Version July 2025
INTRODUCTION —
Soft tissue musculoskeletal disorders refer to localized or multifocal pathologic syndromes involving the periarticular tissues, including muscle, tendon, ligament, fascia, aponeurosis, retinaculum, bursa, and subcutaneous tissue. These disorders are extremely common.
Although soft tissue musculoskeletal disorders refer to nonarticular pain, patients often attribute their symptoms to nearby joints. Thus, when patients complain of hip pain, the cause is often not pain in the joint itself, but rather in the "hip region": the groin, buttock, upper lateral thigh, greater trochanteric area, and iliac crest. Similarly, complaints of elbow, wrist, knee, and shoulder pain frequently mean pain in the general region of those joints, which may reflect soft tissue conditions such as epicondylitis, tenosynovitis, and bursitis.
Soft tissue disorders may be divided into several broad categories and include:
●Tendinitis
●Enthesitis
●Fasciitis
●Bursitis
●Structural disorders
●Myofascial pain syndrome
●Generalized pain disorders
Many of these disorders occur in the absence of systemic disease, and some are a consequence of chronic repetitive low-grade trauma and overuse. Many are self-limiting and respond to conservative measures.
This topic will provide a brief overview of the soft tissue musculoskeletal disorders. A general discussion on the approach to the patient with these disorders is also included. More detailed discussions of these disorders are presented separately. (See appropriate topic reviews.)
SPECIFIC SYNDROMES
Tendinitis — Tendinitis (or tendonitis) is a clinical and pathologic disorder with common features of local pain, dysfunction, and age-related degeneration. Tendinitis often results from overuse or a sports injury but may also be due to inflammatory rheumatic diseases or metabolic disturbances such as calcium apatite deposition. Tendinitis and tendon rupture have also been associated with the use of fluoroquinolone antibiotics and statins [1-3].
Tendinitis, tendinosis, and tendinopathy are some of the terms used to characterize acute or chronic tendon pain. The term tendinitis can be confusing because inflammation is often not seen on histopathology, and the other terms may be more appropriate. For the purposes of this discussion, we will use the common term tendinitis. A more detailed discussion on terminology is included elsewhere. (See "Tendinopathy: Overview of pathophysiology, epidemiology, and presentation", section on 'Pathology and terminology'.)
Common sites of tendinitis include supraspinatus tendinitis of the shoulder (rotator cuff tendinopathy), lateral and medial epicondylitis (tennis and golfer's elbow), bicipital tendinitis, gluteus medius/minimus tendinopathy, Achilles tendinopathy, and flexor carpi radialis and flexor carpi ulnaris tendinitis. These conditions are discussed in more detail separately:
●(See "Rotator cuff tendinopathy".)
●(See "Elbow tendinopathy (tennis and golf elbow)".)
●(See "Biceps tendinopathy and tendon rupture".)
●(See "Achilles tendinopathy".)
Enthesitis — The enthesis is the site of insertion of ligaments, tendons, joint capsules, and fascia to bone (figure 1). These areas are highly vascular and are susceptible to bacterial and antigen deposition [4]. Enthesitis is often seen in spondyloarthropathies; common sites are the insertion of the plantar fascia and the Achilles tendon region (see "Clinical manifestations and diagnosis of peripheral spondyloarthritis in adults", section on 'Musculoskeletal features'). Ultrasonography is helpful for delineation [5,6]. (See "Musculoskeletal ultrasonography: Clinical applications", section on 'Enthesitis'.)
Fasciitis — Fasciitis includes Dupuytren's contracture, fascia lata fasciitis, and plantar fasciitis. They have discrete and disparate pathologies which include proliferation and degeneration of fascia. Magnetic resonance imaging (MRI) is often useful in identifying these conditions. These disorders are discussed in more detail separately, as are other forms of fasciitis that have more systemic involvement, including necrotizing fasciitis and eosinophilic fasciitis:
●(See "Dupuytren's contracture".)
●(See "Approach to the adult with unspecified hip pain".)
●(See "Plantar fasciitis".)
●(See "Necrotizing soft tissue infections".)
●(See "Eosinophilic fasciitis".)
Bursitis — Bursitis is inflammation of the small fluid-filled pads, called bursae, that act as cushions between the bones and adjacent tendons and muscles, protecting the soft tissues from underlying bony prominences. Bursitis may be caused by direct trauma, repetitive injury, infection, or a rheumatic disease such as rheumatoid arthritis or gout. A diagnosis of bursitis is based on the findings of exquisite local tenderness at bursal sites, pain on motion and at rest, and sometimes associated regional loss of active movement. Swelling may be evident when bursitis occurs close to the body surface (eg, bunion or prepatellar bursitis) [7]. Bursitis is described in more detail separately:
●(See "Bursitis: Clinical manifestations, diagnosis, and management".)
