Scoping review and interpretation of myofascial pain/fibromyalgia syndrome: An attempt to assemble a medical puzzle.

BACKGROUND: Myofascial Pain Syndrome (MPS) is a common, overlooked, and underdiagnosed condition and has significant burden. MPS is often dismissed by clinicians while patients remain in pain for years. MPS can evolve into fibromyalgia, however, effective treatments for both are lacking due to absence of a clear mechanism. Many studies focus on central sensitization. Therefore, the purpose of this scoping review is to systematically search cross-disciplinary empirical studies of MPS, focusing on mechanical aspects, and suggest an organic mechanism explaining how it might evolve into fibromyalgia. Hopefully, it will advance our understanding of this disease. METHODS: Systematically searched multiple phrases in MEDLINE, EMBASE, COCHRANE, PEDro, and medRxiv, majority with no time limit. Inclusion/exclusion based on title and abstract, then full text inspection. Additional literature added on relevant side topics. Review follows PRISMA-ScR guidelines. PROSPERO yet to adapt registration for scoping reviews. FINDINGS: 799 records included. Fascia can adapt to various states by reversibly changing biomechanical and physical properties. Trigger points, tension, and pain are a hallmark of MPS. Myofibroblasts play a role in sustained myofascial tension. Tension can propagate in fascia, possibly supporting a tensegrity framework. Movement and mechanical interventions treat and prevent MPS, while living sedentarily predisposes to MPS and recurrence. CONCLUSIONS: MPS can be seen as a pathological state of imbalance in a natural process; manifesting from the inherent properties of the fascia, triggered by a disrupted biomechanical interplay. MPS might evolve into fibromyalgia through deranged myofibroblasts in connective tissue ("fascial armoring"). Movement is an underemployed requisite in modern lifestyle. Lifestyle is linked to pain and suffering. The mechanism of needling is suggested to be more mechanical than currently thought. A "global percutaneous needle fasciotomy" that respects tensegrity principles may treat MPS/fibromyalgia more effectively. "Functional-somatic syndromes" can be seen as one entity (myofibroblast-generated-tensegrity-tension), sharing a common rheuma-psycho-neurological mechanism.

Peripheral EphrinB1/EphB1 signalling attenuates muscle hyperalgesia in MPS patients and a rat model of taut band-associated persistent muscle pain.

BACKGROUND: Myofascial pain syndrome (MPS) is an important clinical condition that is characterized by chronic muscle pain and a myofascial trigger point (MTrP) located in a taut band (TB). Previous studies showed that EphrinB1 was involved in the regulation of pathological pain via EphB1 signalling, but whether EphrinB1-EphB1 plays a role in MTrP is not clear. METHODS: The present study analysed the levels of p-EphB1/p-EphB2/p-EphB3 in biopsies of MTrPs in the trapezius muscle of 11 MPS patients and seven healthy controls using a protein microarray kit. EphrinB1-Fc was injected intramuscularly to detect EphrinB1s/EphB1s signalling in peripheral sensitization. We applied a blunt strike to the left gastrocnemius muscles (GM) and eccentric exercise for 8 weeks with 4 weeks of recovery to analyse the function of EphrinB1/EphB1 in the muscle pain model. RESULTS: P-EphB1, p-EphB2, and p-EphB3 expression was highly increased in human muscles with MTrPs compared to healthy muscle. EphB1 (r = 0.723, n = 11, P < 0.05), EphB2 (r = 0.610, n = 11, P < 0.05), and EphB3 levels (r = 0.670, n = 11, P < 0.05) in the MPS group were significantly correlated with the numerical rating scale (NRS) in the MTrPs. Intramuscular injection of EphrinB1-Fc produces hyperalgesia, which can be partially prevented by pre-treatment with EphB1-Fc. The p-EphB1 contents in MTrPs of MPS animals were significantly higher than that among control animals (P < 0.01). Intramuscular administration of the EphB1 inhibitor EphB1-Fr significantly suppressed mechanical hyperalgesia. CONCLUSIONS: The present study showed that the increased expression of p-EphB1/p-EphB2/p-EphB3 was related to MTrPs in patients with MPS. This report is the first study to examine the function of EphrinB1-EphB1 signalling in primary muscle afferent neurons in MPS patients and a rat animal model. This pathway may be one of the most important and promising targets for MPS.

