Trapezius Myalgia

Original Editor - Lauren Trehout

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Definition/Description

Myalgia is generally known as a muscle ache or muscle pain.

Trapezius myalgia (TM) is the complaint of pain, stiffness, and tightness of the upper trapezius muscle. It is characterised by acute or persistent neck-shoulder pain.
TM is not a medical disorder or disease but rather a symptom of an existing underlying condition. The pain in the muscle can last a few days or longer.

Image: Trapezius muscle (highlighted in green) - posterior view

Clinically Relevant Anatomy

Trapezius muscle

Trapezius is a large fan-shaped muscle that extends from the cervical to thoracic region on the posterior aspect of the neck and trunk and attaches onto the clavicle and scapula.

It consists of three parts with different actions:

• Superior fibres of Trapezius - elevates the shoulder girdle.
• Middle fibres of Trapezius - retracts the scapula
• Inferior fibres of Trapezius - depresses the scapula

Typically the area of pain involved with TM is the superior fibres of the trapezius.

Aetiology/Epidemiology 

Monotonous jobs with highly repetitive work, forceful exertions, high level of static contractions, prolonged static loads, constrained work postures or a combination of these factors are possible causes of neck and shoulder disorders (which include TM) in the working population.

More research is required to conclude that computer work alone increases the risk of developing musculoskeletal disorders.
As recent research suggests with most musculoskeletal conditions there is a strong relationship between psychosocial factors and the occurrence of TM. There is some evidence that there is a link between TM and other social issues such as: lack of support from colleagues, mental stress at work and low influence.

Epidemiology

Persistent TM concerns 10-20% of the 20% of the adult population with severe chronic pain in the neck and shoulder region. The persistent form of TM also shows a higher prevalence in women, but also in low-income groups.

Gender seems to play an important role in the development of neck disorders since the prevalence is much higher among women. Women more often experience neck pain and develop persistent pain than men do. This difference might be explained by the content of their jobs. Women’s work tasks involve more static load on the neck muscles, high repetitiveness, low control, and high mental demands, which are all risk factors for developing neck disorders.

Characteristics/Clinical Presentation

Typical symptoms of “myalgia” are:

• Sudden onset of pain
• Muscle stiffness and spasms
• Tightness of the neck-shoulder complex
• Heaviness of the head and occipital headache
• Tenderness of the upper trapezius area

Other symptoms:

• Low mood
• Anxiety
• Paresthesia

Persistent TM can cause pain and stiffness after periods of inactivity. The pain usually eases after reasonable exercise.

Differential Diagnosis

TM can be diagnosed when neck pain, muscle tightness, and trigger points are present, but tension neck syndrome or cervical syndrome is not present.

Other pathologies that can cause similar symptoms are:

• Cervical spondylosis
• Cervical osteoarthritis
• Cervical radiculopathy
• Thoracic Outlet Syndrome
• Shoulder pathology - including rotator cuff pathology and shoulder osteoarthritis
• Polymyaglia rheumatica

Diagnostic Procedures

The basis for diagnostic criteria of neck and shoulder myalgia is not very clear and the diagnostic terminology and methods for assessment are variable.

• Thorough subjective assessment
• Objective assessment - including neurological exam, and shoulder assessment
• Imaging studies - can be useful if no improvement in symptoms, neurological symptoms or if red flags present
• Use of diagnostic injections (if qualified to do so)
• Referral to orthopaedic consultant if no improvement in symptoms with conservative management

In general, no objective diagnostic methods are available specifically for TM. The diagnosis is mostly based on symptom presentation and history of illness.

Outcome Measures

Visual analogue scale
This scale measures visualises to what extend the patient experiences pain or another sensation. It is a 100mm line on which the patient need to draw a perpendicular line to indicate how he experiences pain. On the left is the minimum score of 0 meaning ‘no pain’ and on the right, stands the maximus score of 10, which means ‘unbearable pain’.

McGill pain questionnaire (MPQ)
The MPQ is a subjective questionnaire used to asses the quality and intensity of pain in patients with a number of diagnoses.

Neck disability index (NDI) 
The NDI is a questionnaire that inquires the functional status of a patient concern the following 10 items: pain, personal care, lifting, reading, headaches, concentration, work, driving, sleeping and recreation.

Neck Bournemouth Questionnaire (NBQ)
The NBQ is administered to patients with non-specific neck pain. It assesses pain, disability, effective and cognitive aspects of the neck pain. The questionnaire contains seven items: pain intensity, function in activities of daily living, function in social activities, anxiety, depression levels and fear avoidance behaviour. The NBQ has been shown to be reliable, valid, and responsive to clinically significant change in patients with non-specific neck pain.

Examination

Subjective assessment is vital in assessing the condition history, potential cause and severity. It is also necessary in order to assess the patient's outlook and mental well being, which is a good indicator for prognosis and recovery in all types of injury or illness.

