Massage Therapy Treatment of the Upper Trapezius, Anatomy, Myofascial Pain

Although the upper trapezius is only a division of the entire trapezius muscle, it is being treated as a single muscle because it has a distinct and different function, as well as a stand-alone clinical presentation than the other divisions of the muscle (middle and lower trapezius).

The upper trapezius has been termed the “coat hanger” muscle (Travell), as it suspends the shoulder girdle from the axial skeleton like a coat hanger hangs a suit jacket from a coat stand.

Anatomy

Attachment points: Medial third of the superior nuchal line of the occiput, spinous processes of the cervical vertebrae 2 through 5, proceeding laterally to attach onto the lateral 1/3 of the clavicle (Travell).

Actions: The upper trapezius elevates the scapula and rotates it so that the glenoid fossa rotates upward during glenohumeral abduction. It can also extend the cervical spine and sideflex it ipsilaterally (Travell).

Postural Effects: Chronic tension in the upper trapezius tends to elevate the shoulders, draw the head forward and the occiput downward, causing the neck to lose vertical dimension and creating pressure on the discs and facet joints in the neck (Liebenson).

Signs and Symptoms of Dysfunction

The upper trapezius is often placed in a shortened position by poor ergonomics (Travell). In particular, chair elbow rests that are too high, or resting the elbows on a desk often creates a shortness in the muscle that is present long after the person walks away from the desk or chair.

This can be made worse if we have a weak core. If our spinal muscles are not strong, then we will not have the strength to hold ourselves up, and we tend to use our shoulder girdle muscles to do so, either at desks or even as we stand and walk around (Rolf)!

The upper trapezius is also a secondary muscle of respiration (Lewitt). When we take a deeper breath than normal, or when breathing is difficult, we tend to ask the upper trapezius (as well as the scalene and sternocleidomastoid muscles) to help out by pulling the rib cage upward, to open the chest and draw in more air.

People with a history of asthma and/or other breathing problems often have a long-standing pattern of upper trapezius tension as a result of the effort required to breathe!

The upper trapezius can also be activated by stressful thoughts and feelings (Hanna).

When we feel under threat mentally and/or emotionally our shoulders tend to automatically rise to protect our head and neck.

This was learnt in an evolutionary sense a long time ago when stressful situations were physically threatening in which we had to defend our very lives (Hanna).

Although most of us are not under direct physical threats, our bodies tend to respond as if we were!

Another source of upper trapezius tension is when we have neurological irritation in the upper extremity (Butler). The nerves to the arms and hands travel in the space between the clavicle and the first rib. If we have tingling and/or numbness in the arm or hand, it is often relieved by lifting the clavicle off the nerves that run under it.

Sometimes upper trapezius tension will not settle down until the compression and/or irritation of these nerves is resolved (Butler).

Assessment

The size and shape of the upper trapezius can often be seen through a client’s shirt, or directly in people wearing a low-neck line. If your client has the upper trapezius development of a body builder and they don’t lift weights, then they probably lift their shoulder girdles daily through the upper trapezius assisting their tense breathing!

It is important to look for upper trapezius recruitment during normal “relaxed” breathing. If the shoulders and/or chest rise with each inspiration then the upper trapezius (and sternocleidomastoid and scalene muscles) are over-active. Sometimes you can even see the upper trapezius contracting with each breath a client takes!

One can also assess the upper trapezius role in common movements. For example, when you hand the case history form to your client, does their shoulder rise upward when they are reaching forward? If it does, then they have an overactive upper trapezius.

Monitoring scapulo-humeral rhythm during shoulder abduction can formally test upper trapezius function (Kasman). The initial part of this movement should be purely glenohumeral motion. Then, at a certain point (commonly 35 – 60 degrees), the shoulder girdle should rise as the upper trapezius is activated to upwardly rotate the glenoid fossa to allow further abduction. If this movement occurs early or tends to predominate during shoulder abduction, then the client has an overly active upper trapezius.

The length of the upper trapezius can be assessed by stabilizing the shoulder while side-bending the spine away from the shoulder, and then turning the head back toward the direction you originally took the client away from (ie. Contra-lateral side-flexion and ipsi-lateral rotation).

This rotary movement turns the attachment line along the medial third of the superior nuchal line away from the attachment point along the shoulder.

The last - but by no means least important - assessment is palpation. Allow your fingers to thoroughly explore the bulk of the upper trapezius where the neck and shoulder join each other.

Is this muscle more or less developed than other muscles in the client? What is its texture? Is it soft and pliant at rest, or is it extremely dense and hard or rubbery? Is its texture uniform, or does it have taut bands and/or dense spots within more softly textured neighboring tissue?

Challenge any distinct densities with firm, yet sensitive pressure to determine whether they may be myofascial trigger points that refer pain to the side of the neck and head, or even into the temple (Travell). Every massage therapist ought to commit to memory the pattern of upper trapezius trigger point referral since it is so common.

As you are palpating the upper trapezius you might even feel its tone increase and then fall with each breath your client takes!

Any of these findings indicate that the trapezius is hypertonic and may be causing the client pain, compressing their neck and/or perpetuating tense thoughts and feelings.

