mrzy 1952
may be accompanied by vasoconstnctton and
other autonomic effects limited to the reference
zone of pain.
A trigger area at a particular spot gives rise
to a similar distribution of referred pain in one
person as in another.
This constancy of pattern indicates that im-
pulses concerned in the unfamiliar reference of
somatic (like visceral) pain follow fixed ana-
tomic pathways.
This fact enables one to use a known refer-
ence pattern to locate the myofascial source of
pain.
THE PAIN CYCLE
Myofascial trigger mechanisms may be mltl-
ated by direct trauma to muscle or joint, chronic
muscular strain, chilling of fatigued muscle,
acute myositis, arthritis, nerve root injury, vis-
ceral ischemia or dyskinesia, and hysteria.
Predisposing factors may be general fatigue,
low metabolic rate with creatinuria, chronic in-
fection and psychogenic stress.
HEALTH Protracted myofascial pain following activa-
tion of trigger area is thought to depend on a
ANNUAL
AMERICAN
reflex pain cycle maintained by the trigger area.
The pain cycle is often terminated permanent-
425
 ly by local block procedures with only transitory
pharmacologic actions: procaine infiltration or
dry needling of trigger areas, sustained heavy
pressure on them, and spraying the overlying
skin with ethyl chloride.
Efficacy of local block implies that the mech-
anism which set the pain cycle in motion is not
the same as that which keeps it going. The pain
cycle continues long after the precipitating cause
has vanished.
After local block the pain cycle is reactivated
if a remote lesion supplies a fresh stream of
noxious impulses.
When local block relieves pain, no immediate
deduction can be made from that fact alone as
to the primary cause of the pain syndrome.

Trigger Areas Appear at Site of Trauma

ANKLE SPRAIN 44 HOURS AFTER INJURY IN 43 YEAR OLD WOMAN
Downloaded by [RMIT University Library] at 02:51 04 May 2016

rlJ.lZI AREA OF EDEMA AND ECCHYMOSIS

1,2,3,4 SPOTS OF EXQUISITE TENDERNESS

t:ZI!II PAIN MOMENTARILY INDUCED BY INFILTRATION OF ABOVE

TENDER SPOTS (X), FOLLOWED BY RELIEF OF PAIN.

The spread of pain does not follow any sensory nerve onstrates trigger areas in the periarticular structures.
distribution, but represents referred pain which dem- No pain spread results from infiltrating nontender spots.

Trigger Areas Appear in Reference Zone of Visceral Pain

PATHWAYS OF NOXIOUS IMPULSES IN PAIN OF CORONARY ARTERY DISEASE

CLINICAL TYPES OBSERVED EXPLANATION OF CLINICAL DATA

MYOFASCIAL RELIEF BY BLOCKING THEORETICAL SOURCE OF
TR IGGE~ AREAS SOMATIC COMPONENT STAGES NOXIOUS IMPULSES

ABSENT VISCERAL
et\ ~~
~EART
A
------. ~~
""'~"
I~ '"'"''""
NONE OR PARTIAL (DEPEND- 11 VISCEROSOMATIC
ING ON PREDOMINATING PATH-
WAY) SOMA

PRESENT COMPLETE, BUT TEMPORARY

B
~11§~'
COMPLETE AND PERMANENT Ill. SOMATIC
~~
Diagram explains why local block of trigger areas in the chest muscles sometimes relieves cardiac pain.

426 POSTGRADUATE MEDICINE

 Once the Pain Reference Pattern of a Muscle Is Known, It Can Be
Used to Locate the Muscle That Is the Source of Pain
HEAD AND NECK -
STERNOMASTOID SPLENIUS CAPITIS
Downloaded by [RMIT University Library] at 02:51 04 May 2016

TEMPORALIS MASSETER

TRAPEZIUS TRAPEZIUS

LEVATOR SCAPULAE POSTERIOR CERVICAL

PAIN PATTERN E<=>l TRIGGER AREA X

May 1952 427
 SHOULDER AND ARM

INFRASPINATUS SUPRASPINATUS
Downloaded by [RMIT University Library] at 02:51 04 May 2016

DELTOID

SUBSCAPULARIS MIDDLE EXTENSOR

FINGER CARPI
EXTENSOR RADIALIS SUPINATOR$

./i'--
1

FIRST INTEROSSEOUS ADDUCTOR POLLICUS

PAIN PATTERN Et?.J TRIGGER AREA X

428 POSTGRADUATE MEDICINE
 CHEST AND BACK

PECTORALS PECTORALIS MAJOR

SERRATUS ANTERIOR
Downloaded by [RMIT University Library] at 02:51 04 May 2016

ILIOCOSTALIS

PAIN PATTERN Et :l TRIGGER AREA X

May 1952 429
 LOWER EXTREMITY

GLUTEUS MINIMUS ADDUCTOR LONGUS

VASTUS MEDIALIS BICEPS FEMORIS

Downloaded by [RMIT University Library] at 02:51 04 May 2016

SOLEUS GASTROCNEMIUS ABDUCTOR HALLUCIS

TIBIALIS LONG SHORT PERONEUS

ANTICUS EXTENSORS EXTENSORS LONGUS

PAIN PATTERN Ee;::·.J TRIGGER AREA X

430 POSTGRADUATE MEDICINE

 Transitory Local Block of Trigger Areas May Relieve Myofascial Pain Permanently
ETHYL CHLORIDE SPRAY PROCEDURE
Downloaded by [RMIT University Library] at 02:51 04 May 2016