Inhibition of Peripheral ERK Signaling Ameliorates Persistent Muscle Pain Around Trigger Points in Rats.

The purpose of this study was to investigate whether the ERK signaling pathway was involved in ameliorating chronic myofascial hyperalgesia from contused gastrocnemius muscle in rats. We established an animal model associated with myofascial pain syndrome and described the mechanism of muscle pain in an animal model. Changes in the mechanical pain threshold were observed 0.5, 1, 2, 3, 4, 5, 8, 12, 18, and 24 h after ERK inhibitor injection around myofascial trigger points (MTrPs) of the gastrocnemius muscle in rats. Morphological changes in gastrocnemius muscle cells were observed by hematoxylin and eosin (H&E) staining. ERK signaling pathway activation was detected through immunohistochemistry and Western blotting. The main morphological characteristics of injured muscle fibers around MTrPs include gathered circular or elliptical shapes of different sizes in the cross-section and continuous inflated and tapering fibers in the longitudinal section. After intramuscular injection of U0126 (ERK inhibitor), the mechanical pain threshold significantly increased. The reduction in mechanical hyperalgesia was accompanied by reduced ERK protein phosphorylation, myosin light chain kinase (MLCK) protein, p-MLC protein expression, and the cross-sectional area of skeletal muscle cells around MTrPs. An ERK inhibitor contributed to the attenuation of mechanical hyperalgesia in the rat myofascial pain model, and the increase in pain threshold may be related to MLCK downregulation and other related contraction-associated proteins by ERK.

[Effect of Resistance Exercise Program for Middle-Aged Women with Myofascial Pain Syndrome on Shoulder Pain, Angle of Shoulder Range of Motion, and Body Composition Randomized Controlled Trial, RCT].

PURPOSE: This study aimed to identify the effects of myofascial pain syndrome on shoulder pain, range of motion, and body composition around the shoulder in middle-aged women. METHODS: A total of 72 women participated in the randomized controlled trial. The subjects were grouped into an experimental group (n=39) and a control group (n=33). The experimental group received a resistance exercise program using an elastic band for 8 weeks, 3 days a week. The control group followed a normal daily for 8 weeks. Measurements were conducted three times; before the experimental treatment (pre-test), the 2nd and 8th weeks after treatment. RESULTS: Regarding the general characteristics and homogeneity of the dependent variables, there were no significant differences between the two groups, except for the thickness of the left and right muscles and the left fat. After treatment, shoulder pain was significantly different between the two groups (F=18.54, p<.001) and the range of shoulder motion was significantly different (left, F=86.70, p<.001; right, F=98.66, p<.001). Furthermore, there were a significant differences in the thickness of muscles between the two groups (left, F=40.20, p<.001; right, F=29.57, p<.001); however, the thickness of fat was not significantly different. CONCLUSION: The resistance exercise program reduces shoulder pain and improves the range of motion of the shoulder joint and increases muscle mass on around the shoulder. It suggests to conduct a study to confirm the long-term exercise effect.

Comparison between Collagen and Lidocaine Intramuscular Injections in Terms of Their Efficiency in Decreasing Myofascial Pain within Masseter Muscles: A Randomized, Single-Blind Controlled Trial.

