Some ideas on the management of Tight Upper Traps

..after they’ve been unsuccessfully stretched, poked, zapped, taped, stabbed, scrapped and cupped.

This is a no-paywall blogpost with some (I think) valuable information. If you find this post of value, please consider ‘Buying Me A Coffee’ to say thanks and help me continue to be motivated to share everything I’ve learned in the clinic with the world for free.

Nick Ilic | Physio Clinician

Introduction

If you have a glowing red body part and you have not recently been abducted by aliens or had a radioactive implant please seek out a pharmaceutical company, they’ll use you as an actor without the need for future computer graphics to overlay glowing red body parts on people. This is a BIG money opportunity, you’re welcome.

Recently (but perhaps not) a pattern has emerged in the new patients that are coming to see me.

An epidemic of unresolved ‘Upper Traps Tightness’, however has everything thrown at it except a few important things.

Simply lean over against a doorway, put a firm object in your upper traps area, shrug your shoulder up against the firm object, and VOILA! you look silly.

The story remains the same:

“I’ve had 1–3 years of upper traps tightness/pain discomfort”

“I’ve seen 4–5 Physios”

“I’ve tried stretches, deep tissue massage, dry needling, shoulder strengthening, massage guns, ultrasound, tens machine”

“Nothing gets into that tightness like it used to, now I have to get someone to stick their knee in my upper traps to “release” the tightness”

Then after a bunch of important clinical questions from me that they usually haven’t been asked before and after a thorough assessment including things that they haven’t been assessed for before they sit back and say:

“Ummmm….why has no one asked me all those important things or assessed me like that?”

That’s a bloody good question.

However, let’s rewind and cover what I commonly see in patients who are fed up with their unresolved ‘Upper Traps (trapezius muscle) Tightness/Pain/Discomfort’ (abbreviated to UTT).

The Location

This fine specimen has a body fat index of 0.0% and the stock-standard glowing red radioactive trapezius muscles.

Lately it appears 1 in 3 “shoulder” issues that walk in the door are “neck”. Whether it’s the patient who doesn’t have the best grasp of anatomy, or it’s the previous HCP before them that has misinformed them, I’m not sure.

When I double-check with the patient that their “shoulder” issue is in fact their neck (pointing at the upper traps area) they usually initially look at me like I’m being an Obsessive Compulsive Anatomical Jerk, however it’s super important to know whether the ‘glenohumeral joint’ (shoulder) is actually fine because it allows the patient to continue with many things in life (gym, exercise, daily activities etc). So no! …. I will happily be seen as an Obsessive Compulsive Anatomical Jerk and clarify that is their neck not their shoulder. Concerningly I have seen several patients who are about to have ‘shoulder surgery’ to fix all the broken things in their ‘shoulder MRI’ when in fact their shoulder is fine on assessment, whereas their Neck is not fine and is causing pain in their upper traps area, and they had a GP or orthopaedic specialist who just didn’t confirm with the patient what the patient thinks is their “shoulder”.

It matters. It matters to me: The Clinician. It matters to them: The Patient. The deserve to know what is going on. Let’s not dumb all things down so meaning is lost.

I once had a patient with pain in this area, for them they called it “the shoulder”, and it had even slipped through from the GP to the shoulder surgeon who MRI’d their actual shoulder (glenohumearl joint) and was about to operate on it to repair the rotator cuff and a few other things on the MR image. Thankfully the patient saw me for a 3rd opinion….Their shoulder was completely fine on assessment. It was their neck. The patient was able to return to rock climbing and swimming, which they had been doing the entire time, not possible with a cranky glenohumeral joint, another reason to always listen to the patients story and also never assume the healthcare professional(s) before haven’t done a good job.

This is where the shoulder (glenohumeral joint refers). This is where the AC (shoulder) joint refers:

This is where the Cervical Spine refers (facet joints/intervertebral discs):

Yes there is some crossover between the Acromioclavicular (AC) joint, but the AC joint is quite easy to assess and there’s usually a clear mechanism of injury that indicates it being the issue.

