THE CLINICAL SYNDROME

• Myofascial pain syndrome can manifest itself in the teres major muscle if the proper precautions are not taken.

• Falls onto the lateral scapula, as well as injuries to the teres major muscle caused by stretching or impact, have been linked to the development of teres major syndrome.

• These types of injuries can occur while participating in sports or being involved in automobile accidents.

• In addition, the development of myofascial pain in the teres major muscle can be caused by repetitive microtrauma that is the result of reaching up and behind, such as when retrieving a briefcase from the backseat of a car.

• Other causes of myofascial pain include overhead throwing and other sports injuries.

• Myofascial pain syndrome is a type of chronic pain syndrome that can affect a specific part of the body or a regional part of the body.

• The identification of myofascial trigger points during a physical examination is a prerequisite for the diagnosis of myofascial pain syndrome.

• Although these trigger points are typically localized to the part of the body that is affected, pain is frequently referred to other regions of the body.

• This referred pain may be misdiagnosed or attributed to other organ systems, which may then lead to extensive evaluation and treatment that is not successful.

• Patients who suffer from myofascial pain syndrome that affects the teres major muscle frequently experience referred pain in the shoulder that travels down the upper extremity.

SIGNS AND SYMPTOMS

• The pathologic lesion of teres major syndrome is known as the trigger point, and it is characterized by a local point of extreme tenderness in the axillary or posterior portion of the muscle. When a trigger point is mechanically stimulated, either by palpation or stretching, it produces intense local pain as well as referred pain in the surrounding area.

• Pain over the teres major muscle that is localized to the proximal portion of the posterolateral upper extremity is another symptom that is indicative of teres major syndrome. The jump sign is also a hallmark of this condition.

TESTING

• The results of biopsies performed on clinically identified trigger points have not revealed abnormal histologic features in a consistent manner.

• The muscle that is home to the trigger points has been variously referred to as "moth-eaten" and as having "waxy degeneration" in its structure.

• In some patients with teres major syndrome, an increased plasma myoglobin has been reported; however, this finding has not been supported by the findings of any other researchers.

• Electrodiagnostic testing performed on patients suffering from teres major syndrome has shown an increase in muscle tension in some patients; however, this finding has not been able to be replicated, so it cannot be considered conclusive.

• Because there isn't an objective diagnostic test for teres major syndrome, the clinician has to rule out other disease processes that may be present simultaneously and look like teres major syndrome.

DIFFERENTIAL DIAGNOSIS

• Clinical findings, as opposed to more specific laboratory, electrodiagnostic, or radiographic testing, are used to arrive at a diagnosis of teres major syndrome.

• Because of this, a focused history and physical examination, including a methodical search for trigger points and the identification of a positive jump sign, are required to be performed on every patient who may have teres major syndrome.

• The clinician needs to rule out other diseases that may coexist and mimic teres major syndrome, such as primary inflammatory muscle disease, multiple sclerosis, and collagen vascular disease.

• These diseases are all possibilities.

• The use of electrodiagnostic and radiographic testing can assist in the diagnosis of coexisting conditions such as tendinitis, bursitis, and tears in the rotator cuff of the shoulder.

• The clinician needs to be aware of any coexisting psychological or behavioral abnormalities, as these can either obscure or exacerbate the symptoms of teres major syndrome.

TREATMENT

• The primary goals of treatment are to inhibit the myofascial trigger and bring about sustained relaxation in the muscle that is being affected.

• When developing a treatment strategy, it is common practice to incorporate an element of trial and error due to the limited understanding of the underlying mechanism of action.

• The first step in treatment is typically conservative therapy, which may include trigger point injections with either a local anesthetic or saline solution.

• As a result of the fact that many patients suffering from fibromyalgia of the cervical spine also experience underlying depression and anxiety, the administration of antidepressants is an essential component of the majority of treatment plans.

• It has also been demonstrated that pregabalin and gabapentin can provide some relief from the symptoms associated with fibromyalgia.

• Milnacipran, which is an inhibitor of the reuptake of both serotonin and norepinephrine, has also been demonstrated to be effective in the treatment of fibromyalgia.

• Nabilone, a synthetic cannabinoid, has also been used to manage fibromyalgia in certain patients who have not responded favorably to other treatment modalities.

• These patients have been carefully selected.

COMPLICATIONS AND PITFALLS

• If one pays close attention to the clinically relevant anatomy, trigger point injections can be performed in a completely risk-free manner.

• In order to prevent infection, sterile technique must be utilized, and universal precautions must be taken in order to lessen the likelihood that the operator will be put in harm's way.

• The majority of complications associated with trigger point injection are due to trauma caused by the needle at the injection site and in the tissues beneath the skin.

• If pressure is applied to the injection site immediately after the injection, this can help reduce the risk of complications such as ecchymosis and hematoma formation.

• It is possible to reduce the risk of trauma to the structures beneath the skin by avoiding needles that are excessively long.

• When injecting trigger points that are close to the underlying pleural space, one must exercise extreme caution so as to prevent pneumothorax from occurring.