Background and Objective: A novel option for myofascial pain (MFP) management and muscle regeneration is intramuscular collagen injections. The aim of the study was to evaluate the efficiency of intramuscular injections of collagen and lidocaine in decreasing MFP within masseter muscles. Methods: Myofascial pain within masseter muscles was diagnosed on the basis of the Diagnostic Criteria for Temporomandibular Disorders (II.1.A. 2 and 3). A total of 43 patients with diagnosed MFP within masseter muscles were enrolled to the study (17 male and 26 female, 40 ± 3.8 years old) and randomly divided into three groups. The first group received injections using 2 ml of collagen MD Muscle (Guna), the second group received 2 ml of 2% lidocaine without a vasoconstrictor, and the third group 2 ml of saline as a control (0.9% NaCl). All patients received repeated injections at one-week intervals (days 0 and 7). The visual analogue scale was used to determine pain intensity changes during each follow-up visit (days 0, 7, and 14) in each group. The masseter muscle activity was measured on each visit (days 0, 7, and 14) with surface electromyography (sEMG) (Neurobit Optima 4, Neurobit Systems). Results: We found that sEMG masseter muscle activity was significantly decreased in Group I (59.2%), less in Group II (39.3%), and least in Group III (14%). Pain intensity reduction was 53.75% in Group I, 25% in Group II, and 20.1% in Group III. Conclusions: The study confirmed that intramuscular injection of collagen is a more efficient method for reducing myofascial pain within masseter muscles than intramuscular injection of lidocaine.

Novel method to measure active myofascial trigger point stiffness using ultrasound imaging.

INTRODUCTION: Myofascial trigger points (MTrPs) are one of the most common and important causes of musculoskeletal pain. Ultrasound is a useful modality in examining musculoskeletal disorders. By applying compressive stress and observing changes in ultrasound images, the elastic modulus (Young's modulus) can be calculated. Our objective was to develop a novel method to distinguish MTrPs from normal tissues. METHODS: A total of 29 subjects with MTrP in the sternocleidomastoid muscle were assessed. A force gauge was attached to a transducer to obtain stress levels. To obtain strain, images were recorded in both with stress and without stress states. By dividing the stress level by the measured strain, the elastic modulus was determined. RESULTS: Elastic modulus in MTrPs and the normal part of the muscle were measured to be 13379.57 ± 1069.75Pa and 7078.24 ± 482.92Pa, respectively (P = 0.001). This indicated that MTrPs were stiffer than normal parts of the muscle. CONCLUSION: This study presents a new method for the quantitative measurement of the elastic modulus of MTrP, thereby distinguishing MTrPs from normal adjacent muscular tissue, with more simplicity and lower cost, compared to other ultrasound methods.

Quantitative Ultrasound Using Texture Analysis of Myofascial Pain Syndrome in the Trapezius.

Objective-The objective of this study is to assess the discriminative ability of textural analyses to assist in the differentiation of the myofascial trigger point (MTrP) region from normal regions of skeletal muscle. Also, to measure the ability to reliably differentiate between three clinically relevant groups: healthy asymptomatic, latent MTrPs, and active MTrP. Methods-18 and 19 patients were identified with having active and latent MTrPs in the trapezius muscle, respectively. We included 24 healthy volunteers. Images were obtained by research personnel, who were blinded with respect to the clinical status of the study participant. Histograms provided first-order parameters associated with image grayscale. Haralick, Galloway, and histogram-related features were used in texture analysis. Blob analysis was conducted on the regions of interest (ROIs). Principal component analysis (PCA) was performed followed by multivariate analysis of variance (MANOVA) to determine the statistical significance of the features. Results-92 texture features were analyzed for factorability using Bartlett's test of sphericity, which was significant. The Kaiser-Meyer-Olkin measure of sampling adequacy was 0.94. PCA demonstrated rotated eigenvalues of the first eight components (each comprised of multiple texture features) explained 94.92% of the cumulative variance in the ultrasound image characteristics. The 24 features identified by PCA were included in the MANOVA as dependent variables, and the presence of a latent or active MTrP or healthy muscle were independent variables. Conclusion-Texture analysis techniques can discriminate between the three clinically relevant groups.

An evaluation tool for Myofascial Adhesions in Patients after Breast Cancer (MAP-BC evaluation tool): Concurrent, face and content validity.

