ARTHUR W. CURTIS, M.D.

UNION HEALTH SERVICE

1634 WEST POLK STREET

CHICAGO, IL  60612

CHRONIC MUSCLE PAIN

Chronic muscle pain is one of mankind’s most common afflictions. Muscles have a unique capacity to hurt for long periods of time because of a phenomenon known as pain cycling. It is a normal reflex for pain anywhere in the body to cause nearby muscles to tighten, or go into spasm. This happens most dramatically in response to a broken bone but also occurs in response to other types of pain. A muscle that is in spasm will soon start to hurt as it becomes tired from being tight. This sets up the vicious cycle of pain in the muscle causing spasm, and the spasm in turn causing more pain—allowing the pain to go on and on.

Muscular pain is often referred, meaning that it is also felt in a nearby area, often more severely than in the muscle itself. This tendency to refer pain can cause muscular pain to mimic other diseases.

The most common site of chronic muscular pain is the lower back. Other common places include the back of the neck and the chest wall. The most frequent sites in my patients are the jaw muscles, the throat muscles, and the muscles of the back and sides of the neck.

I want to first explain about the characteristics of chronic muscle pain in these regions of the head and neck and then talk about treatment. People frequently have chronic muscle pain in more than one area of the head and neck and may also have muscle pain in different areas of the body, so the symptoms and findings that I describe will often overlap.

JAW MUSCLES (TMJ SYNDROME)

Chronic pain in the jaw muscles, better known as TMJ syndrome, causes pain with chewing, yawning, and other wide mouth opening, limitation of jaw motion, and a clicking in the jaw  joint—the temporomandibular joint, or TMJ.  The jaw may also lock open or lock shut. All of these symptoms are the result of chronic spasm in the jaw muscles, even though it may seem that the jaw joint itself is the problem. The clicking is the result usually of uncoordinated movement of the jaw muscles, not arthritis or a deformity in the joint.

The TMJ syndrome can cause a multitude of ear symptoms. The pain that the patient experiences in this syndrome is often referred to the ear, jaw joint or somewhere else on the side of the face or head. For reasons not fully understood, there is often ringing in the ear(s) and/or a feeling of pressure in the ear(s)  and/or a  subjective hearing loss.  With subjective hearing loss, sounds seem distant and muffled to the sufferer, and yet the hearing is normal on testing.

THROAT

Muscular throat pain may be on one or both sides. The pain is typically made worse by swallowing. There is often associated spasm of the muscles that make the voice. The excessive tension of these muscles may cause normal conversation to be as damaging to the vocal cords as yelling. As a result, the voice may give out easily with prolonged talking, which can also cause the pain to become more intense.

NECK MUSCLES

It is common to have chronic muscular pain in the back and/or sides of the neck. The pain tends to be worse with turning the neck or putting the neck in certain positions.  There may be clicking with turning the neck. There will often be limitation of neck motion, which can cause difficulty in turning the head to back up or change lanes while driving. The ear symptoms found in the TMJ syndrome can also be found with chronic muscular neck pain, and it is not uncommon to have brief episodes of dizziness with turning the neck. The pain associated with chronic neck muscle spasm is often referred to the ears, face or head. A sore neck or a TMJ syndrome is a common cause of headache.

TREATMENT

Treatment for chronic muscular pain consists of various methods for decreasing the pain and relaxing the muscles. This is a situation in which taking aspirin, Advil (ibuprofen) or other NSAIDs or Tylenol can actually help you get better rather than just relieve symptoms. Non-prescription counter-irritants, such as Ben Gay, Absorbine Jr. and the Icy Hot Patch, can also help relieve the pain. Massage can help once you find the right spot. Gentle stretching can also help, but do not do any stretching that is painful.

Muscular relaxation is also an important part of treatment. Heat applied to the painful muscles is one of the best ways to bring about relaxation. An electric heating pad used for 20 minutes four times a day is usually quite helpful or for longer periods of time according to your schedule. Sitting quietly for a few minutes and consciously relaxing all of your muscles from top to bottom a few times a day is also helpful. It is important to use a scarf or some other means to keep your neck warm when outside in the cold.

Moderate exercise is good for people with chronic muscle pain, but the painful muscles should not be used to the point of causing pain. It is important not to stay in the same position for long periods of time, especially in front of a computer or with other sedentary activity. TMJ sufferers who tend to awaken with their worst symptoms often benefit from a biteplate, which could be an athletic tooth guard, to keep them from clenching or grinding their teeth in their sleep. 

Avoiding causing pain is important. Part of the treatment for TMJ syndrome is eating a soft diet and avoiding opening the mouth widely. Patients with chronic neck pain should not do exercises that put strain on the neck, and patients with muscular throat pain should use their voices sparingly and not loudly.

PRESCRIPTION MEDICINES

Amitriptyline, or Elavil, is often quite helpful for treating chronic muscle pain. Elavil was the original antidepressant drug but is nowadays more often used for pain. You do not, however, need to be depressed to be helped by amitriptyline. Its main side effect is sleepiness, so it would be a particularly good drug  for a muscle pain patient with insomnia and/or depression.

The dose of Elavil must be individualized. Since it works for 24 hours and its main side effect is sleepiness, it is normally given at bedtime. You normally start at the low dose of 10 mg.  If you are a little sleepy the next morning, that should wear off in a day or two.  If you are really sleepy for an hour or two or more upon arising, you should cut the tablet in two. The tablet tends to crumble, so you should take half of the crumbles and save or throw out the other half. If you are not sleepy the next morning and not better after three days of a full tablet, increase the dose to two tablets. If you are more than a little sleepy, you should go back to one tablet and try it for a month. If you are not better and are still not sleepy with two tablets, you can add an extra tablet every three days until you start experiencing sleepiness the next day and then back off a tablet. Typically, people take one or two tablets.

Less common side effects are dry mouth, constipation and a feeling of faintness upon arising in the morning. The faintness is aggravated by getting up quickly and can usually be avoided by getting up slowly. Good hydration can help all of these symptoms. These tablets should be given only very cautiously to anyone over 65 because of the problems with sedation and faintness upon arising.

Alternative drugs include muscle relaxants, which have sleepiness as a troublesome side effect, Neurontin (gabapentin) and Lyrica, which is quite expensive yet.

It is usually best to use a combination of home remedies and, if necessary, medication. Any of the treatments should give some temporary help, but permanently breaking up the cycle of pain and spasm usually requires conscientious use of more than one treatment for at least a week.

PSYCHOLOGICAL ASPECTS

Muscular pain can be brought on many different ways, such as minor injuries, exposure to a draft, or as the aftermath of a viral infection. For the pain to persist for longer than a week in the absence of repetitive injury, however, there are usually personality and stress factors involved. The people who are prone to chronic muscular pain tend to be conscientious and managerial and to keep their feelings inside. The typical chronic muscle-pain sufferer keeps up a “good front” in adversity and may deny even to himself that a certain situation is upsetting to him. It can help a muscle pain sufferer to search for and, if possible, eliminate sources of stress and aggravation.

FOLLOW UP

Chronic muscular pain often mimics other diseases and vice versa. I only make the diagnosis of chronic muscle pain after I feel reasonably certain that no other disease is causing your symptoms. If, however, the symptoms do not respond to the treatment, the diagnosis may be wrong. So be sure to come back if you are not doing well. It is also possible that more aggressive treatment may be necessary, such as stronger medicine, a biteplate, physical therapy, or voice therapy.