Trapezius Myalgia

Definition/Description[edit | edit source]

Trapezius muscle (highlighted in green) - posterior view

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.[1]
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[2]

Clinically Relevant Anatomy[edit | edit source]

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.[3]

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 [edit | edit source]

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. [4]

More research is required to conclude that computer work alone increases the risk of developing musculoskeletal disorders. [5]
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.[6]

Epidemiology[edit | edit source]

Persistent TM concerns 10-20% of the 20% of the adult population with severe chronic pain in the neck and shoulder region. [7] The persistent form of TM also shows a higher prevalence in women, but also in low-income groups. [8]

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.[8]

Characteristics/Clinical Presentation[edit | edit source]

Typical symptoms of “myalgia” are:

  • Sudden onset of pain[1]
  • Muscle stiffness and spasms[1]
  • Tightness of the neck-shoulder complex[1]
  • Heaviness of the head and occipital headache
  • Tenderness of the upper trapezius area[1]

Other symptoms:

Persistent TM can cause pain and stiffness after periods of inactivity. The pain usually eases after reasonable exercise.[11]

Differential Diagnosis[edit | edit source]

TM can be diagnosed when neck pain, muscle tightness, and trigger points are present, but tension neck syndrome or cervical syndrome is not present.[4]

Other pathologies that can cause similar symptoms are:

Diagnostic Procedures[edit | edit source]

The basis for diagnostic criteria of neck and shoulder myalgia is not very clear and the diagnostic terminology and methods for assessment are variable.[4]

  • 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[12]
  • Use of diagnostic injections (if qualified to do so)[12]
  • Referral to orthopaedic consultant if no improvement in symptoms with conservative management[13]

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[edit | edit source]

Visual analogue scale[11]
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)[14] [15] [16]
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) [17][18] [16]
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)[19] [18] [16]
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.[19]

Examination[edit | edit source]

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.[20]

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 [21]

Patients suffering from TM can present with neck pain, headaches, tightness of the trapezius muscle and palpable trigger points.[21] [22]

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.[23]

Medical Management[edit | edit source]

  • Analgesia
  • Ergonomic advice[24]
  • Referral to physiotherapy[25]
  • Injection therapy[25]
  • Radiofrequency denervation[25]

Physical Therapy Management[edit | edit source]

Prevention[edit | edit source]

Raising awareness for at risk groups of people:[25]

  • Repetitive movement jobs[4]
  • Sedentary jobs (computer work)[5]
  • High work demands
  • Work posture
  • Vibration
  • Stress[6]
  • Low activity level outside of work[25]
  • Gender (women)[8]

Exercise Therapy[edit | edit source]

Different forms of exercise is recommended for acute or persistent neck pain. [25]

Physical activity and exercise have been proven to give the most immediate and long-term pain relief in patients with TM[26]. Both general fitness training and specific strength training generate significant effects on decreasing pain[27]. 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.[28] [29][30]

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.[31]

  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. [32]

Psychosocial involvement[edit | edit source]

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. [6]

Manual Therapy[edit | edit source]

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.[33][34]

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.[35]

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.[33]

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.[24] [36][33]

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.[33][36]

Clinical Bottom Line[edit | edit source]

Trapezius Myalgia is rather a symptom of an underlying problem than the problem itself and is often categorised with neck and shoulder disorders[13]. 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[edit | edit source]

This 2-minute video is a good overview of the trapezius muscle.[37]

References[edit | edit source]

