Trapezius myofascial pain

[clubdeac]

I am a pain physician looking for some advice on a patient I have referred to PT as my patient has received some disparate advice. My patient is a young male with an 8 mos h/o insidious in onset right trapezius pain. No injury or accident. Cervical MRI was negative. Xrays were notable for slight scoliosis. On exam he does have a somewhat lower right shoulder. The trapezius has palpable large trigger points and taut bands throughout. I have tried tpi's without effect as well as various oral and topical medications. Exercise and heat seem to help temporarily. One therapist recommended stretching and deep tissue massage. Another believes the trapezius is weak, hence the lowered shoulder, and has recommended trapezius strengthening and latisimuss stretching. Any recommendations/thoughts?

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[_FNG_]

Trapezius myofascial triggerpoints can be a pain (pun intended) because, in my opinion, pain in this area can be caused by several sources. These include cervical spine facet referral, stress/postural habits (although we know research shows posture isn't well correlated with pain I still believe it can be a factor), rib angle pain (TTP over rib angle of upper thoracic different from uninvolved side), compensation of upper trapezius as a result of shoulder dysfunction, visceral referral, etc. etc.

For me, treatment is based on examination findings. If the guy's examination reveals nothing out of the ordinary with cervical, thoracic, and shoulder testing then my treatment (as long as screening for visceral referral is negative-area specific questions) would likely entail cervicothoracic joint manipulation and mid-thoracic manipulation along with scapular and neck retraction exercises. Cervical manipulation for UT TPs has had more research but it is my stance not to manipulate the cervical first (respect the neck) however it would be an option if examination revealed asymmetrical pain/tightness with joint testing. If this does not yield any significant changes than trigger point dry needling would be an option however if TPIs weren't successful this may be lower on my intervention list. Other options available would be postural taping, ultrasound, massage, heat, ionto...but all these have minimal supportive research and my experience aren't as helpful as the previously mentioned interventions.

Obviously my interventions would be different from another PT but I think manual therapy is a beneficial intervention for MSK pain and use it accordingly.

 

[clubdeac]

So you think there's some cervical or thoracic joint dysfunction referring pain to the trap or causing secondary myofascial pain in the trap and manipulation would be your first recommendation

 

[rlw237]

I obviously haven't seen the patient, but try looking at the patients 1st or 2nd rib, sometimes its even ribs 3-5. If these are subluxed in any way they can cause the levator scap or upper trap to initiate muscle gaurding. Over time if the ribs remain subluxed the muscle gaurding eventually leads to hypertonia and tender to palpate. Cervical rotation, opp side bending and flexing becomes limited. Pain/discomfort with upper respiratory breathing. Point tenderness over levator scap and rib one. Try palpating directly over the transverse processes and rib facets on thw affected side. Most patients say "it feels like a knot", this should be your indication its probably a rib. Usually after I mobilize the first rib or perform a grade 5 mob on ribs 3-5 the patient reports a decrease in pain. I perform rib mobs for 2-4 more visits and begin focusing on the upper trap and levator involvement. Something is causing the muscles to flare up. Look above, below and within.

 

[_FNG_]

So you think there's some cervical or thoracic joint dysfunction referring pain to the trap or causing secondary myofascial pain in the trap and manipulation would be your first recommendation

Again, it is hard to say what is the pain source but in my experience I've found treating the cervical and thoracic spine and ribs beneficial for MTrP.

 

[jesspt]

I am a pain physician looking for some advice on a patient I have referred to PT as my patient has received some disparate advice. My patient is a young male with an 8 mos h/o insidious in onset right trapezius pain. No injury or accident. Cervical MRI was negative. Xrays were notable for slight scoliosis. On exam he does have a somewhat lower right shoulder. The trapezius has palpable large trigger points and taut bands throughout. I have tried tpi's without effect as well as various oral and topical medications. Exercise and heat seem to help temporarily. One therapist recommended stretching and deep tissue massage. Another believes the trapezius is weak, hence the lowered shoulder, and has recommended trapezius strengthening and latisimuss stretching. Any recommendations/thoughts?

Are these the only significant findings on physical exam? Cervical ROM is normal and pain-free? The trigger points are "active", meaning that when palpated, they reproduce your patient's symptoms and/or you ellicit a local twitch response when you "strum" over the taught band? Have the medications you presscribed been anti-inflammatories or another type of medication (his reponse to NSAIDs or the like would help determine if his pain is chemically or mechanically mediated)?

Overall, I'd echo a lot of what FNG has said - C-T junction and mid thoracic thrust manipulation is safe, quick, and has some research behind it, particularly when paired with ROM exercises.