As you can see in the above picture, anatomically the Neck and Shoulder are quite distinct. The traps area is shown in yellow and sits between the neck and the shoulder. The referral patterns picture on the right demonstrates that the traditional ‘shoulder’ (glenohumeral joint) only refers down (not up), the AC joint refers between the neck and shoulder, and the neck (cervical spine facet joints/intervertebral discs) refers to the shoulder but not past it (unless there is a radiculopathy occurring from cranky nerve roots).

If it travels away from the neck…

and down the upper limbs then it’s going to take some careful management as there’s likely a nerve or nerve root involved (stuff on radicular pain and radiculopathy coming below). If it follows any visceral referral patterns and there’s a medical history and symptoms associated with visceral issues, get a GP involved quick-smart!

Otherwise, let’s assume it’s just plain old Vanilla Upper Traps Tightness without any of the other jazz.

Scratching That Itch

Back to the Upper Traps Tightness (UTT)…..

Patients report they keep trying to scratch that itch but it gets harder and harder to do so and they end up with a home gym tool box that is full of every possible sharp pointy trigger point tool ever made.

The problem with scratching an itch is that it doesn’t address the problem that is causing the itch. Trust me, when a mosquito has bitten you on the leg, nothing feels better that giving it a quick but effective scratch after a while of trying not to, but then it’s addictive and you can’t stop, then eventually it’s as if nothing can relieve it so you try other modalities (ice, anti-itch creams (stingose) etc).

Same thing happens with these chronically “tight” areas (including Quadratus Lumborum (QL) and perhaps even glute and hip flexors). Yet it seems that very few stop the ask “hang on, what is CAUSING this itch?”

Charlie performs a self-release of his right upper trapezius muscle to create a short term PAWS in symptoms.

The Narrative

Narratives are important. We are a story-based species who have used stories and songs/lyrics to communicate important concepts through generations. It is often not the specific pathology that is remembered, but the metaphor or the narrative, nefarious examples include: “my rib is out, my pelvis is twisted, I’ve slipped a disc”… all of which don’t really happen but have been used to describe something to patients so often that they are now imbedded in society as ‘Science’.

The common narrative for ‘upper traps tightness’ is that the muscles are “really tight” usually accompanied by some creepy therapist feeling the muscles and verbalising the following:

“hmmmm hmmm so tiiiiight, feel thaaaaaat…. Woooowwww.. so tiiiiiight”.

This narrative suggests that you have muscles and they shorten or contract or shrivel up, perhaps so much that they literally form a “knot”. By jabbing, zapping, stabbing, scraping, poking them you can “release” them from their contracted state and they magically and suddenly “lengthen” and are no longer tight.

Abraham Lincoln once famously said (on a podcast) “don’t believe anything you read on the internet”

This narrative and the above picture is complete and utter pseudoscience.

Patients ask me all the time: “Can you feel that tightness”. My answer is the same: “No, but you can”.

Tightness is a feeling. Not a physical thing. There are no “knots”. “Knots” are a feeling.

The treatment for ‘tightness’ is another feeling, usually a mechanical stimulus put into the area by another human being or a little toy with a ball on it that goes in and out really fast and has as the very therapeutic branding: Massage Gun. Shooting healing bullets of magical myofascial release, for a low price of $399.

So what is my narrative and does it have any scientific basis behind it? What do I say after I’ve done an assessment and the patient asks “well what is that feeling of tightness there then?”

Well…. I’ll write down what the assessment typically looks like and then what I tell the patient and we can analyse it together for its credibility.

On Assessment

There are no restrictions from the upper traps at all, they feel like they are meant to, like a bunch of meat under skin. The shoulder (AC/GHJ) is completely fine. Then I get to the neck, I palpate around their C5-C7 area on the unaffected side, sometimes there is a mild pain, I tell them this is often normal. Then I swap sides, feel around C5-C7 on the affected side and they jump off the bed (or equivalent reaction) then say:

“THAT’S IT!! THAT REFERRED INTO MY UPPER TRAPS”

(or wherever their referral is)

Explanation/Narrative

“The tightness you feel in that area is a referred feeling or sensation from somewhere else. It is a feeling that does not exactly match the source of the referral. Much like when you put something very cold in your mouth you can experience pain in your head — an ice cream headache or brain freeze is a feeling (pain) from a different area (mouth) from a different stimuli (cold). Sometimes the nerves in our body create “fake news”. It is a referred sensation from a different area due to a stimulus and often the stimulus (cold food/drink) has nothing to do with the sensation (pain/tightness).”