●(See "Knee bursitis".)
●(See "Greater trochanteric pain syndrome (formerly trochanteric bursitis)".)
Structural disorders — Musculoskeletal structural disorders, such as decreased joint range of motion, articular laxity, and body asymmetry, are relatively common. As an example, one study of 127 medical students found that 73 percent had one or more congenital, developmental, or acquired structural abnormalities [8].
These subtle disorders often contribute significantly to pain syndromes in the lower extremity. Miserable malalignment syndrome is a term used to describe a combination of malalignments of the leg that include excess femoral anteversion with internal rotation of the hip, genu valgus, squinting patellae, external tibial torsion, and flat feet. Affected individuals are predisposed to overuse injuries and are often advised to avoid sports such as long-distance running. Structural disorders frequently contribute to injury in athletes. (See "Running injuries of the lower extremities in adults: Risk factors and prevention".)
Body asymmetry is a common cause of many regional pain disorders. As an example, temporomandibular joint dysfunction is more common when one side of the face is smaller (picture 1). The rest of the ipsilateral body may also be small in such patients, sometimes resulting in a scapulothoracic syndrome related to scoliosis or back pain in association with a short leg or an underdeveloped buttock.
Myofascial pain syndrome — Myofascial pain syndrome (MPS) is a regional pain disorder caused by the presence of trigger points within muscles or their fascia (figure 2) [9,10]. It has been described as "hyperirritable spots, usually within a taut band of skeletal muscle or in the muscle's fascia that is painful on compression and can give rise to characteristic referred pain, tenderness, and autonomic phenomena" [11]. MPS shares some features with fibromyalgia that are discussed separately (table 1). (See "Differential diagnosis of fibromyalgia", section on 'Myofascial pain syndromes'.)
●Epidemiology – MPS is a relatively common source of chronic pain in the general population. The lack of universally accepted diagnostic criteria has resulted in variable estimates from epidemiologic studies, and most of the available data pertain to musculoskeletal pain in general. One study that estimated the prevalence of myofascial pain in a general internal medicine practice found that the primary complaint of 30 percent of patients was due to myofascial pain [12].
●Clinical features – The pain of MPS is of a deep aching quality, occasionally accompanied by a sensation of burning or stinging. The pain often occurs in just one anatomic region, and patients often complain of restricted active movement in that area.
Myofascial trigger points (MTP) are the characteristic findings on physical examination. One or more trigger (pain) points will be found if the examiner gains familiarity with the likely point locations for each body region (figure 3A-B). Trigger points often feel indurated to palpation, and palpation reproduces the pain in the "target zone," often at some distance away. Trigger points may result from acute trauma, repeated minor microtrauma of daily living, or the chronic strain of sedentary work or living habits. Thus, evaluation of such patients with myofascial pain should include inquiry into activities and habits of movement. Patients with whiplash-associated myofascial pain have a higher prevalence of trigger points along the semispinalis capitis muscle than at other sites in the neck, jaw, and upper shoulder [13]. (See "Overview of joint protection".)
Many clinicians are skeptical about the existence of trigger points. Confusion also arises when differentiating trigger points from the tender points of fibromyalgia. Fibromyalgia tender points are said to differ in that they typically are not indurated and occur in tissues other than muscle (table 1). However, some find little difference in the tender point and trigger point examination in patients with fibromyalgia and MPS. A number of reports have questioned the reliability of the tender point evaluation, and it has been eliminated from the 2010/2011 preliminary and revised American College of Rheumatology diagnostic criteria for fibromyalgia [14]. Interestingly, microdialysis studies comparing active versus latent trigger points showed biochemical differences with elevated levels of sensitizing substances within the former [15]. (See "Fibromyalgia: Clinical manifestations and diagnosis in adults".)
●Associated conditions – MPS may include other common regional pain disorders such as tension headaches, idiopathic low back and cervical strain disorders, repetitive strain syndromes, occupational overuse syndrome, cumulative trauma disorder, work-related musculoskeletal disorder, and temporomandibular joint (TMJ) syndrome [16-19]. In the head and neck, the pain may be associated with unexplained dizziness and with neurocognitive disturbances. The etiology of these complaints is not understood, although some neurovestibular abnormalities are often found in patients with TMJ and myofascial pain of the head. These poorly understood pain disorders are also associated with fatigue, sleep abnormalities, irritable bowel syndrome, and mood disturbances, which may also be observed with fibromyalgia (see "Fibromyalgia: Clinical manifestations and diagnosis in adults", section on 'Symptoms'). Chronic, unexplained pelvic and urethral pain, sometimes termed the female urethral syndrome, is often considered to be a variation of myofascial pain.