 

[facetguy]

...my treatment... would likely entail cervicothoracic joint manipulation and mid-thoracic manipulation along with scapular and neck retraction exercises. Cervical manipulation for UT TPs has had more research but it is my stance not to manipulate the cervical first (respect the neck) however it would be an option if examination revealed asymmetrical pain/tightness with joint testing.

Obviously my interventions would be different from another PT but I think manual therapy is a beneficial intervention for MSK pain and use it accordingly.

I obviously haven't seen the patient, but try looking at the patients 1st or 2nd rib, sometimes its even ribs 3-5. If these are subluxed in any way they can cause the levator scap or upper trap to initiate muscle gaurding. Over time if the ribs remain subluxed the muscle gaurding eventually leads to hypertonia and tender to palpate.... Usually after I mobilize the first rib or perform a grade 5 mob on ribs 3-5 the patient reports a decrease in pain.

Overall, I'd echo a lot of what FNG has said - C-T junction and mid thoracic thrust manipulation is safe, quick, and has some research behind it, particularly when paired with ROM exercises.

Hmmm. Maybe those crazy chiropractors were right.

 

[jesspt]

Hmmm. Maybe those crazy chiropractors were right.

As long as they don'tt think they're correcting the mythical subluxation with HVLA, then they actually might be.

 

[clubdeac]

First thank you my fellow colleagues for all the input

jesspt - to answer your question, the trigger points seem to be latent. Not overtly tender when I palpate but there are notable knots in comparison to the left trap and this is where he describes his pain. Pain is described as a deep, dull ache and is diffuse withing the superior trap and occasionally deep within the supraclavicular fossa. Cervical ROM is pain free although head rotation to the right with chin tuck into the supraclavicular fossa will accentuate the pain. Again there is asymmetry with the right shoulder slightly dropped in comparison to the left. No relief with oral and topical NSAIDs or lidoderm. Started cymbalta which seems to be helping. Patient has started trap stretching and strengthening exercises and is 50% improved.

So to get this guy over the hump you'd recommend CT junction thrust manipulation and/or possible rib manipulation? I will see if the PT down the hall is experienced and I am certainly open to any other noninvasive recommendations before I pursue facet injections and/or botox into the muscle.....

Thanks again!

 

[truthseeker]

Clubdeac,

I recently went to a course called "explain pain" taught by a PT named Adriaan Luow. It is based upon a book written by Lorimer Moseley and David Butler. It was fantastic. I am still trying to integrate the education part into my practice. I whole heartedly recommend the book and the course. When I went, it was mostly PTs, one psychologist, and two pain docs.

Rather than summarizing the course, (which discussed how pain is central, how it is every bit as complex as vision/hearing or any other sensory perception, and can be fooled, ion channels, as well as inflammation and nociception) I would recommend either buying the book (very science/evidence based) or attending the course if it is offered nearby.

Based on what I have read, the Cymbalta is probably working very well as an ion channel blocker. I would recommend a basic walking program 15-20 minutes per day to burn off excess stress chemicals, improve his sleep hygiene, and use ice to calm the nervous system. That empowers the patient and teaches him that he can manage the pain himself. When we continue to talk about things that we need to do to him to fix him, we make him dependent upon us and perhaps elevate the importance of the pain in his mind. If there is nothing ominous about his exam, reinforce that the warning that he is getting from his trapezius is being over-reacted to by his brain.

 

[jesspt]

First thank you my fellow colleagues for all the input

jesspt - to answer your question, the trigger points seem to be latent. Not overtly tender when I palpate but there are notable knots in comparison to the left trap and this is where he describes his pain. Pain is described as a deep, dull ache and is diffuse withing the superior trap and occasionally deep within the supraclavicular fossa. Cervical ROM is pain free although head rotation to the right with chin tuck into the supraclavicular fossa will accentuate the pain. Again there is asymmetry with the right shoulder slightly dropped in comparison to the left. No relief with oral and topical NSAIDs or lidoderm. Started cymbalta which seems to be helping. Patient has started trap stretching and strengthening exercises and is 50% improved.

So to get this guy over the hump you'd recommend CT junction thrust manipulation and/or possible rib manipulation? I will see if the PT down the hall is experienced and I am certainly open to any other noninvasive recommendations before I pursue facet injections and/or botox into the muscle.....

Thanks again!

Yeah, I think that thrust manipulation to the CT junction, and ribs and mid thoracic spine, coupled with some strengthening emphasizing the lower trapezius will likely be of benefit. Another non-invasive treatment to consider would be training of the deep cervical flexors, which is described here.

 

[jesspt]

Clubdeac,

I recently went to a course called "explain pain" taught by a PT named Adriaan Luow. It is based upon a book written by Lorimer Moseley and David Butler. It was fantastic. I am still trying to integrate the education part into my practice. I whole heartedly recommend the book and the course. When I went, it was mostly PTs, one psychologist, and two pain docs.