Treatment

My initial intervention with a hypertonic upper trapezius is often a blending or entrainment.

I place my hands in contact with the contour of the muscle and allow the muscle to cycle in tone with the client’s breathing.

After a few breaths, I often exaggerate the increase in tone with inhalation and the relaxation with exhalation by squeezing my client’s upper trapezius gently as they breathe in and then broadening and flattening their upper trapezius as they exhale.

In this way I acknowledge the importance of the muscle to their breathing as well as emphasize the relaxation that tends to occur on exhalation.

After entraining with my client’s upper trapezius, my second approach is often to perform some soothing Swedish massage techniques to the muscle. This is usually a flowing effleurage that runs along the sides of the neck and over the shoulders, and up the back of the neck.

I do this two handed with the client’s head and neck in neutral (see the three images at right).

After they settle into this pattern of movement, I usually proceed, unilaterally, allowing the client’s head and neck to gently roll with the massage movement.

At this point I often need to coach them in letting go of the neck and allowing me to move them passively.

This can be very difficult for some people. The more difficult it is for them to allow their necks to be moved passively, the more unconscious and entrenched their tension is.

If the client does let go during the previous interventions, or at least allows their upper trapezius to release enough to allow my movement, I tend to proceed to exploring the muscle with petrissage manipulations.

This includes a wide variety of kneading using my thumbs, fingers, and the flats of my phalanges, palms and gentle knuckles (see 3 images at right).

It is also important to eventually focus on the spots in the muscle with higher tone. These are the motor unit territories that tend to recruit early during use of the muscle and not turn off very quickly after the movement is done.

They will also be activated when the client has tense thoughts and feelings. Helping the client find a way to drop the resting tone in these areas of the muscle will help them let go of their characteristic patterns of tense thoughts and feelings.

Conversely, if a person finds it extremely difficult to let go of tense thoughts and feelings, they may not be able to relax their upper trapezius muscle at all! This can become a referral issue to a talking therapy professional.

Trigger points in the upper trapezius can be treated with a variety of manipulations depending on the client’s desire for them to be treated, and their responsiveness to manipulation. Common interventions include precise kneading, ischemic compression (see image at right) and myofascial stripping.

When the tone has been dropped in the upper trapezius it is usually important to restore a longer resting length to the muscle. This can sometimes be achieved by simply depressing the shoulders. Shoulder girdle depression can be coupled with a bit of cervical traction to decompress the neck.

The muscle may need to be orthopedically stretched by placing it in a stretch position. This can be accompanied by gentle to gently ruthless stripping manipulations. Make sure you give the muscle a sustained stretch for at least 30 seconds to help reset the tone and length in it!

Homecare

Appropriate homecare prescription requires a good handle on what has set up and/or perpetuated the upper trapezius tension. If it is simply an ergonomic issue, then guidance about not resting the elbows on high surfaces and readjusting elbow rests and desk heights may be enough.

If the tension is really embedded in the upper trapezius the client will often need to perform sustained stretching to the muscle to begin to teach it to relax.

It is important to tell people they might not feel any or much improvement with stretching the muscle for a week or two, but then when they return for their next massage (in a week or two), they will likely be more able to relax the muscle during treatment!

If your client is using their upper trapezius for “normal relaxed” breathing, then they will likely need to begin to recruit their diaphragm muscle more when they breathe.

This can be done through you coaching them in abdominal breathing and having them practice it (see image at right). Let them know that sometimes people are made more anxious by paying attention to their breathing and that if this is the case, they should not pursue it at the current time.

Sometimes breathing with a sandbag resting on the abdomen is necessary to cue their body awareness into the action of the diaphragm and to strengthen it (see image at right). The stronger the diaphragm is, the more likely they are to use it day to day!

Occasionally, other interventions may need to be considered. If the tone is really high in the upper trapezius, sometimes it won’t drop unless neighboring muscles join in the process. Treating the sternocleidomastoid and scalene muscles often helps the whole “team” of respiratory muscles to relax.

Sometimes the upper trapezius is so dominant, that only by activating the lower trapezius through exercise will the upper trapezius be inhibited and allowed to relax.

When the client has tingling and/or numbness in one or both arms and/or hands when the shoulder girdle rests in a neutral position, this will need to be treated before the upper trapezius will relax.

This may mean a lot of massage and self care focus to the forearms and/or hands, or sometimes releasing the scalenes so they don’t pinch the nerves. Sometimes a client will need support and/or intervention from another professional whether it is a manual therapist, such as a physiotherapist or chiropractor, or a psychologist or social worker.

Conclusion

I hope you have more awareness and skills when approaching your clients’ upper trapezius muscles after this brief article. There is usually so much going on when the upper trapezius is short and high-toned that we need never be bored again by “just another” head, neck and shoulder massage!

Biography

Doug Alexander has been absorbed in releasing upper trapezius tension in himself and others for several decades! He is the editor of Massage Therapy Practice.com and teaches at Algonquin College in Ottawa, Canada. Doug can be reached at alexander2000@sympatico.ca

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