8.0 TREATMENT
The podiatrist's in the management of MPS is generally to address any biomechanical abnormalities that could have led to the formation and perpetuation of TrPs. Although most podiatrists do not usually have formal training in some of the wide-ranging treatments for MPS, many of the physical therapy modalities listed below could be easily adopted into our treatment repertoire. Conversely, we could refer to a myotherapist, osteopath or physiotherapist with more experience in the area of myofascial manipulation and rehabilitation.
8.1 FOOT ORTHOSES
From a podiatric perspective, many of the aches and pains that are successfully treated with orthoses could have a TrP related component. The only research uncovered relating to the treatment of MPS with orthoses was conducted by Saggini et al (1996). The authors examined twelve patients with a limb length discrepancy and unilateral TrPs in peroneus longus. The subjects were assigned either a heel lift to correct the discrepancy or functional foot orthoses. The heel lift intervention group reported a moderate reduction in symptomology after 7 to 14 days with no further improvement. The orthoses group on the other hand, had a significant reduction in pain after 7 days and complete resolution of pain and the active TrPs at 30 days.
There is also anecdotal evidence to implicate TrPs in the failure of orthotic therapy. For example, an individual suffering from heel pain can develop an antalgic gait pattern and as a result of the abnormal muscular activity, form a TrP in the soleus muscle. Upon correction of the offending biomechanical anomaly with orthoses, symptoms of heel pain may persist due to referred pain from the soleal TrP.
8.2 PHYSICAL THERAPY
Many physical therapy modalities are used in the treatment of MPS. The spray and stretch technique involves the use of a vapocoolant spray as a distraction, to block the reflex spasm and sensation of pain (Auleciems, 1995). This allows the muscle to be passively stretched to a greater degree and facilitates its return to a normal resting length (Mennell, 1976). The use of an ice-pack over the area of referred pain has also been shown to be effective in reducing pain.
Heat therapy via ultrasound or a moist heat-pack is often used to relax the surrounding muscles and help reduce tension in a TrP, especially prior to a myofascial release of the affected area (Auleciems, 1995). Other forms of manipulation include ischaemic compression and deep massage yet they all serve the same purpose of mechanically breaking up the fibrous bands that constitute a TrP. The use of heat and manipulation is effective on its own or in combination with the spray and stretch technique. Other treatments include transcutaneous nerve stimulation, cold laser, iontophoresis and phonophoresis (Miller, 1994).
Exercise is another important factor in the treatment process. Passive stretching of the affected musculature not only allows for a quicker rehabilitation but also helps limit the recurrence of MPS. Similarly, a strengthening program helps maintain healthy muscle tissue, making it less susceptible to injury. The use of non-steroidal anti-inflammatories and capsaicin have also been used with variable success (Auleciems, 1995).
8.3 TRIGGER POINT INJECTION
Injection therapy can be performed 'dry', through acupuncture or 'wet' by infiltrating the area with either saline or a local anaesthetic. Needling is viewed as the definitive treatment for MPS, and is particularly indicated in the 20%-30% of cases that are unresponsive to standard treatment (Cantu & Grodin, 1992). Saline or local anaesthetic injections help disrupt the fibrous banding within a TrP and are associated with significantly reduced post injection soreness when compared with acupuncture (Hong et al, 1997).