Guard against fire hazards. Repeat sweeps in rhythm of a few seconds on and off.
Raise patient's head above level sprayed. Lengthen interval between sweeps if aching develops.
Hold container 2 feet away. Do not frost skin.
Stretch muscle by gentle movement.
Start stream at trigger area, carry over reference zone.
Continue until pain disappears and tenderness at trig-
Apply stream at acute angle. ger area is less.
Spray in one direction, with slow sweeping motion. Stop if no effect in five minutes.

TYPES OF RESPONSES TO SPRAY IN 40 CASES OF ACUTE "STIFF NECK"

%
100~~~~----------------------------------~

(/)
(/)
75
~[rs.ro,:.u:------
, ~
UJ
z I ---- I I) Total et once }
LL..
LL..
I! , ..., ·••••••••12) ~ecarr~~.~~~:~~em•ld 70~ of cons

1- ~! / i - · - (3) Step-like with } ~

~.. - i
(/) repeated spraying 25 of costs
50~
0
z I b::
~
[-{3)
.
- - (4) Ne91iq•ble } 5'\ of cases

<(
(l}f=H !
z
~ 25
!Ill
iW
I
2

··..
l
!___ _
r::-;s,,., .
....... • ....,
.,u..
0+---~--~···~·----~---+----~--~--~
-12 0 12 24 36 48 -60 72
TIME IN HOURS

When there is little response to spraying, procaine infiltration may be effective.

May 1952 431

 PROCAINE INFILTRATION PROCEDURE
Downloaded by [RMIT University Library] at 02:51 04 May 2016
By pressing on trigger area, demonstrate pain reference
to patient.
Ask patient to announce when pain radiation is felt
during infiltration.
When needle hits trigger area, pepper region by mov-
ing it in and out of muscle, injecting I to 2 cc. con-
tinuously.
TYPICAL CLINICAL RESPONSE TO PROCAINE:
CASE OF MASSETER SPASM AFTER TOOTH EXTRACTION
Dramatic relief of pain after first treatment. Step-like increase in range of motion with each treatment.
432
Use 0.25 to 0.5 per cent procaine hydrochloride in
physiologic saline (unless history of procaine allergy).
Use a sharp 22 to 24 gauge needle, I to 3 inches long,
depending on site of trigger area.
Apply hemostasis promptly.
Check success of injection. If trigger area is still tender,
reinfiltrate at different depths and angles.
(N.B., MALE, 21 YRS.)
POSTGRADUATE MEDICINE
 ACUTE MYOCARDIAL INFARCTION WITH SOMATIC COMPONENT
W. T. 73 YEARS OLD. AWAKENED BY INTENSE SUBS.T'ERNAL PAIN RADI-
ATING DOWN LEFT ARM PAIN CONSTANT UNTIL RELIEVED BY PROCAINE INFILTRATION OF TWO TRIGGER AREAS IN
LEFT PECTORAL MUSCLES 13 HOURS AFTER ONSET. RELIEF IMMEDIATE, COMPLETE AND PERMANENT.

MORPHINE
z SULFATE

f GLYCERYL TRINJRATEl
PROCAINE
INFILTRATION

INFLUENCE ~ ! m 1111 j
OF >-
1-
THERAPY
ON ~
PAIN
1&1
1- ••
Downloaded by [RMIT University Library] at 02:51 04 May 2016

12N 12M

CHANGES Il
OF
ANTERIOR
WALL m
INFARCTION
"N CLINICAL COURSE

PECTORALIS MAJOR PECTORALIS MINOR SERRATUS ANTERIOR

COMMON SITES OF SOMATIC TRIGGER AREAS WHICH REPRODUCE CARDIAC PAIN

EVIDENCE THAT PAIN WAS OF CARDIAC ORIGIN

SERIAL CHANGES IN ELECTROCARDIOGRAM
SIGNS OF CIRCULATORY COLLAPSE
SIGNS OF TISSUE NECROSIS
Otporlmtnl of Pharmacology
Cll•lltll Uni""'''J Mdlcal Colltgt