PURPOSE: To investigate the concurrent, face and content validity of an evaluation tool for Myofascial Adhesions in Patients after Breast Cancer (MAP-BC evaluation tool). METHODS: 1) Concurrent validity of the MAP-BC evaluation tool was investigated by exploring correlations (Spearman's rank Correlation Coefficient) between the subjective scores (0 -no adhesions to 3 -very strong adhesions) of the skin level using the MAP-BC evaluation tool and objective elasticity parameters (maximal skin extension and gross elasticity) generated by the Cutometer Dual MPA 580. Nine different examination points on and around the mastectomy scar were evaluated. 2) Face and content validity were explored by questioning therapists experienced with myofascial therapy in breast cancer patients about the comprehensibility and comprehensiveness of the MAP-BC evaluation tool. RESULTS: 1) Only three meaningful correlations were found on the mastectomy scar. For the most lateral examination point on the mastectomy scar a moderate negative correlation (-0.44, p = 0.01) with the maximal skin extension and a moderate positive correlation with the resistance versus ability of returning or 'gross elasticity' (0.42, p = 0.02) were found. For the middle point on the mastectomy scar an almost moderate positive correlation with gross elasticity was found as well (0.38, p = 0.04) 2) Content and face validity have been found to be good. Eighty-nine percent of the respondent found the instructions understandable and 98% found the scoring system obvious. Thirty-seven percent of the therapists suggested to add the possibility to evaluate additional anatomical locations in case of reconstructive and/or bilateral surgery. CONCLUSIONS: The MAP-BC evaluation tool for myofascial adhesions in breast cancer patients has good face and content validity. Evidence for good concurrent validity of the skin level was found only on the mastectomy scar itself.

Far-infrared ray patches relieve pain and improve skin sensitivity in myofascial pain syndrome: A double-blind randomized controlled study.

OBJECTIVE: Myofascial pain syndrome (MPS) is a common disorder characterized by muscle pain if myofascial trigger points (MTrP) are stimulated. This study evaluated the effectiveness of far-infrared ray (FIR) patches in reducing the severity of pain in patients with MPS. METHODS: A double-blind, randomized controlled study involving 125 patients with MPS and 201 MTrPs located in the trapezius muscle. A FIR patch was applied to 98 MTrPs for 24h in the intervention group (61 patients) and a placebo patch was applied to 91 MTrPs in the control group (57 patients) at the end. Pain intensity was measured using the visual analogue scale (V) while pressure pain threshold (P) and maximal pain tolerance (T) were measured using an algometer before and after treatment. RESULTS: The mean age of the patients was 37.16 years old and 67% were female. There was a positive correlation between P and T (p<0.001). Older Age was associated with higher P and T due to poor skin sensitivity (p<0.001). V improved significantly in both groups to a similar extent, but only in the intervention group, P and T decreased significantly (which implied better skin sensitivity) (p<0.05). P and T decreased the most in the female group aged over 35, probably due to thinner skin in this subgroup. CONCLUSIONS: FIR and placebo patches were equally effective at relieving pain (with decreased V), but P and T dropped only in the intervention group with FIR patches. This probably resulted from FIR penetrated only to the skin layer and improved skin sensitivity with more blood circulation, but the muscle remained unaffected. Further studies should investigate the effect of longer exposure or higher energy applications.

Brain structural changes in patients with chronic myofascial pain.