●Treatment – Myofascial pain is generally treated similarly to fibromyalgia (see "Fibromyalgia: Treatment in adults"). However, myofascial pain also responds well to local treatments such as application of a cold spray and passive stretch of the involved muscle. Trigger point injections, using dry needling, saline, or botulinum toxin, have been effective in clinical trials for the treatment of myofascial pain [17,18,20].
Generalized pain disorders — Generalized pain disorders include the hypermobility spectrum disorders and fibromyalgia. These disorders may cause widespread pain and in some cases disability.
●Hypermobility spectrum disorders – The hypermobility spectrum disorders are comprised of connective tissue disorders characterized by chronic pain and joint laxity. Widespread arthralgias and a sensation of joint swelling (without objective physical signs of swelling) that lasts for hours rather than days are typical of this disorder. (See "Clinical manifestations and diagnosis of hypermobile Ehlers-Danlos syndrome and hypermobility spectrum disorder".)
●Fibromyalgia – Fibromyalgia is a clinical syndrome marked by widespread pain, fatigue, and is often associated with a variety of other symptoms. There is often overlap of fibromyalgia with chronic fatigue syndrome (CFS), also known as myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) (table 2). (See "Fibromyalgia: Clinical manifestations and diagnosis in adults".)
DIFFERENTIAL DIAGNOSIS —
There is a broad range of conditions that may cause soft tissue musculoskeletal disorders, including the following:
●Inflammatory arthritis (eg, rheumatoid arthritis, spondyloarthropathy) (see "Clinical manifestations of rheumatoid arthritis" and "Overview of the clinical manifestations and classification of spondyloarthritis")
●Crystalline arthropathy (eg, gout, calcium pyrophosphate crystal deposition [CPPD] disease) (see "Gout: Clinical manifestations and diagnosis" and "Calcium pyrophosphate crystal deposition (CPPD) disease: Clinical manifestations and diagnosis")
●Osteoarthritis (see "Overview of the management of osteoarthritis")
●Endocrine disorders (eg, hypothyroidism) (see "Clinical manifestations of hypothyroidism")
●Celiac disease (see "Epidemiology, pathogenesis, and clinical manifestations of celiac disease in adults", section on 'Nonclassic celiac disease')
●Chronic infections (eg, hepatitis, Lyme) (see "Hepatitis B virus: Clinical manifestations and natural history", section on 'Extrahepatic manifestations' and "Clinical manifestations of Lyme disease in adults", section on 'Arthritis')
●Vitamin D deficiency (see "Vitamin D deficiency in adults: Definition, clinical manifestations, and treatment", section on 'Clinical manifestations')
●Complex regional pain syndrome (see "Complex regional pain syndrome in adults: Pathogenesis, clinical manifestations, and diagnosis")
●Nerve entrapments (eg, carpal tunnel syndrome) (see "Overview of upper extremity peripheral nerve syndromes" and "Overview of lower extremity peripheral nerve syndromes")
●Small fiber neuropathy (see "Overview of polyneuropathy")
●Adverse drug effects (eg, statin-induced myopathy) (see "Drug-induced myopathies" and "Statin muscle-related adverse events")
Sometimes conditions that cause joint pain can predispose the patient to other soft tissue musculoskeletal disorders (eg, osteoarthritis in a knee may cause gait abnormalities that predispose to developing greater trochanteric pain syndrome). Pain may also be exacerbated by comorbid conditions such as depression and sleep disorders.
GENERAL INITIAL APPROACH —
Six points of management can often be initiated during the first visit in a patient with a suspected soft tissue musculoskeletal disorder, even before the results of appropriate laboratory or radiologic tests are available:
●Exclude systemic disease
●Eliminate aggravating factors
●Explain the illness
●Provide self-help strategies
●Provide pain relief
●Explain prognosis
Exclude systemic disease — Patients presenting with a suspected soft tissue musculoskeletal disorder should be evaluated for alternative or comorbid diagnoses, which may vary depending on their specific clinical presentation. Concurrent disorders are common. (See 'Differential diagnosis' above.)