May 1952 433

 MYALG lA OF CHEST AND SHOULDER
SIMULATING ACUTE MYOCARDIAL INFARCTION
H. H. 65 YEARS OLD.
RADIATING TO LEFT ARM, WHILE WALKING. CONSTANT PAIN DURING 5 WEEKS PRIOR TO PROCAINE INFILTRATION OF
TRiGGER AREAS IN .LEFT POSTERIOR SCAPULAR AND INTERSCAPULAR MUSCLES.
COMPLETE IMMEDIATE RELIEF BY ONE SUCH TREATMENT. NO RECURRENCE IN SIX YEARS.
MAXIMUM EXTENT OF MOTION AT SHOULDER
JUST BEFORE INFILTRATION
Downloaded by [RMIT University Library] at 02:51 04 May 2016
EXTE.NSION 0° ABDUCTION 26°
EVIDENCE THAT PAIN WAS OF SOMATIC ORIGIN:
POSITIVE
MOTION LIMITED
MOTION PAINFUL
PAIN CONSTANT, SEVERE AND CHRONIC
REFERRED PAIN INDUCED BY PRESSURE ON
TRIGGER AREAS
REFERENCES
J. TaAVELL, J., RINZLEa, S. H. and HuMAN, M.: Pain and dis~
ability of the shoulder and arm. Treatment by intramuscular
infiltration with procaine hydrochloride. I .A.M.A. 120:417 (Octo-
ber 10) 1942.
2. TaAVELL, J., BnaY, C. and BIGELOW, N.: Effects of referred
somatic pain on structures in the reference zone. Federation
Proc. 3:49 (March) 1944·
3· TI.AYELL, J, and 8JGELOW, N. H.: Referred somatic pain does
not follow a simple "segmental" pattern. Federation Proc. 5:1o6
(March) 1946.
4· TuvELL, ). and BIGELOW, N. H.: Role of somatic trigger areas
in the patterns of hysteria. Psyehosom. Med. 9:353 (NovembcJ·
December) 1947.
5· TuvELL, 1. and TuvELL, W.: Therapy of low back pain by
manipulation and of referred pain in the lower extremity by
procaine infiltration. Arch. Phys. Med. 27:537 (September) t946.
6. TuvELL, 1.: Basis for the multiple uses of local block of somatic
trigger areas (procaine infiltration and ethyl chloride spray).
Mississippi Valley M. 1. 71:13 (January) 1949·
7• TuvELL, 1.: Rapid relief of acute "11ilf neck" by ethyl chloride
spray. 1. A. M. Women's A. 4:8g (March) 1949.
8. TuvELL, I· and RINZLER, S. H.: lnftuence of ethyl chloride
spray on deep pain and ischemic contraction of skeletal muscle.
Federation Proc. 8:339 (March) 1949.
g. Tu.VELL, J.: The adductor longus syndrome. A cause of groin
pain; iu treatment by local block of trigger areas (procaine in~
filtration and ethyl chloride spray). Bull. New York Acad. Med.
26::z&t (April) 1950.
434
SUDDEN ONSET OF AGONIZING PRECORDIAL PAIN
20 MINUTES AFTER INFILTRATION
CIRCUMDUCTION COMPLETE
NEGATIVE
NORMAL ELECTROCARDIOGRAM
NORMAL TEMPERATURE AND BLOOD SEDI-
MENTATION RATE
NORMAL CHEST X-RAY
Dopofi-Mqt"""•-.:o~oe,
C.<hOIIUno ..rt!<yMQICOIC.IIoeo
10. TkAVELL, J. and RINZLEI., S. H.: Relief of cardiac pain by local
block of somatic trigger aroas. Proc. Soc. Exper. Bioi. & Med.
63:480 (November) 1946.
n. RINZLEJt, S. H. and TaAVELL, J.: Therapy directed at the somatic
component of cardiac pain. Am. Heart 1. 35:248 (February) 1948.
12. Tt.AVELL, J. and RIHZLEI, S. H.: Pain syndromes of the chest
muscles: Resemblance to dfort angina and myocardial infarction,
and relief by local block. Canad. M. A. J. 59:333 (OctobcJ) 1948,
13. RINZLER, S. H.: Cardiac pain: Present status of its mechanism
and therapy. Am. 1. Med. 5:736 (NovembcJ) 1948.
14. TuvuL, 1.: Early relief of chest pain by ethyl chloride spray in
acute coronary thrombosis. Circulation 3:120 (January) 1951.
t5. RrNZLER, S. H.: Cardiac Pain. Springfield, Illinois, Charles C
Thomaa, 1951.
16. Ta.AVELL, J.: Conferences on therapy: Management of pain due to
muscle spasm. New York State I. Med. 45:2095 (October) 1945·
Cornet! Conferences on Therapy, vol. 3· New York, The Mac-
millan Company, 1949, p. 202.
17. TaAVELL, J.: Conferences on therapy: Treatment of painful
disorders of skeletal muscle. New York State I. Med. 48:2050
(September) 1948. Cornell Conferences on Therapy, vol. 4• New
York, The Macmillan Company, 1951, p. 253.
18. TuvELL, 1.: Ethyl chloride spray for painful muscle spasm. Arch.
Phys. Med. (In press.)
19. Ta.AVELL, }.: Pain Mechanisms in Connective Tiuue. Connective
Tissue, Transactions of the Second Conference, Josiah Macy, Jr.
Founolation, New York. (In press.)
POSTGRADUATE MEDICINE