Myofascial trigger point perpetuating factor: visceral disease

As with the viscera referenced in the metabolic perpetuating factors, visceral disorders may initiate a somatic pain response and conversely persistent somatic pain will elicit a visceral response. Clinically silent triggers (Phase 3) will not initiate a referral into the abdominal region until palpated or snapped transversely. However, active (Phase 1-2) will.  As previously referenced, triggers may form not only in the muscles and the fascia surrounding them, but also may form in the fascia surrounding organs, adhesions, and periosteum. 

Also, as previously mentioned, mid thoracic nerve compression may only have minor tenderness at the site of compression but will initiate a wide array of autonomic and somatic abdominal symptomatology to include nausea, vomiting, distention, flatulence, and pain. 

Usually visceral disease has progressed prior to initiating pain. As the metabolic dysfunction is usually disturbed, triggers have multifaceted perpetuating factors to be considered.  Just as one can treat out pectoralis triggers and reduce the pain complaint of ischemic heart disease, this is also true of other visceral diseases.  Obviously this is poor health care to unwittingly do so. 

Therefore, extreme care must be utilized when assessing abdominal or pelvic pain for the underlying systemic causation. Triggers in the rectus abdominis, pectoralis group, obliques, sternalis, rhomboid group, pyramidalis, iliopsoas, and pelvic floor are renowned for mimicking visceral complaint. 

Additionally, persons are frequently surgerized in the abdominal/pelvic regions with those resulting post surgical adhesions developing triggers with unique referral patterns.  Therefore sites of previous incisions should be noted on a body form chart especially when the pain complaint has a visceral implication.

Common sites of Surgical Adhesions

• Sites of trocar placement, bikini cuts, (super pubic incision), may be barely discernible through casual observation.

• Sites of cardiac catheterization, tubal ligations, episiotomies and intervaginal hysterectomies may not be detectable at all. With intervaginal hysterectomies most surgeons tack the surgerized pocket to the posterior inferior aspect of the rectus abdominis; thus surgical adhesions and subsequent TrPs may form at this sight, resulting in periodic, elusive and unexplained abdominal/pelvic pain.  Most individuals will express a pain complaint directly related to these activated TrPs following episodes of persistent sitting and then suddenly standing, lifting, stretching or straining of the abdominal/pelvic muscles, or secondary to dysfunction within the rectus abdominis or a shortened iliopsoas. The primary referral for activated TrPs which had formed in the adhesions of the surgerized area seems to be localized to the umbilical, pelvic, and/or vaginal region.  Like all TrPs they can generate a more diffuse complaint when secondary TrPs are activated in the muscles of the abdomen or pelvic floor.  Possibly, leading the provider to require elaborate diagnostics to rule out visceral disease, or worse yet, dismissing the complaint, due to the fact that disease cannot be present in tissue that has been removed.

Visceral Reflex Pain

• In both genders, cardiac pain is typified as episodic or constant sub-sternal pressure dull and aching, or sharp and lancinating pain.  Which may occur, in concert with or independent of pain radiating down the left arm, and up to the anterior neck, and jaw.  It is frequently accompanied with nausea, diaphoresis, and shortness of breath.  In females, symptomatology has a tendency to be more vague and diffuse.  It is not uncommon for women to experience only back or shoulder blade discomforts as a precursor to a myocardial infarction (heart attack).

• Vascular pain is usually localized to the area of the dysfunctional vessels.  However, it may be diffuse when an inflammatory process has ensued.  Depending on the authority, vascular anomalies such as an iliac aneurysm or deep vein thrombosis are asymptomatic for pain. 

• Pulmonary pain is usually only experienced in the most advanced stage of disease.  However, pain referral may occur in the chest and/or back, when this occurs. 

• Due to the location of the pancreas an individual may experience pain in one or both upper quadrants. 

• Hepatic and gall bladder disease predominantly refer pain into the upper right quadrant.  The spleen refers into the upper left.

• The appendix refers into the lower right with an occasional reflex pain into the upper right. 

• The intestines refer to the respective quadrant of the sight of the disease, blockage, or impaction.

• Ovaries usually refer to the lower ipsilateral respective quadrant. However, with an ectopic pregnancy it is not uncommon to have reflex pain to a shoulder.

• An enlarged prostate, aortic or iliac aneurysm may have a tendency to refer pain of a deep boring quality to the low back.

• Gastroesophagitis is represented through sub-sternal pain usually following the consumption of spicy foods or alcohol, or smoking.

• Peptic ulcer or a hiatal hernia also refers pain sub-sternally, but like esophagitis has distinctive symptomatic differentiation from that of a myocardial nature.

• Pleurisy and pulmonary involvement may also be segregated from cardiac involvement through the taking of a careful case history and interview.

However, all of the above listed conditions can either perpetuate triggers or generate reflex pain. Therefore, if there is the most remote question of etiology, further diagnostics are required prior to treating.

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