Disclosures: James A. Underwood, MD: Nothing to disclose

Case Description: A patient with a history of myofascial pain that had improved with trigger point injections in the past returned to PM&R clinic for evaluation of left-sided posterior shoulder pain. Pain was described as intermittent, radiating from shoulder to periscapular region. The pain increased with physical exertion and stress. Prior to referral to PM&R, he was evaluated by outpatient Cardiology who performed a stress ECG and deemed the pain to be non-cardiac. Initial diagnosis of myofascial pain versus radiculopathy was suggested, but after trigger point injections his symptoms did not improve. The patient returned to the PM&R clinic with persistent symptoms, therefore it was recommended that he report to the Emergency Department at the next occurrence of pain for repeat cardiac evaluation. The patient reported to the Emergency Department shortly thereafter.

Setting: Outpatient PM&R Clinic

Patient: A 69-year-old male with a history of myofascial pain and CAD

Assessment/Results: Upon Emergency Department evaluation, he was found to have a troponin of 0.45 which increased to a peak of 5.3; A diagnosis of NSTEMI was made. He was admitted to the Cardiology service and underwent cardiac catheterization revealing 80% stenosis of the RCA, requiring DES placement. Upon re-evaluation in the PM&R clinic after this hospitalization the patient reported complete resolution of symptoms.

Discussion: Although the patient had a history of myofascial trigger point pain, it is important to consider alternative pain generators in a patient with a complex medical history. Given the complete resolution of symptoms after stent placement, we suggest that this patient’s pain was indeed cardiac in origin.

Conclusion: This case highlights the importance of continued vigilance in a patient whose symptoms are not resolving. It also notes the importance of considering serious and life-threatening diseases in a medically complex patient with pain.

Level of Evidence: Level V

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PM&R Meeting Abstracts - https://pmrjabstracts.org/abstract/when-trigger-points-dont-go-away-reconsider-the-diagnosis/