BACKGROUND: Myofascial trigger points (MTrPs) are a highly prevalent source of musculoskeletal pain. Prolonged ongoing nociceptive input from MTrPs may lead to maladaptive changes in the central nervous system. It remains, however, unknown whether pain from MTrPs is associated with brain atrophy. In addition, stress, which may contribute to the formation of MTrPs, is also known to affect brain structures. Here, we address whether structural brain changes occur in patients with chronic pain originating from MTrPs and whether such changes are related to pain or stress. METHODS: Voxel-based morphometry was used to compare grey-matter (GM) volumes in 21 chronic pain patients, with MTrPs in the bilateral upper trapezius muscles, with 21 healthy controls. Hyperalgesia was assessed by pressure pain thresholds, and stress was assessed by cortisol levels and anxiety questionnaires. RESULTS: Patients exhibited normal stress levels but lowered pain thresholds. GM atrophy was found in dorsal and ventral prefrontal regions in patients. The GM density of the right dorsolateral prefrontal cortex correlated with pain thresholds in patients, i.e. the more atrophy, the lower pain threshold. GM atrophy was also found in the anterior hippocampus, but the atrophy was neither related to pain nor stress. CONCLUSIONS: Patients with chronic myofascial pain exhibit GM atrophy in regions involved in top-down pain modulation and in processing of negative affect. The relationship between the dorsolateral prefrontal cortex and pain thresholds suggests the presence of pain disinhibition. No evidence was found for the involvement of stress. It remains unclear whether the observed atrophy contributes to the development of the chronic pain state or is caused by the ongoing nociceptive input. SIGNIFICANCE: Chronic myofascial pain, caused by myofascial trigger points, is associated with localized brain atrophy in areas involved in pain processing and modulation, among others. These findings extend previous knowledge about peripheral and spinal changes to the supraspinal level.

Pain modulation is affected differently in medication-overuse headache and chronic myofascial pain - A multimodal MRI study.

Background Neuroimaging studies revealed structural and functional changes in medication-overuse headache (MOH), but it remains unclear whether similar changes could be observed in other chronic pain disorders. Methods In this cross-sectional study, we investigated functional connectivity (FC) with resting-state functional magnetic resonance imaging (fMRI) and white matter integrity using diffusion tensor imaging (DTI) to measure fractional anisotropy (FA) and mean diffusivity (MD) in patients with MOH ( N = 12) relative to two control groups: patients with chronic myofascial pain (MYO; N = 11) and healthy controls (CN; N = 16). Results In a data-driven approach we found hypoconnectivity in the fronto-parietal attention network in both pain groups relative to CN (i.e. MOH < CN and MYO < CN). In contrast, hyperconnectivity in the saliency network (SN) was detected only in MOH, which correlated with FA in the insula. In a seed-based analysis we investigated FC between the periaqueductal grey (PAG) and all other brain regions. In addition to overlapping hyperconnectivity seen in patient groups (relative to CN), MOH had a distinct connectivity pattern with lower FC to parieto-occipital regions and higher FC to orbitofrontal regions compared to controls. FA and MD abnormalities were mostly observed in MOH, involving the insula. Conclusions Hyperconnectivity within the SN along with associated white matter changes therein suggest a particular role of this network in MOH. In addition, abnormal connectivity between the PAG and other pain modulatory (frontal) regions in MOH are consistent with dysfunctional central pain control.

A afferent fibers are involved in the pathology of central changes in the spinal dorsal horn associated with myofascial trigger spots in rats.

A afferent fibers have been reported to participate in the development of the central sensitization induced by inflammation and injuries. Current evidence suggests that myofascial trigger points (MTrPs) induce central sensitization in the related spinal dorsal horn, and clinical studies indicate that A fibers are associated with pain behavior. Because most of these clinical studies applied behavioral indexes, objective evidence is needed. Additionally, MTrP-related neurons in dorsal root ganglia and the spinal ventral horn have been reported to be smaller than normal, and these neurons were considered to be related to A fibers. To confirm the role of A fibers in MTrP-related central changes in the spinal dorsal horn, we studied central sensitization as well as the size of neurons associated with myofascial trigger spots (MTrSs, equivalent to MTrPs in humans) in the biceps femoris muscle of rats and provided some objective morphological evidence. Cholera toxin B subunit-conjugated horseradish peroxidase was applied to label the MTrS-related neurons, and tetrodotoxin was used to block A fibers specifically. The results showed that in the spinal dorsal horn associated with MTrS, the expression of glutamate receptor (mGluR1α/mGluR5/NMDAR1) increased, while the mean size of MTrS-related neurons was smaller than normal. After blocking A fibers, these changes reversed to some extent. Therefore, we concluded that A fibers participated in the development and maintenance of the central sensitization induced by MTrPs and were related to the mean size of neurons associated with MTrPs in the spinal dorsal horn.