Abraham Lincoln once famously said (in a Zoom interview) “I really like ice cream, and please don’t believe everything you read on the internet, especially Physio blogs”.

At this point, the patient is on board, you can see lightbulbs going off and a little bit of salivation because, hey, who doesn’t like ice-cream.

Once I have them entrapped with their engagement, I satisfy their curiosity:

“The cervical spine refers sensations (including pain/tightness/discomfort) in known referral patterns based on the level of the irritation.”

I show them this picture.

“For you, you have upper traps area tightness, well guess what….. look at where the cervical spine refers to”

At this point I have to wear PPE, head to toe and cover the room in cling-film (ala Dexter) because their minds literally blow.

Marrying the Narrative to Medical Pathophysiology

As my medical cousins (aka doctors) know, the majority of UTT symptoms are as a result of Neck Pain or ‘non-specific Neck Pain’, neck pain that came seemingly out of nowhere with no definite structural cause. If there is any referral down the upper limbs towards the hand it is termed Radicular Pain and if there are any neurological symptoms associated with it, it is termed a Radiculopathy (literally “problem with nerve root”). Many of these have no mechanism of injury.

A 2021 Physiotherapy management of Neck Pain review by Verhagen summarised where we’re at nicely.

Many patients feel like Neck pain is a problem with their “Posture”.

What they all have in common is:

The pain seemingly started from nowhere, or there was a change in how much they move and load their upper limbs/neck/upper back in life, whether they suddenly were doing nothing or they were suddenly doing a lot, then their neck pain started.

Whatever it is, whenever someone with upper traps tightness comes to me and it has a Cervical Spine influence (99% of the time), I don’t pretend to be a hero for the next 2–3 months and try to manage it on my own, I get help from their GP. I will refer to their GP and ask for help via oral NSAIDS (usually Meloxicam or something similar) for at least 2 weeks.

Areas with lots of joints in a small area and frequent movement (hands/feet/spine) need extra help to calm down most of the time, of course it depends, but for someone who has had long-term (>3 months) upper traps tightness or cervical spine referred pain they usually need pharmaceutical assistance. There’s been a few cases of long-term neck issues that simply needed oral NSAIDS but those patients were of the “I don’t do drugs” sort and took some convincing that “there is a time and a place in the right patient, and it’s you”.

Drugs! Glorious Drugs! … for the right patient at the right time with the right prescription and weaning off plan.

The other area that can help with the cervical spine is the thoracic spine.

Much like having stiff hips can eventually overload the lumbar spine. Having stiff thoracic spine (particularly extension and rotation) can stir up the lower cervical spine. Most patients drool and go “ooooo that feels so good” when you examine their thoracic spine range of movement into extension and rotation. My management of necks revolves around “not poking the angry bear” (poking the neck) and instead hammering away at the thoracic spine whilst waiting for the neck to settle down with a multi-pronged management program consisting of not only oral anti-inflammatories and mobility but also addressing stress/sleep. This approach is reflected by the evidence outlined in the previously mentioned 2021 Physiotherapy Management of Neck Pain review.

Here is some examples of mobility exercises that can assist:

Marrying Medical Pathophysiology with the PsychoSocial Factors

If there is a part of the body that is influenced by the BioPsychoSocial model it’s the neck/cervical spine. Followed closely by the shoulder and the lower back/lumbar spine, the Cervical Spine is a part of the body that be very influenced by LIFE STUFF, especially Stress and Sleep.

Often I will ask patients:

“Does your upper traps tightness/neck pain get worse when your pain-in-the-ass Ex is in town”

Of course, they say “yes”.

“Do your symptoms get worse when you have poor sleep quality?”

Of course, they say “yes yes yes!”

“What is stopping you from getting good sleep quality?”

Usually, “life”.

Many find it difficult to turn their mind off, to destress before bed. Or they deploy short-term fixes such as Alcohol to take the edge off which helps them get to sleep, but then inevitably leads to worse sleep quality.