The extent of the workup is dependent on the diagnosis. As an example, a patient with tendinitis or bursitis following a cumulative movement strain is not likely to benefit from radiologic or laboratory studies. By contrast, a patient presenting with enthesitis of the Achilles tendon and inflammatory back pain who is under the age of 40 may require additional studies to evaluate for the possibility of ankylosing spondylitis. (See "Diagnosis and differential diagnosis of axial spondyloarthritis (ankylosing spondylitis and nonradiographic axial spondyloarthritis) in adults" and "Diagnosis and differential diagnosis of rheumatoid arthritis".)
In many cases, conservative management of soft tissue musculoskeletal disorders can be initiated prior to receiving the test results. Furthermore, plain film radiographs or other imaging studies can often be deferred until a later visit if they are not likely to change initial management.
Eliminate aggravating factors — We review events and activities preceding the onset of pain in order to identify aggravating factors that can be modified or avoided in the future. Factors that may exacerbate soft tissue musculoskeletal disorders include the following:
●Improper sitting and work ergonomics with insufficient rest periods are common precipitating factors.
●Soft tissue strain resulting from repetitive job tasks or a new hobby should be recognized and modified.
●Biomechanical strain resulting from structural disorders (eg, flat feet, head-forward posture or heavy pendulous breasts) can also be altered with appropriate instructions.
●Psychosocial factors that might influence outcome including untreated mood disorders, chronic insomnia, poor nutrition, drug dependency, interpersonal relationships, and other stressors should be investigated.
Joint protection advice should be provided. Ergonomic assessment is indicated when symptoms are severe, significantly interfering with life, persistent, and unresponsive to treatment. The overview of joint protection and the approach to upper and lower limb joint protection are provided separately:
●(See "Overview of joint protection".)
●(See "Joint protection program for the upper limb".)
●(See "Joint protection program for the lower limb".)
Explain the illness — Patients are often reassured when they are told that they have a soft tissue musculoskeletal disorder rather than more serious illnesses such as systemic lupus erythematosus or rheumatoid arthritis. In addition, validation that their problem is "real" (eg, in patients with myofascial pain syndrome [MPS] or fibromyalgia) often relieves anxiety. (See "Fibromyalgia: Treatment in adults", section on 'Explaining fibromyalgia to patients'.)
Explain self-help strategies — At-home therapeutic exercises and ergonomic modifications should be outlined on the first visit, if appropriate. Patients may benefit from enrolling in a program that combines aerobics, strength training, and stretching. Activities to address pain in the neck, upper limb, and lower limb are discussed elsewhere:
●(See "Joint protection program for the neck".)
●(See "Joint protection program for the upper limb".)
●(See "Joint protection program for the lower limb".)
Explain prognosis — Most soft tissue musculoskeletal pain disorders are of short duration and the time until improvement becomes evident can be projected. Relief from soft tissue strain, bursitis, or tendinitis may require only a few days, while symptoms due to hypermobility syndrome or disorders of other structural deficits may require several months before moderate or optimal improvement is seen.
The expected clinical course should be explained to the patient at the initial visit if possible. Patients should also understand that this course is dependent upon the performance of the self-help program and that their response to the program may impact the diagnosis.
Provide pain relief — It is important to provide analgesia in order to prevent a vicious cycle of muscle spasm and pain, as well as to enable patients to participate in self-help strategies. The initial management of acute injuries is described in detail elsewhere (see "Initial management of soft tissue musculoskeletal injuries"). Otherwise, pain control for patients who do not have soft tissue musculoskeletal disorders will depend in part on the specific cause of pain (eg, tendinitis, bursitis), but may include the following elements:
●Application of heat and cold – Despite the paucity of adequate controlled clinical studies, heat and cold modalities have been used for many years in the treatment of musculoskeletal disorders [21].
•Heat – Heat can readily be applied by hot packs or hot water bottles and can increase the threshold for pain, produce analgesia by acting on free nerve endings, and decrease muscle spasm. A review of the effects of superficial heat on low back pain showed moderate evidence for heat therapy providing a small short-term reduction in pain and disability [22]. Heat is not indicated in acute arthritis, since it contributes to increased inflammation and pain, but may be helpful for some patients with moderate joint inflammation, where it may reduce pain and muscle spasm.
•Cold – Ice is sometimes useful to control pain and swelling because it induces vasoconstriction of superficial and intraarticular tissues, reduces local metabolism, and slows nerve conduction. It may be applied using cold packs, ice baths, and vapocoolant sprays [23].