Painful connections: densification versus fibrosis of fascia.

Deep fascia has long been considered a source of pain, secondary to nerve pain receptors becoming enmeshed within the pathological changes to which fascia are subject. Densification and fibrosis are among such changes. They can modify the mechanical properties of deep fasciae and damage the function of underlying muscles or organs. Distinguishing between these two different changes in fascia, and understanding the connective tissue matrix within fascia, together with the mechanical forces involved, will make it possible to assign more specific treatment modalities to relieve chronic pain syndromes. This review provides an overall description of deep fasciae and the mechanical properties in order to identify the various alterations that can lead to pain. Diet, exercise, and overuse syndromes are able to modify the viscosity of loose connective tissue within fascia, causing densification, an alteration that is easily reversible. Trauma, surgery, diabetes, and aging alter the fibrous layers of fasciae, leading to fascial fibrosis.

Myofascial trigger points and innervation zone locations in upper trapezius muscles.

BACKGROUND: Myofascial trigger points (MTrPs) are hyperirritable spots located in taut bands of muscle fibres. Electrophysiological studies indicate that abnormal electrical activity is detectable near MTrPs. This phenomenon has been described as endplate noise and it has been purported to be associated MTrP pathophysiology. Thus, it is suggested that MTrPs will be overlap the innervation zone (IZ). The purpose of this work was to describe the location of MTrPs and the IZ in the right upper trapezius. METHODS: We screened 71 individuals and eventually enrolled 24 subjects with neck pain and active MTrPs and 24 neck pain-free subjects with latent MTrPs. Surface electromyography (sEMG) signals were detected using an electrode matrix during isometric contraction of the upper trapezius. A physiotherapist subsequently examined the subject's trapezius to confirm the presence of MTrPs and establish their location. IZ locations were identified by visual analysis of sEMG signals. IZ and MTrPs locations were described using an anatomical coordinate system (ACS), with the skin area covered by the matrix divided into four quadrants. RESULTS: No significant difference was observed between active and latent MTrPs locations (P = 0.6). Forty-five MTrPs were in the third quadrant of the ACS, and 3 were included in second quadrant. IZs were located approximately midway between the seventh cervical vertebrae and the acromial angle in a limited area in the second and third quadrants. The mean distance between MTrP and IZ was 10.4 ± 5.8 mm. CONCLUSIONS: According to the acquired results, we conclude that IZ and MTrPs are located in well-defined areas in upper trapezius muscle. Moreover, MTrPs in upper trapezius are proximally located to the IZ but not overlapped.

Myofascial trigger point, falls in the elderly, idiopathic knee pain and osteoarthritis: an alternative concept.

Knee malalignment and associated pathological abnormal forces transmitted through the knee is thought to provoke joint protective mechanism in reflex arthrogenous muscle inhibition (AMI) and the start of the idiopathic knee osteoarthritis process. The current prevailing hypothesis is AMI initiates quadriceps muscle weakness, cause aberrant loading of the knee joint and focal cartilage destruction. This paper investigates for evidence in the literature if this conceptual framework is consistent with the clinical evidence, and if there is an alternative explanation to AMI hypothesis for the pathogenesis of idiopathic knee osteoarthritis. One crucial question yet to be answered by the AMI hypothesis is; where are the initial aggravating factors of reflex AMI emanate from? AMI hypothesis relies on joint damage and changes in joint homeostasis to provoke a reflex arthrogenous response which can be found later in the development of knee OA. Myofascial trigger point (MTrP) hypothesis only relies on muscle tightness, pain and weakness to detect early pathological neuromuscular changes including knee instability and falls in the elderly. AMI is implicated in the knee OA pathological process but much later on when there are changes in joint homeostasis and joint cartilage damage have occurred. Falls in the elderly is a result of early pathological neuromuscular changes. The MTrP hypothesis is more sensitive and advanced in the early detection of neuromuscular impairment and pathological changes, allowing early intervention, prevention of falls in the elderly and idiopathic knee osteoarthritis.