Poor sleep quality is one of the biggest prognostic factors with cervical spine dysfunction, by prognostic I mean, once you have neck pain or upper traps tightness, poor sleep quality is one of the biggest factors that can prolong the condition.

More and more I am recommending that patients address their stress and their sleep quality with exercise, clinical psychologist referral or smartphone meditation apps that have simple breathing exercises that help ‘switch the mind off’ (meditate) to reach a restful state faster and have a better sleep quality.

Ironically, many have stopped regular exercise that they like because they’ve been told my well-meaning health professionals that it will make it worse. Some thought it was their shoulder so they stopped swimming (which can be great for upper backs and necks) or as already mentioned, they just didn’t know where a neck refers vs where a shoulder refers. Which is again why it is so important to educate the patient and provide sound activity modification advice.

You can always try horizontal rock climbing… less impressive but it’s all about perspective.

Finally, one of the biggest hurdles that can impact on pain and dysfunction is incorrect negative beliefs about pain and dysfunction. When someone with a small niggle see’s a health professional who labels them as “weak, unstable, tight” (et cetera) patients can experience a phenomenon called a NOCEBO. Being told that something is a problem and it will take a while and a bunch of appointments to fix ends up turning something (that is not a big problem and only needs a few appointments with a good clinician) into a big problem. It is the opposite of Placebo. Therefore, time may need to be taken to re-educate the patient on their condition and reassure them that:

“no.. your posture isn’t the worst I’ve ever seen”

“yes… you will be able to exercise again”

“no.. if you don’t do deep neck flexor exercises your head won’t fall off”

Even the use of the term “Whiplash” in ‘trauma-related neck pain’ can itself be nocebic.

Posture

“What about Posture? I’ve been told by….” (list of HCPs and also also non-professionals) “…that my posture is terrible”.

Frankly, for the majority of neck pain and upper traps tightness, I don’t care about posture.

The common saying these days is “it’s not the position you’re in, it’s how long you’re in it for” and “the next posture is your best posture”. The key message is: There are other drivers of neck/upper back pain that are much more significant than how you sit, however the more you move in life generally the better you are. However I also noticed that it’s not “BAD posture” (whatever that is) that causes neck pain and stress, it’s stress and neck pain that causes “BAD posture” (whatever that is).

Deep Neck Flexors

What about all the Deep Neck Flexor exercise that we were told to do all the time?

Haven’t done any of that stuff in years and patients are getting better regardless.

Much like everywhere else in the body, if a patient is painful and they are weak near their painful site it’s more likely (but not always) due to inhibition rather than actual weakness. I’ve monitored my patients for the past several years and they have more force production from their deep neck flexors once their pain settles down. Did they get stronger? No, there were just able to produce force because of less pain.

So do I still do manual therapy then?

Yep, …usually. The patient usually wants it even though they understand it’s

1. Short-term pain relief only

2. Not doing anything specific

I make sure they know those two important things because I (and all HCPs) am legally bound to gain Informed Consent by the patient for any intervention. By saying anything otherwise I feel that I am lying to them and deceiving them.

I am 100% on board with give the patient some short-term pain relief, but only after we have discussed and planned out everything else as discussed already.

If the patient is happy to not have anything done to them, I’m happy to not do it. Most of my patients are just keen to get going with the program/multi-modal approach, after all, they’ve already had pretty much all hands-on techniques already done to them.

For those that do want something, normally I will work around the neck rather than on it, maybe I’ll do some gentle lateral cervical glides (in the direction of the painful side, from the non-painful side). Do some general mobilising of the thoracic spine (for extension and rotation gains). Maybe some gentle traction and SNAGs if the patient seems to have a strong need for manual therapy in the first 1–2 sessions.

Can we do better in this area, as a Trade?

We can always to better in every area (is the politically correct answer). However, we must choose narratives that closely match the science, “tight muscles” in this situation isn’t one, “Knots” and the Clinicians ability to feel them certainly not.

