A 50-year-old woman suffered a right-sided tibia/fibula fracture requiring open reduction and internal fixation and postoperatively developed complex regional pain syndrome in her foot and lower leg with discoloration, swelling, restricted range of motion, allodynia, and decreased temperature. Her initial diagnosis was made at a prominent New York City hospital. She received ketamine infusions, spinal cord stimulation, and a variety of traditional medications utilized for CRPS. She was unable to wear a sock or a closed-toe shoe. She was severely depressed. She was seen for assessment five and a half years after the onset of her symptoms. Examination revealed pain emanating from the bilateral quadratus lumborum, left piriformis, left peroneus, left tibialis posterior, left soleus, left extensor hallucis longus, and left extensor digitorum longus muscles. The muscles were treated in the fashion previously described. She was pain free for approximately 4 months after her last treatment, with no restrictions and no medication, wearing a normal shoe and playing golf.

Her pain then returned, coincident with failed rotator cuff surgery and cessation of her prescribed lower body exercises, as well as the onset of wintry weather. Interestingly, only the dysesthetic pain and allodynia at the surgical scar site returned and not the skin color, temperature, and sweat changes. She was found to have MPAI in the following muscles: right quadratus lumborum (pain reduced 50 % after injection), piriformis (pain reduced 30 % after injection), extensor digitorum longus (pain reduced 10 % after injection), and extensor hallucis longus (complete relief of pain after injection). At the time of this writing, the patient has been essentially pain free for more than two years.

A 65-year-old entrepreneur with a 15-year history of back and leg pain was diagnosed with spinal stenosis and underwent two failed lumbar spine fusions at a prominent surgically oriented hospital. He was told that his only option for his persistent pain, which prevented him from leaving his home and socializing with friends and family, was a spinal cord stimulator or an epidural morphine pump. He was on round-the-clock opioid analgesia. In November 2005, he was evaluated for the presence of muscles as a source of his now persistent bilateral anterior thigh pain. Three muscles were identified—the right gluteus maximus and the left tensor fascia lata and vastus lateralis—and injected. One month after, he was essentially pain free and ambulating normally and remains pain free 5 years after his last injection. He has been able to travel to Vietnam and China and reports no impairments secondary to back or proximal leg pain.

FBSS is generally considered to be only amenable to palliative interventions such as spinal cord stimulation and/or lifelong delivery of potent analgesics, orally or parenterally. We have previously reported on a series of patients with FBSS successfully treated for muscle pain in the same fashion [145].

A 42-year-old woman with a 2-year history of neck, head, back, and lower extremity pain following an auto accident (causing her to spend days and weeks in bed with severe pain) was evaluated by multiple physicians and diagnosed with fibromyalgia. It was suggested that she undergoes cervical/lumbar spinal fusion as well. She was evaluated for the presence of muscle pain, and 13 muscles were identified—in the upper body, bilateral frontalis, infraspinatus, pectoralis minor, and left anterior/medial scalenes; and in the lower body, bilateral quadratus lumborum, gluteus medius, and right gluteus maximus, and piriformis. Since the most intense and disabling pain was in her head and neck, this region was treated first. After five muscles had been injected in her upper body (bilateral infraspinatus, frontalis, and left pectoralis minor), she reported that nearly all of the upper and lower body pain was eliminated. No other muscle injections needed to be done. She is now without any pain-related impairment, 1 year after her last treatment.

Patients with imaging studies suggesting clinically meaningful spinal pathology may also present with diffuse pain diagnosed as FMS. Spinal fusion may be suggested. Some of these patients may have treatable muscle pain.

A 60-year-old medical assistant with a 2-year history of severe right shoulder pain and markedly restricted of range of motion was found to have a full-thickness buttonhole tear of the supraspinatus tendon on MRI. He was scheduled for rotator cuff surgery repair but was evaluated prior to surgery for muscle-based pain and found to have tenderness in six muscles of his shoulder girdle—coracobrachialis, trapezius, levator scapula, posterior para-cervicals, biceps brachii, and pectoralis major—which were successfully injected with elimination of all pain and total restoration of his range of motion (and subsequent cancellation of his surgery). He remained without pain or restriction for the 1 year he was followed.

Shoulder pain is inconsistently evaluated and treated [146–148]. Including the routine examination for specific shoulder muscle pain and dysfunction could decrease unnecessary surgeries and long-term use of analgesics.

Neuroreflexotherapy (NRT) consists of the temporary implantation of a number of epidermal devices (surgical staples and small “burins” implanted subcutaneously) in trigger points in the back at the site of dermatomes and at the referred tender points located in the ear. The purpose is to “deactivate” neurons assumed to be involved in the persistence of pain, neurogenic inflammation, muscle dysfunction, and contracture.

As recognized by the Cochrane Back Review Group, NRT is one of the few technologies which has shown to be effective through high-quality, randomized, controlled trials and to provide “unusually positive” results [149]. This technology is currently implemented in Spain through the Spanish National Health System [150], and its evaluation in other countries is warranted.

Muscles do not function in a vacuum, and the relationship of muscle to its adjacent fascia and ligaments has not been systematically explored. As obscure as the data on muscle pain may be, fascial pain is even more so. The dynamic structure and function of fascia has not been appreciated. Fascia appears to have contractile properties that make it integral to efficient muscle contraction [151], as well as mechanosensitive properties which provide important information to surrounding muscles. Fascia has been shown to refer pain to different structures [152]. Therefore, damaged fascia may play an important role in chronic and recurrent low back pain [153, 154].

Stretching of injured muscle and tendon appears to inhibit scarring, which may be related to the production of transforming growth factor (TGF) beta 1 by damaged fascia [155]. In surgical procedures where fascia is resected, one should at least consider preservation of functional integrity whenever possible.

Regional pain such as neck pain is loosely defined [156], and although muscles are acknowledged as one of the pain-producing structures, little data exist on their importance. Andersen et al. [157] demonstrated that when pain was predominantly from the trapezius muscle (i.e., trapezius myalgia), strength training of the trapezius and surrounding muscles resulted in large decreases in pain that were sustained months after cessation of the study. Vuillerme and Pinsault [158] demonstrated the importance of intact nonpainful neck muscles in maintaining normal balance. In using manual palpation to identify muscle-related neck pain, facet arthropathy may be confused with pain associated with muscle attachments on the cervical spine [159]. Multifaceted treatment remains the norm for generic neck pain. In a systematic review, Chow found low-level laser therapy (LLLT) to be effective for acute- and moderate-duration neck pain [160], although a recent Cochrane review found that LLLT appeared to be ineffective [161].