Myoelectrical activity and muscle morphology in a rat model of myofascial trigger points induced by blunt trauma to the vastus medialis.

OBJECTIVES: To explore myoelectrical activity and muscle morphology of myofascial trigger points (MTrPs) in an injury model of rats. METHODS: A total of 24 male SD rats were randomly divided into a control group (group A) and model group (group B). A blunt striking injury and eccentric exercise were applied to the vastus medialis (VM) of rats in group B for 8 weeks. Later, the palpable taut band (TB), local twitch response, myoelectrical activities and morphology in the two groups were examined. RESULTS: An average of 2.5 (30/12) palpable TBs were detected in the VM in group B compared with none in group A. The MTrPs had two types of abnormal potential. Their amplitudes were significantly higher than those in the control group (p<0.01) but their durations showed no significant differences. A series of reflex contractions appeared in groups A and B in response to external stimulation to the ear. Their amplitude and duration in group B were significantly lower than those in group A. A series of lower fibrillation potentials repeatedly occurred in model MTrPs in group B. The morphology of MTrPs showed abnormal muscle fibres with large round or ellipse shapes in cross-section and enlarged tapering shapes in longitudinal section. CONCLUSIONS: Active MTrPs can be provoked by repeated blunt injury. Active MTrPs are a group of muscle fibres with abnormal shapes and abnormal myoelectrical potentials. External stimulation provokes low-voltage responses in MTrPs, which is different from the response of normal muscle fibres.

Hallux límitus post-quirúrgico. A propósito de un caso / Post surgical hallux limitus. A clinical case

En el presente trabajo se expone un caso clínico de una mujer de 53 años que acude a la Clínica Podológica por presentar artralgia de la Primera Articulación Metatarsofalángica durante la fase propulsiva, de 4 años de evolución. Tras exploración podológica se diagnosticó de Hallux Límitus Funcional caracterizado por una alteración biomecánica de la 1ª AMTF con disminución de la flexión dorsal del Hallux por debajo de los 65º en dinámica con probable etiología quirúrgica por descenso plantar de la primera cabeza metatarsiana. Dicha alteración biomecánica comporta una serie de mecanismos compensatorios al resto del antepié y retropié causados por la insuficiencia estructural y funcional del primer radio. A nivel podológico, se pueden realizar una amplia variedad de tratamientos pero sin lugar a dudas y en cualquier caso, es de relevancia una minuciosa y planificada exploración y valoración del pie junto a toda la Extremidad Inferior del paciente. El objetivo del trabajo es justificar si existe una relación entre Hallux Límitus Funcional y el descenso plantar de la primera cabeza metatarsiana o se contemplan como entidades patológicas independientes y analizar qué tratamientos serían los más indicados. Para ello, se analizó la exploración la patomecánica, el tratamiento del caso clínico estudiado, y se realizó una revisión bibliográfica de la documentación científica relacionada con dichas alteraciones. Tras exhaustivos análisis se concluye que dichas patologías pueden presentar una relación etiológica si durante la fase propulsiva se produce un momento dorsiflexor de la 1ª cabeza metatarsiana como respuesta a las Fuerzas Reactivas del Suelo, limitándose así la flexión dorsal y la activación del Mecanismo Windlass para convertir el pie en una palanca rígida y producir un despegue del primer radio eficiente. Tanto la exploración como la patomecánica del primer radio, son determinantes para el diagnóstico y tratamiento de dichas patalogías, así como conocer las consecuencias que pueden desencadenar en el resto del pie y extremidad inferior, ya que variarán el tratamiento ortopodológico, quirúrgico y físico. En el paciente, las patologías expuestas se atribuyen a una corrección quirúrgica de Hallux Abductus Valgus que ha provocado un descenso plantar de la cabeza metatarsiana (AU)

