Tensor Fasciae Latae Myofascial Pain Syndrome

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Tensor Fasciae Latae Myofascial Pain Syndrome

Tensor Fasciae Latae (TFL) Myofascial Pain Syndrome is a source of referred pain to the lateral hip and upper thigh. It is often misdiagnosed as “trochanteric bursitis”.

Myofascial pain is a prevalent and frequent cause of visits to primary care physicians and pain clinics. Different studies have demonstrated that myofascial trigger points are associated with several pain conditions including cervicogenic headache, migraine, tension-type headache, temporomandibular joint disorders, neck pain, shoulder pain, carpal tunnel syndrome, low back pain, hip pain, and whiplash syndrome.

Myofascial Trigger Points – A myofascial trigger point is a contraction knot found within a band of a muscle or in the muscle’s fascia. This contraction knot is considered to be responsible for nodularity which can be detected by palpation. Previous publications have suggested that trigger points are found in specific locations within a muscle. However, more recent publications suggest that they can be found anywhere within a muscle. Therefore, the entire muscle should be thoroughly examined in order to locate them.

Diagnostic Criteria for Myofascial Trigger Points – A 2019 international consensus concluded that moderate to excellent reliability for the presence of myofascial trigger points is based on the combination of a taut band, tender spot, local twitch response, and referred pain. The consensus was that at least two of these criteria are required for a myofascial trigger point diagnosis. 

Taut Band and Tender Spot – Myofascial trigger points typically involve an exquisitely tender spot found within a taut band of the muscle or in the muscle’s fascia.

Local Twitch Response – A local twitch response is defined as a quick visible or palpable contraction of the muscle fibers when pressure is applied within a taut band of a trigger point.

Active and Latent Trigger Points – Myofascial trigger points can be classified as active or latent. An active trigger point is one that reproduces or intensifies the patient’s familiar (referred) pain when it is compressed. A latent trigger point is one that does not reproduce the patient’s familiar pain when it is compressed.

Referred Pain – A key feature of an active trigger point is the presence of referred pain which is a manifestation of central sensitization. This central sensitization results in a spread of perceived pain to distant and larger areas of the body than just the local tenderness found at the taut band.

Research suggests that the combination of acidic pH and pro-inflammatory mediators at the active trigger point contributes to the segmental spread of nociceptive input into the dorsal horn of the spinal cord. The dorsal horn neuron, in turn, sensitizes the central nervous system by transmitting nociceptive impulses superiorly to activate the somatosensory cortex where pain information is perceived and interpreted. This is believed to cause hyperalgesia and referred pain.

Risk Factors – Many different activities and medical conditions may place individuals at greater risk for developing myofascial pain syndrome. These include:

• Joint hypermobility or ligamentous laxity (i.e., when the ligaments are unable to provide joint stability, muscles remain in constant contraction to stabilize the joint. This is believed to cause the formation of trigger points within muscles)
• Musculoskeletal injuries
• Unaccustomed or intense exercise
• Muscle overload or repetitive physical activity
• Prolonged incorrect posture (e.g., poor ergonomics or habitual postures)
• Cold drafts or intense cooling of muscles (e.g., sleeping in front of an air conditioner or under a ceiling fan)
• Lack of sleep or poor sleep
• Leg length inequality or other biomechanical disturbances
• Psychological stress, anxiety, and depression
• Fatigue

• Lateral hip and lateral upper thigh pain
• Pain that is aggravated by prolonged sitting and when arising from the seated position
• Pain that is aggravated when lying on the involved side
• Pain that is aggravated by activities such as running and jumping and is relieved by rest

Please note: Trigger points may be located anywhere within muscles and their fascia. Therefore, the entire muscle should be examined thoroughly, particularly because trigger points are often located well away from the site of pain. However, based on clinical experience, the trigger point in the Tensor Fasciae Latae muscle is most commonly found as depicted by the black cross in the image above.

• Palpation reveals the presence of one or more trigger points within the tensor fasciae latae muscle which is identified by at least two of the following: taut band, tender spot, local twitch response, and/or referred pain
• Pressure applied to trigger points reproduces or aggravates the patient’s symptoms
• A postural examination may reveal an anterior pelvic tilt, increased lumbar lordosis, and slight flexion of the hip on the involved side
• The patient may demonstrate a lack of hip extension during gait analysis
• The patient may demonstrate a loss of hip adduction on a range of motion assessment

Imaging is not usually required in cases of myofascial pain syndrome, except to help rule out other conditions.

The following are examples of red flags for patients presenting with hip pain:

• History of a significant injury
• Severe pain
• Unrelenting pain
• Nocturnal pain or pain at rest
• Unexplained weight loss
• Fever
• Deformity
• Large joint swelling
• Significant loss of range of motion
• Significant neurological impairment
• Severe tenderness on palpation or severe pain with any examination procedure

If any red flags are identified during history taking and clinical examination, referral for urgent medical evaluation and further investigation is warranted.

Myofascial Therapy

In our clinical experience, ultrasound therapy and the myofascial release technique have been beneficial in treating patients with myofascial trigger points.

Ultrasound Therapy

In our clinical experience, many patients with myofascial trigger points can be treated with ultrasound (or ultrasound phonophoresis) directly over the trigger points. The goal of this therapy is to help disperse the accumulation of congestion (e.g., lactic acid or other inflammatory chemicals) that commonly accompanies trigger points. The advantage of using ultrasound over the myofascial release technique (described below) in treating myofascial trigger points is that ultrasound is not painful for the patient, it targets the trigger points at a deeper level, and may help to speed up recovery.

Myofascial Release Technique

When performing the myofascial release technique:

Step 1: Begin by applying a gentle pressure on the trigger point and gradually increase this pressure until the patient reports some initial local pain (you will feel an increase in tissue resistance). Maintain this pressure without increasing it until the patient reports that the pain has eased (you will feel a concurrent easing of tissue resistance).

Step 2: Once the pain has eased, gradually apply deeper pressure on the trigger point until the patient once again reports the return of local pain (you will once again feel an increase in tissue resistance). Maintain this pressure until the patient reports that the pain has eased.

Step 3: Once the pain has eased again, gradually apply an even deeper pressure on the trigger point until the patient reports the return of local pain (you will feel an increase in tissue resistance). Maintain this pressure until the patient reports that the pain has eased.

Recommended Sleeping Posture

Patients with Tensor Fasciae Latae Myofascial Pain Syndrome may experience hip discomfort during sleep. Sleeping on the uninvolved side with a pillow between the knees may help to reduce that discomfort.

Lateral Hip Pain Differential Diagnosis

In the adult age group, the differential diagnosis of lateral hip pain includes conditions such as:

• Trochanteric Bursitis
• Greater Trochanteric Pain Syndrome (gluteus medius and gluteus minimus tendinopathy)
• Myofascial Pain Syndrome of the tensor fasciae latae, proximal vastus lateralis and the deep portions of the quadratus lumborum muscles