  1. 1.0 1.1 1.2 1.3 1.4 De Meulemeester K, Calders P, De Pauw R, Grymonpon I, Govaerts A, Cagnie B. Morphological and physiological differences in the upper trapezius muscle in patients with work-related trapezius myalgia compared to healthy controls: A systematic review. Musculoskeletal Science and Practice. 2017 Jun 1;29:43-51.
  2. Trapezius muscle (highlighted in green) - posterior view image - © Kenhub
  3. Simons SM, Dixon JB. Physical examination of the shoulder. Up-To-Date Online. 2013 Nov.
  4. 4.0 4.1 4.2 4.3 Larsson B, Søgaard K, Rosendal L. Work-related neck/shoulder pain: a review on the magnitude, risk factors, biochemical characteristics, clinical picture, and preventive interventions. Best Practice & Research Clinical Rheumatology. 2007 Jun 1;21(3):447-63.
  5. 5.0 5.1 Wærsted M, Hanvold TN, Veiersted KB. Computer work and musculoskeletal disorders of the neck and upper extremity: a systematic review. BMC musculoskeletal disorders. 2010 Dec;11(1):79.
  6. 6.0 6.1 6.2 Burton AK. Back injury and work loss: biomechanical and psychosocial influences. Spine. 1997 Nov 1;22(21):2575-80.
  7. Gerdle B, Ghafouri B, Ernberg M, Larsson B. Chronic musculoskeletal pain: a review of mechanisms and biochemical biomarkers as assessed by the microdialysis technique. Journal of pain research. 2014;7:313.
  8. 8.0 8.1 8.2 Marker RJ, Balter JE, Nofsinger ML, Anton D, Fethke NB, Maluf KS. Upper trapezius muscle activity in healthy office workers: reliability and sensitivity of occupational exposure measures to differences in sex and hand dominance. Ergonomics. 2016 Sep 1;59(9):1205-14.
  9. 9.0 9.1 Sjörs, A., Larsson, B., Persson, A. L., & Gerdle, B. (2011). An increased response to experimental muscle pain is related to psychological status in women with chronic non-traumatic neck-shoulder pain. BMC Musculoskeletal Disorders, 12(1). doi:10.1186/1471-2474-12-230
  10. Larsson, R., Öberg, Å. P., & Larsson, S.-E. (1999). Changes of trapezius muscle blood flow and electromyography in chronic neck pain due to trapezius myalgia. Pain, 79(1), 45–50. doi:10.1016/s0304-3959(98)00144-4 
  11. 11.0 11.1 Waling K, Sundelin G, Ahlgren C, Järvholm B. Perceived pain before and after three exercise programs–a controlled clinical trial of women with work-related trapezius myalgia. Pain. 2000 Mar 1;85(1-2):201-7.
  12. 12.0 12.1 12.2 Pateder DB, Berg JH, Thal R. Neck and shoulder pain: differentiating cervical spine pathology from shoulder pathology. Journal of surgical orthopaedic advances. 2009;18(4):170-4.
  13. 13.0 13.1 13.2 13.3 Mitchell C, Adebajo A, Hay E, Carr A. Shoulder pain: diagnosis and management in primary care. BMJ: British Medical Journal. 2005 Nov 12;331(7525):1124.
  14. Hawker GA, Mian S, Kendzerska T, French M. Measures of adult pain: Visual analog scale for pain (vas pain), numeric rating scale for pain (nrs pain), mcgill pain questionnaire (mpq), short‐form mcgill pain questionnaire (sf‐mpq), chronic pain grade scale (cpgs), short form‐36 bodily pain scale (sf‐36 bps), and measure of intermittent and constant osteoarthritis pain (icoap). Arthritis care & research. 2011 Nov 1;63(S11):S240-52.
  15. Melzack R. The McGill Pain Questionnaire: major properties and scoring methods. Pain. 1975 Sep 1;1(3):277-99.
  16. 16.0 16.1 16.2 OHLSSON K, ATTEWELL RG, JOHNSSON B, AHLM A, Skerfving S. An assessment of neck and upper extremity disorders by questionnaire and clinical examination. Ergonomics. 1994 May 1;37(5):891-7.
  17. Macdermid JC, Walton DM, Avery S, Blanchard A, Etruw E, Mcalpine C, Goldsmith CH. Measurement properties of the neck disability index: a systematic review. Journal of orthopaedic & sports physical therapy. 2009 May;39(5):400-C12.
  18. 18.0 18.1 Gay RE, Madson TJ, Cieslak KR. Comparison of the Neck Disability Index and the Neck Bournemouth Questionnaire in a sample of patients with chronic uncomplicated neck pain. Journal of Manipulative and Physiological Therapeutics. 2007 May 1;30(4):259-62.
  19. 19.0 19.1 Bolton JE, Humphreys BK. The Bournemouth Questionnaire: a short-form comprehensive outcome measure. II. Psychometric properties in neck pain patients. Journal of manipulative and physiological therapeutics. 2002 Mar 1;25(3):141-8.
  20. Chida Y, Steptoe A. Positive psychological well-being and mortality: a quantitative review of prospective observational studies. Psychosomatic medicine. 2008 Sep 1;70(7):741-56.