Rather than summarizing the course, (which discussed how pain is central, how it is every bit as complex as vision/hearing or any other sensory perception, and can be fooled, ion channels, as well as inflammation and nociception) I would recommend either buying the book (very science/evidence based) or attending the course if it is offered nearby.

Based on what I have read, the Cymbalta is probably working very well as an ion channel blocker. I would recommend a basic walking program 15-20 minutes per day to burn off excess stress chemicals, improve his sleep hygiene, and use ice to calm the nervous system. That empowers the patient and teaches him that he can manage the pain himself. When we continue to talk about things that we need to do to him to fix him, we make him dependent upon us and perhaps elevate the importance of the pain in his mind. If there is nothing ominous about his exam, reinforce that the warning that he is getting from his trapezius is being over-reacted to by his brain.

It's a great course, as is Mobilization of the Nervous System, and that group is doing great work on researching the mechanisms behind chronic pain and how we can impact it.

I would like to address the highlighted quote above. I agree that patient empowerment is a key factor in treating patients with chronic symptoms, but I also think a good bit of this can be addressed during our communication with the patient, and how we discuss the interventions we do, or have the patient do. I use the attached diagram to show the multiple inputs that the brain is processing in order to determine the threat level, and the optons the brain has when it has determined that something may be threatening, with one of them being pain, and another important one being action plans (Or a motor/muscle output). So, if I choose to employ a manual therapy intervention, I discard all of the biomechanical mumbo-jumbo we were taught as an explanatory model, and use the work of Bialosky et al to explain how manual therapy may be of benefit of reducing the influence of one of the inputs the brain is processing as it assesses threat level, and then highlight that there are other inputs it is also processing. Notably, there are inputs the patient can impact themselves, such as anxiety and stress. Many patients come in to the clinic with stress/anxiety coping mechanisms already in place, but have not thought about hos they might be of benefit now that they are having a pain experience. If they don't have them in place, that in itself leads to a helpful conversation and an opportunity to educate the patient nad empower them.

My point here really, is that we do'nt have to discard some of the things we have seen work for us in the past, but we need to place them in a different context (which requires grounding them in more modern pain science) that allows for patient interaction, education and empowerment. I think Adrian, coming from a strong Maitland based manual therapy background, wouild likely agree.

 

[truthseeker]

I don't disagree Jess, I am not discounting the posture concept but that alone doesn't work all of the time. It does give the patient a better place to "be" if they are an accountant during tax season. The manual stuff can certainly be helpful in the short term but in my view, the patient should not be made or encouraged to think that the manual therapy is essential to their recovery.

Many of our colleagues and many practitioners of other health care professions fail to make this distinction.

 

[facetguy]

I don't disagree Jess, I am not discounting the posture concept but that alone doesn't work all of the time. It does give the patient a better place to "be" if they are an accountant during tax season. The manual stuff can certainly be helpful in the short term but in my view, the patient should not be made or encouraged to think that the manual therapy is essential to their recovery.

Many of our colleagues and many practitioners of other health care professions fail to make this distinction.

It's no more essential than anything else. But if it's what they need to move them forward then it's a good thing.

 

[jesspt]

I don't disagree Jess, I am not discounting the posture concept but that alone doesn't work all of the time. It does give the patient a better place to "be" if they are an accountant during tax season. The manual stuff can certainly be helpful in the short term but in my view, the patient should not be made or encouraged to think that the manual therapy is essential to their recovery.

Many of our colleagues and many practitioners of other health care professions fail to make this distinction.

I'm about the furthest person from the posture police you'll ever come across. I just think, having seen several people attend the NOI courses and struggle with how to impliement that valuable and paradigm shifting information into their clinical practice, that there is a tendency of those folks to move away from the things that have worked for them in the past. And, I think that many of those things can continue to be used and still be in line with the most recent pain science, and need not make the patient less empowered, or to cause them to think that manual therapy is the keystone to their recovery. There is an excellent blog post here, initally started by an excellent clinician/scientist by the name of Jason Silvernail, that does a better job of explaining my position that I have apparently done in my previous post. It's lengthy, but it is a great read.

 

[facetguy]

I'm about the furthest person from the posture police you'll ever come across. I just think, having seen several people attend the NOI courses and struggle with how to impliement that valuable and paradigm shifting information into their clinical practice, that there is a tendency of those folks to move away from the things that have worked for them in the past. And, I think that many of those things can continue to be used and still be in line with the most recent pain science, and need not make the patient less empowered, or to cause them to think that manual therapy is the keystone to their recovery. There is an excellent blog post here, initally started by an excellent clinician/scientist by the name of Jason Silvernail, that does a better job of explaining my position that I have apparently done in my previous post. It's lengthy, but it is a great read.

The blog you mentioned looks like interesting stuff. Thanks for the link.