In this paper, we present a clinical case of a 53 years old woman who comes to the podiatry clinic, suffering from an arthralgia of the 1st metatarsophalangeal joint, during the propulsive stage of gait, for 4 years. After the clinic examination, she was diagnosed as a functional hallux limitus, characterized by a biomechanical alteration of the 1st metatarsophalangeal with a disminution of the dorsal flexion of the hallux below 65º in the dynamic with a probable surgery etiology, because of the descending of the 1st metatarsal head. This biomechanical alteration involves a series of compensatory mechanism for the rest of the forefoot and hindfoot caused by structural and functional failure of the first radio. At a podiatric level, we can executive a wide variety of treatments but, in all cases, we need a planned and through examination and assesment of the foot and lower extremities of the patient. The aim of this paper is to justify whether there is a relationship between Functional Hallux Limitus and the descent of the first metatarsal head, or if they are independent pathological identities and to analyze what kind of treatments are the most suitable. For this purpose, we analyzed the examination, the patomechanics, the treatment and we carried out a bibliographic revision of the scientific documentation related to those alterations. After exhaustive analysis, we conclude that these conditions may have an etiological relationship if during the propulsive phase there is a dorsiflexor moment of the 1st metatarsal head in response to the reactive forces on the ground, thus limiting the dorsal flexion and activating the Windlass Mechanism in order to convert the foot into a rigid lever and produce an efficient launch of the first radio. Both exploration and patomechanics of the first radio are crucial for the diagnosis and treatment for these pathologies, as well as knowing the consequences that can be generated on the rest of the foot and lower limb, as several orthopedic, surgical and physical treatments. The conditions of our patient are attributed to a surgical correction of hallux valgus abductus which led to a lowering of the metatarsal head (AU)

[Chronic cystitis in women of reproductive age].

The examination of 112 women suffering from chronic cystitis has detected frequent comorbidity of genital, gastrointestinal, locomotor and pelvic varicose diseases. Myofascial syndrome, hemodynamic disorders and venous congestion play a leading role in development of pain syndrome in women with comorbid diseases of the small pelvis organs. Clinicopsychological investigation of such women has revealed frequent vegetative and psychoemotional disorders with predominance of anxiodepressive conditions. Pain, dysuria and anxiodepressive disorders are among causes of imbalance of the autonomic nervous system which acvitaves regulatory systems and has an impact on quality of life. Women with chronic cystitis show significant deterioration of quality of life. Combined treatment including physical factors and therapeutic exercise reduced treatment duration, frequency of exacerbations, raised cost effectiveness.

[Differences between myofascial trigger points and tender points]. / Unterschiede zwischen myofazialen Triggerpunkten und "tender points".

The article describes and compares the characteristics of myofascial trigger points (MTrPs) of the myofascial pain syndrome and the tender points (TePs) of the fibromyalgia syndrome. Many statements are hypothetical, because not all aspects of the disorders have been clarified in solid studies. Signs and symptoms of MTrPs: (1) palpable nodule, often located close to the muscle belly, (2) often single, (3) allodynia and hyperalgesia at the MTrP, (4) referral of the MTrP pain, (5) normal pain sensitivity outside the MTrPs, (6) local twitch response, (7) local contracture in biopsy material, (8) peripheral mechanism probable. Signs and symptoms of TePs: (1) no palpable nodule, (2) location often close to the muscle attachments, (3) multiple by definition, (4) allodynia and hyperalgesia also outside the TePs, (5) enhanced pain under psychic stress, (6) unspecific histological changes in biopsy material, (7) central nervous mechanism probable. The multitude of differences speak against a common aetiology and pathophysiology.

[Pudendal nerve entrapment syndrome]. / Sindrome de atrapamiento del nervio pudendo.

INTRODUCTION: Pudendal nerve entrapment syndrome is a poorly known condition and thus rarely included in our differential diagnoses. First described by Amarenco in 1987. DEVELOPMENT: The symptomatology is varied and can be confused with other entities, in particular the pelvic floor myofascial syndrome. CONCLUSIONS: The main symptom is neuropathic pain in the perineal area. The diagnosis is based on the clinical history, physical examination and the confirming neurophysiologic tests.