  21. 21.0 21.1 Sjøgaard G, Søgaard K, Hermens HJ, Sandsjö L, Läubli T, Thorn S, Vollenbroek-Hutten MM, Sell L, Christensen H, Klipstein A, Kadefors R. Neuromuscular assessment in elderly workers with and without work-related shoulder/neck trouble: the NEW-study design and physiological findings. European Journal of Applied Physiology. 2006 Jan 1;96(2):110-21.
  22. Hadrevi J, Ghafouri B, Larsson B, Gerdle B, Hellström F. Multivariate modeling of proteins related to trapezius myalgia, a comparative study of female cleaners with or without pain. PLOS one. 2013 Sep 4;8(9):e73285.
  23. Castelein B, Cools A, Bostyn E, Delemarre J, Lemahieu T, Cagnie B. Analysis of scapular muscle EMG activity in patients with idiopathic neck pain: a systematic review. Journal of Electromyography and Kinesiology. 2015 Apr 1;25(2):371-86.
  24. 24.0 24.1 Holtermann A, Søgaard K, Christensen H, Dahl B, Blangsted AK. The influence of biofeedback training on trapezius activity and rest during occupational computer work: a randomized controlled trial. European journal of applied physiology. 2008 Dec 1;104(6):983-9.
  25. 25.0 25.1 25.2 25.3 25.4 25.5 Jensen, IreneHarms-Ringdahl, Karin et al. Strategies for prevention and management of musculoskeletal conditions. Neck pain. Best Practice & Research Clinical Rheumatology , 2007 Feb;21(1):93-108.
  26. Nielsen PK, Andersen LL, Olsen HB, Rosendal L, Sjøgaard G, Søgaard K. Effect of physical training on pain sensitivity and trapezius muscle morphology. Muscle & Nerve: Official Journal of the American Association of Electrodiagnostic Medicine. 2010 Jun;41(6):836-44.
  27. Andersen LL, Kjaer M, SØgaard K, Hansen L, Kryger AI, Sjögaard G. Effect of two contrasting types of physical exercise on chronic neck muscle pain. Arthritis Care & Research: Official Journal of the American College of Rheumatology. 2008 Jan;59(1):84-91.
  28. Rodrigues EV, Gomes AR, Tanhoffer AI, Leite N. Effects of exercise on pain of musculoskeletal disorders: a systematic review. Acta ortopedica brasileira. 2014 Dec;22(6):334-8.
  29. Hagberg M, Harms-Ringdahl K, Nisell R, Hjelm EW. Rehabilitation of neck-shoulder pain in women industrial workers: a randomized trial comparing isometric shoulder endurance training with isometric shoulder strength training. Archives of physical medicine and rehabilitation. 2000 Aug 1;81(8):1051-8.
  30. Zebis MK, Andersen LL, Pedersen MT, Mortensen P, Andersen CH, Pedersen MM, Boysen M, Roessler KK, Hannerz H, Mortensen OS, Sjøgaard G. Implementation of neck/shoulder exercises for pain relief among industrial workers: a randomized controlled trial. BMC musculoskeletal disorders. 2011 Dec;12(1):205.
  31. Ylinen J, Hakkinen A, Nykanen M, Kautiainen H, Takala E. Neck muscle training in the treatment of chronic neck pain: a three-year follow-up study. Europa medicophysica. 2007 Jun 1;43(2):161.
  32. Andersen LL, Blangsted AK, Nielsen PK, Hansen L, Vedsted P, Sjøgaard G, Søgaard K. Effect of cycling on oxygenation of relaxed neck/shoulder muscles in women with and without chronic pain. European journal of applied physiology. 2010 Sep 1;110(2):389-94.
  33. 33.0 33.1 33.2 33.3 Vernon H, Schneider M. Chiropractic management of myofascial trigger points and myofascial pain syndrome: a systematic review of the literature. Journal of manipulative and physiological therapeutics. 2009 Jan 1;32(1):14-24.
  34. Chow RT, Johnson MI, Lopes-Martins RA, Bjordal JM. Efficacy of low-level laser therapy in the management of neck pain: a systematic review and meta-analysis of randomised placebo or active-treatment controlled trials. The Lancet. 2009 Dec 5;374(9705):1897-908.
  35. Nunes AM, Moita JP. Effectiveness of physical and rehabilitation techniques in reducing pain in chronic trapezius myalgia: A systematic review and meta-analysis. International Journal of Osteopathic Medicine. 2015 Sep 30;18(3):189-206.
  36. 36.0 36.1 Aguilera FJ, Martín DP, Masanet RA, Botella AC, Soler LB, Morell FB. Immediate effect of ultrasound and ischemic compression techniques for the treatment of trapezius latent myofascial trigger points in healthy subjects: a randomized controlled study. Journal of manipulative and physiological therapeutics. 2009 Sep 1;32(7):515-20.
  37. Trapezius muscle image - © Kenhub