●Topical and oral analgesics – Frequently used analgesics include use of oral or topical nonsteroidal antiinflammatory drugs (NSAIDs) and other topical applications with agents such as lidocaine or capsaicin (table 3) [24,25].
●Local injections – For certain soft tissue musculoskeletal disorders (eg, some types of bursitis, tendinitis, and carpal tunnel syndrome) that have not improved with conservative measures, injecting the affected area with a mixture of long-acting glucocorticoid and local anesthetic (eg, lidocaine) may be effective. The use of diagnostic ultrasound has greatly improved our diagnostic accuracy and broadened our understanding of soft tissue musculoskeletal disorders, while also affording greater precision in defining sites to be injected with glucocorticoids [26-28]. Indications for local injections, technique, and medication dosing are discussed in the appropriate topic reviews.
For patients who have tender or trigger points, we do not use botulinum toxin injections, since there is not clear evidence suggesting superiority of botulinum toxin compared with less costly agents. For MPS, several studies suggest that botulinum toxin type A may provide pain [29-31], while others have found an analgesic effect similar to injection of glucocorticoids [31] or saline [32] and less than or similar to that of lidocaine [33,34]. (See "Approach to the management of chronic non-cancer pain in adults".)
●Acupuncture – Acupuncture may be used to relieve pain. Its clinical value varies based on the condition being treated and the specific methodology employed. (See "Overview of the clinical uses of acupuncture".)
●Extracorporeal shockwave therapy – Extracorporeal shockwave therapy is a relatively novel approach in treating recalcitrant painful soft tissue disorders and in several studies has shown efficacy in the management of calcific tendinitis, chronic Achilles tendinopathy, and plantar fasciitis [35].
SUMMARY AND RECOMMENDATIONS
●Overview – Soft tissue musculoskeletal disorders refer to nonsystemic, focal pathologic syndromes involving the periarticular tissues, including muscle, tendon, ligament, fascia, aponeurosis, retinaculum, bursa, and subcutaneous tissue. These disorders are extremely common. (See 'Introduction' above.)
●Specific syndromes – Soft tissue disorders may be divided into several broad categories and include tendinitis, enthesitis, fasciitis, bursitis, structural disorders, and myofascial pain syndrome (MPS). Many of these disorders occur in the absence of systemic disease, and some are a consequence of chronic repetitive low-grade trauma and overuse. Many are self-limiting and respond to conservative measures. (See 'Specific syndromes' above.)
•Tendinitis – Tendinitis (or tendonitis), which often results from overuse, is a disorder with common features of local pain and dysfunction, inflammation, and degeneration.
•Enthesitis – Enthesitis, which is an inflammation of the site of the insertion of the tendon to the bone, is often seen in spondyloarthropathies. Common sites are the insertion of the plantar fascia and the Achilles tendon region. (See 'Enthesitis' above.)
•Bursitis – Bursitis is inflammation of the small fluid-filled pads, called bursae, which provide a cushion between bones and tendons and/or muscles around a joint. Bursitis may be caused by direct trauma, repetitive injury, infection, or a rheumatic disease (eg, rheumatoid arthritis or gout). (See 'Bursitis' above and "Bursitis: Clinical manifestations, diagnosis, and management".)
•Structural disorders – Musculoskeletal structural disorders include decreased joint range of motion, articular laxity, and body asymmetry. They are relatively common, sometimes subtle, and often contribute to pain syndromes and to injury in sports participants. Body asymmetry is a common cause for many regional pain disorders. (See 'Structural disorders' above.)
•Myofascial pain syndrome – In MPS, hyperirritable spots, often in just one body region within a taut band of skeletal muscle or fascia, can give rise to characteristic referred pain. There are usually one or more trigger (pain) points; these are typically indurated and painful on compression. Myofascial trigger points may result from acute trauma, repeated minor microtrauma of daily living, or a chronic strain of sedentary work or living habits. (See 'Myofascial pain syndrome' above and "Differential diagnosis of fibromyalgia", section on 'Myofascial pain syndromes'.)
●General initial approach – Six points of management can often be initiated during the first visit in a patient with a suspected soft tissue musculoskeletal disorder, even before the results of appropriate laboratory or radiologic tests are available. These are excluding systemic disease; eliminating aggravating factors; explaining the illness, self-help strategies, and the prognosis; and providing pain relief. (See 'General initial approach' above.)
ACKNOWLEDGMENT —
The UpToDate editorial staff acknowledges Irving Kushner, MD, who contributed to earlier versions of this topic review.