Outcome measures can be used at the initial assessment to indicate severity and impact on the patient's well being and quality of life (as noted in the Outcome measures section).

Objective examination of the neck and upper extremities can be useful for diagnosing TM or exclude other pathologies. This should include:

1. Cervical and shoulder range of movement (active and passive)
2. Muscle strength
3. Palpation
4. Neurological exam

Patients suffering from TM can present with neck pain, headaches, tightness of the trapezius muscle and palpable trigger points.

A surface electromyography can be done to evaluate muscle function. Parameters that can be studied are amplitude, timing, conduction velocity, fatigability and characteristic frequencies/patterns.

Medical Management

• Analgesia
• Ergonomic advice
• Referral to physiotherapy
• Injection therapy
• Radiofrequency denervation

Physical Therapy Management

Prevention

Raising awareness for at risk groups of people:

• Repetitive movement jobs
• Sedentary jobs (computer work)
• High work demands
• Work posture
• Vibration
• Stress
• Low activity level outside of work
• Gender (women)

Exercise Therapy

Different forms of exercise is recommended for acute or persistent neck pain.

Physical activity and exercise have been proven to give the most immediate and long-term pain relief in patients with TM. Both general fitness training and specific strength training generate significant effects on decreasing pain. However; strength training has been proven to be more effective compared to general fitness training.

High-intensity strength training relying on principles of progressive overload for 20 minutes has been shown to be successful in reductions of neck and shoulder pain.

Following a specific neck strengthening exercise program for up to 1 year can lead to long term reduction and further prevention of recurring pain even after the strength program has ceased.

1. Shoulder shrugs:
   The subject is standing erect and holding the dumbbells to the side, then elevates the shoulders while focusing on contracting the upper trapezius muscle.
2. One-arm row:
   The subject bends their torso forward to approximately 30° from horizontal with one knee on the bench and the other foot on the floor. The subject now pulls the dumbbell towards the ipsilateral lower rib, while the contralateral arm is maintained extended and supports the body on the bench.
3. Upright row:
   The subject is standing erect and holding the dumbbells while the arms are hanging relaxed in front of the body. The dumbbells are lifted towards the chest in a vertical line close to the body while flexing the elbows and abducting the shoulder. The elbows are pointing out- and upwards.
4. Reverse flies:
   The subject is prone on a bench at a 45° angle from horizontal and the arms pointing towards the floor. The dumbbells are raised until the upper arm is horizontal, while the elbows are in a static slightly flexed position (~5°) during the entire range of motion.
5. Lateral raise:
   The subject is standing erect and holding the dumbbells by their side, and then abducts the shoulder joint until the upper arm is horizontal. The elbows are in a static slightly flexed position (5°) during the entire range of motion.

Exercise has been shown to increase blood flow and therefore oxygenation to areas of the body with increased anaerobic muscle metabolism.

Psychosocial involvement

The possible presence of psychosocial causative factors in patients with TM should be considered from the outset. Explanation of pain and the influence of psychosocial factors should also be included in the treatment of TM alongside exercise therapy.

Manual Therapy

There is moderate evidence available for short-term relief of myofascial trigger points by Transcutaneous Electro Nerve Stimulation (TENS), acupuncture and magnet or laser therapy.

Some studies have shown that in the short term acupuncture/dry needling can have the largest effect on pain. There is no evidence of effective treatment to reduce pain in the intermediate and long term periods.

There is conflicting evidence as to whether ultrasound therapy is no more effective than a placebo or somewhat more effective than other therapies in the treatment of myofascial trigger points. Ultrasound can therefore be used as a therapeutic modulation, but is not recommended.

Biofeedback training can also be useful in the treatment of work-related neck and shoulder pain. A study has shown that six weeks of biofeedback training resulted in less pain and neck disability than active and passive treatment, which remained at 6 months post-intervention in the control.

Ischaemic compression, stretching of the upper trapezius muscle, and transverse friction massage are manual techniques to help patients with TM. These techniques appear to have instant improvement on pain. Long-term effects have not yet been well investigated.

Clinical Bottom Line

Trapezius Myalgia is rather a symptom of an underlying problem than the problem itself and is often categorised with neck and shoulder disorders. The typical symptom of a patient with TM is pain in the upper fibers of trapezius that can linger for a few days to weeks but can also be persistent in nature. This pain is often associated with spasms, stiffness, and tenderness in the neck region. Trigger points can also be present and can cause headaches.

Both biomechanical and psychosocial factors can contribute to the development and persistence of TM.
Radiography, MRI, electromyography, nerve conduction studies or blood tests could be done to rule out other conditions, but are not standard procedure.

Physiotherapy is the main treatment method and exercise therapy is highly recommended including healthy lifestyle advice. In conjunction with an exercise program, manual therapy can be used for short term benefits in pain relief.

Resources

This 2-minute video is a good overview of the trapezius muscle.