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Painful Herpetic Reactivation and Degenerative Musculoskeletal Injury

A pain patient presenting with herpetic neuralgia and multiple musculoskeletal issues provides an interesting and challenging case study.

A patient suffering multiple sources of pain may present the clinician with a complex challenge especially when obvious skin lesions of herpetic reactivation and typical painful symptoms of herpetic neuralgia are present. The patient described in the following case study is a classic example of multiple pain conditions originating from systemic as well as focal muscle injury. This article serves to highlight the complex nature of diagnosing comorbid pain conditions.

Case Study

A 42-year-old male presented to this author’s clinic with bilateral cutaneous lesions involving the ear, eye, face, temple, forehead, arms and neck. The skin lesions had first appeared three years ago and had been worse for the past 8 months (see Figures 1 and 2). This patient had seen his primary care provider who had treated him for a staph infection of the skin with no improvement in the skin lesions. The skin lesions were painful with a burning and aching quality. The patient was started on an oral prescription for acyclovir and within 24 hours the skin lesions were beginning to dry up and diminish in size (see Figure 3).

Figure 1. Skin lesions on forehead. Figure 2. Skin lesion on left ear lobe. Figure 3. Twenty-four hours after acyclovir lesions on right ear are drying up and diminishing in size.

The skin lesion pain served as an overlay for musculoskeletal symptoms that were not noticed until the skin lesions started drying up from the acyclovir medication. Local anesthetic testing confirmed temporal tendinitis and splenius capitis muscle syndrome. The patient also suffered TMJ related changes that impacted his clinical picture. The mandibular range of motion was 40mm in maximum opening (N=45-55mm). Orthodontic issues included a retruded maxillary dental arch, small palate with compromised space for the tongue, and popping of the TMJ articular discs, as well as anterior tongue thrust.

Other mitigating factors included the patient having been intubated three separate times. It is probable that the dental problems represent a maxillofacial abnormality that is pathognomic for TMJ together with musculoskeletal degenerative changes.1-3 This patient also had a history of extracted maxillary first bicuspid teeth and a history of previous orthodontic therapy.


Annika Isberg3 reported in the 1980s that a displacement of the TMJ articular disc led to a loss of muscle resting period and chronic activation of the involved temporal muscles. The latter were often found to be painful and sore on palpation. If the patient has experienced oral intubation, motor vehicular trauma and/or a prolonged dental procedure, the impact of those stresses are cumulative to the TMJ and craniofacial structures. In a patient who suffers herpetic reactivation, with its painful symptoms of burning and aching and the inconvenience of skin lesions, it is more difficult to localize the source of the patient’s suffering.

This patient had seen several doctors who believed that the skin lesions were a staphylococcus infection and was treated with an antibiotic. However, this author’s exam and local anesthetic testing suggested that the patient was suffering:

  • herpetic reactivation
  • possible post-herpetic neuralgic pain
  • musculoskeletal attachment pain

Local anesthetic infiltration of the temporal tendons and splenius capitis muscles resulted in 80% pain relief. A prescription of acyclovir 400 mg three times daily resulted in a 50% reduction of the skin lesions and burning and aching in a 24-hour period. When the local anesthetic testing effect wore off, the pain in those areas returned. The patient also had symptomatic pain at the insertions of the stylomandibular ligaments that appeared to diminish with blockade of the temporal tendons. Since the use of oral and injectible medications did not offer permanent relief of pain, the treatment of choice for the temporalis and splenius capitis insertion pain was radiofrequency thermoneurolysis.

Radiofrequency thermoneurolysis was utilized with the OWL radiofrequency generator (manufactured by Diros Technology, Toronto, Canada). In anatomical areas where sensory qualities of pressure, temperature and touch were to be preserved, thermocoagulation was employed using the pulse mode per the manufacturer’s guidelines.


This case could easily confound the clinician because of the obvious skin lesions of herpetic reactivation and the typical symptoms of herpes infection and herpetic neuralgia. This case highlights the complex challenge of examining the pain patient who suffers multiple sources of painful symptoms. In addition to herpetic reactivation, six comorbid conditions were diagnosed:

  1. temporal tendonitis
  2. splenius capitis muscle syndrome
  3. TMJ disc derangements
  4. retruded maxillary dental arch
  5. anterior tongue thrust
  6. post-orhodontic problems
Last updated on: December 20, 2011
First published on: June 1, 2009