Multiple Sclerosis Presenting as Myofascial Pain: A Case Report

Case Diagnosis: A 35-year-old female with chronic neck and back pain and headaches.

Case Description or Program Description: This patient was referred to physiatry for persistent right neck and back pain. She describes the pain as sharp, stabbing, throbbing, and aching, without radiation. She also endorsed one episode of bilateral hand tingling/numbness and occasional right upper extremity weakness. The patient attributed the pain to an episode where a large dog jumped onto her chest, causing hyperflexion of her neck. Initial physical examination revealed tenderness to palpation and decreased range of motion of the cervical spine, in addition to peri-scapular tenderness and pain whilst performing the empty can test.
Over the past year, the patient’s pain has persisted despite physical therapy, transcutaneous electrical nerve stimulation, massage therapy, and chiropractic care. The patient has trialed gabapentin, amitriptyline, tizanidine, non-steroidal anti-inflammatory medications, and vitamin supplementation, with minimal improvement. She reports relief following trigger point injections that lasts for approximately two weeks. The patient has also been following with neurology for her chronic headaches, which are being managed with occipital nerve blocks.
MRI of the shoulder revealed no acute osseus or rotator cuff pathology. MRI of the cervical spine exhibited mild degenerative cervical spondylosis and findings suggestive of demyelination at C2. Further work-up with neurology revealed the diagnosis of multiple sclerosis.

Setting: Tertiary care outpatient clinic

Assessment/Results: The patient continues to experience daily neck and back pain, with temporary relief from trigger point injections and pharmacotherapy.

Discussion (relevance): This case emphasizes the importance of a thorough evaluation of patients with chronic pain syndromes, as initial musculoskeletal pain may be a presenting feature of an underlying neurologic disorder.

Conclusions: Persistent musculoskeletal pain refractory to conventional PM&R interventions should warrant additional diagnostic studies.