Ensure the patient has enough time when they have a complex condition. This may require some sort of triage system by the admin team or the Clinician when the patient books in. The majority of patients I see these day with any complex condition such as Neck Pain, Low Back Pain, Patellofemoral Pain, Tennis Elbow and perhaps Rotator Cuff Related Shoulder Pain (or whatever we’re calling Sub-Acromial Pain now), require at least 30–40mins to take a full history, do a comprehensive assessment, fully explain to the patient what is going on in a way that they understand and answer questions (and also explaining any relevant diagnostic imaging findings they may have in context to their assessment findings)….. and that’s before I even touch them.

There will be MANY MANY factors associated with Neck pain which will require time to listen to the patient and cover everything relevant in the FIRST appointment. The above picture is for low back pain but it’s pretty similar to neck pain. The article is https://pubmed.ncbi.nlm.nih.gov/31092123/ Cholewicki J, Breen A, Popovich JM Jr, Reeves NP, Sahrmann SA, van Dillen LR, Vleeming A, Hodges PW. Can Biomechanics Research Lead to More Effective Treatment of Low Back Pain? A Point-Counterpoint Debate. J Orthop Sports Phys Ther. 2019 Jun;49(6):425–436. doi: 10.2519/jospt.2019.8825. Epub 2019 May 15. PMID: 31092123; PMCID: PMC7394249.

Fortunately for me I get 60mins for initial consults and I can then do perhaps 15mins of treatment in the first session whilst also chatting to them about life and consolidating on the advice/education I’ve given them then spend 10mins on a tailored physio program that I email to them after their appointment which covers all the main points discussed in the appointment including any exercise prescription.

This Physio has just gotten to work and is already upset as their first 9am patient (first of 22+ patients) for the day has called to say they’re running 5–10mins late for their 20min review appointment.

Patients with persistent UTT often report to me that the previous HCPs they’ve seen (usually they’ve seen 3–4 other physios at least) rush through assessment and education in order to get to treatment, and that’s probably where we see the Nocebic Narratives begin: “you have upper traps tightness, I need to release it, you need to stretch it, see me again in 1–2 weeks for more of the same”.

There is a saying/sad joke/study of “patients understand ½ of what is said and only remember ½ of that” is a common one in healthcare. Some patients require extra time to digest and consolidate in their mind what is being said and have the time to ask questions…. in the first appointment. The physio or clinician will feel like they’ve been understood, but in reality, probably not.

One of the most valued services the patients report is an email they get following their appointment which summarises all the main points discussed during the initial appointment, including the “diagnosis” (if there is one, these days I’m just calling things “cranky joints/nerve roots” etc. as it’s difficult to be accurate/precise), the management plan, any referral recommendations (GP, Psych, Dietitian, EP, Massage etc.), and any exercises including pictures and prescription. Again, I’m fortunate, I get 60mins (45-50mins with the patient, 10–15mins to do admin and emails), however, open disclosure, I take a paycut to see less patients (for longer) in the workday which I’m extremely happy to do in order to get good patient outcomes.

Summary

Neck pain and upper traps tightness is an evolving area in medicine when it comes to what is causing it and what are we doing about it.

I think upper traps tightness is just a sensation (feeling) referred from nearby spinal joints.

I think there are better outcomes using a multi-modal approach (manual therapy, mobility and strength exercises, oral anti-inflammatories, addressing stress/sleep etc) targeting those joints and any nerve root irritability rather than just hammering away at the area of “tightness” and trying to stretch it away. I know the Physiotherapy Trade will yell “yes, we know multi-modal works and that’s what we do”, but from what I hear from patients there are many HCPs out there not doing it or the patients are led to believe it’s a “upper traps tightness” problem.

I think patients are often short-changed with a rushed musculoskeletal healthcare service that is full of nocebic narratives that do more harm than good and perhaps contribute to chronic pain and increased healthcare burden. Especially when coupled with diagnostic imaging that is not explained to the patient in context with their assessment findings allowing them to walk away catastrophizing about every “disc bulge” and “degeneration” finding in the imaging report, some of which may be normal asymptomatic findings (symptom-free) associated with age.

We can always do better.

Did you enjoy this blog or learn something new that will help you with your clinical practise?

Are you a patient and has this helped you in some way?

‘Buy Me A Coffee’ to say thanks and help me continue to be motivated to share everything I’ve learned in the clinic with the world for free.

https://www.buymeacoffee.com/nickilicphysio