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Head, Neck and Shoulder Pain: How Trapezius Plays a Roll

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By: David Kent, LMT, NCTMB

When clients enter complaining of headaches, neck and shoulder pain it is easy to show them that their pain is a “symptom” of a bigger problem. Educating clients about the muscular components of their pain, often determines if they reschedule and refer their family, friends and coworkers. This article will review a few of the trigger point (TrP) patterns of the trapezius muscle and its involvement in various postural patterns.

Trigger Points:

Trigger points form in muscles for a reason and are often a result of trauma or stress. Poor posture can place a great deal of structural stress on the trapezius muscle. The human head is heavy and designed to be support by the bones of the cervical spine. Remember, muscles determine where bones are held in space. So a client with a forward head and rounded shoulder posture, has shortened muscles on the front of the body with over lengthened muscles on the back. The pains or “symptoms” are their headaches, neck and shoulder pain and we want to educate our clients on how we can address the cause.

When clients report that they have a headache that starts in their temple, deep in the head or behind the eye that continues behind their ear and into the back and side of their neck, they are describing TrP # 1 pattern of the trapezius muscle, which is one of the most common TrPs in the body (See Photo 1). Showing clients this pattern on a trigger point chart lets them know you understand the pain they are reporting and have a plan to help. This TrP forms from acute trauma from a whiplash, sustained shoulder elevation from holding a telephone to the ear, working on a keyboard that is too high, compression on the muscle from the shoulder strap of a heavy back pack or the pressure of a bra strap. Skeletal anomalies like a short lower limb or a hemipelvis should also be ruled out.

Commonly overlooked, is TrP 3 in the lower trapezius that refers a deep aching tenderness above the scapula that causes clients to report a “soreness” in the region of the upper trapezius. The pattern typically runs from the base of the occiput out laterally to the acromial process (See Photo 2). TrP1 and TrP 2 in the upper trapezius often develop as satellites within this zone of pain and tenderness that is usually referred from the lower trapezius TrP 3”1

Trigger points in middle and lower trapezius are often a result of tight pectoral muscles that should be released.

Posture:

The human body is designed with a great deal of symmetry or balance and has the same bones and muscles on both sides. Muscles on the front and back of the body counter balance each other. Addressing the cause of your client’s pain requires a whole body approach. Postural analysis is a great tool to document and educate your clients.

Muscles are like guide wires and determine where the bones are moved or held in space. When the bones and joints are properly aligned on the coronal, midsaggital and transverse horizontal planes the muscles are under minimal stress. To demonstrate this to your clients, first use muscular and skeletal charts to show the proper postural alignment of the body. Then review photos taken of your client in front of a postural analysis chart to show them which muscles are shortened, which are over lengthened and the unnecessary stresses being placed on their body causing pain. (see Photo 3)

Let your client’s know you will design a treatment plan to address their pain. Educate them on postural distortions like: forward head, high shoulder, forward rounded shoulders, collapsed abdominal posture, the position of the pelvis, anatomical deviations and more are not an isolated phenomena and cause the formation of trigger points and pain throughout the body.

David Kent, LMT, NCTMB, is an international presenter, product innovator and writer. His clinic, Muscular Pain Relief Center, is in Deltona, Florida, where he receives referrals from various healthcare providers. David is President and Founder of Kent Health Systems which teaches Human Dissection, Deep Tissue Medical Massage and Practice Building seminars, and has developed a line of products, including the Postural Analysis Grid Chart™, Trigger Point Charts, Personalized Essential Office Forms™, and DVD programs. Visit www.KentHealth.com or call (888) 574-5600 for more information.

1 Simons DG, Travell JG, et al. Myofascial Pain and Dysfunction: The Trigger Point Manual, volume 1, 2nd ed. Williams and Wilkins: 1999.

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Back Pain from Gluteus Medius Trigger Points

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By: David Kent, LMT, NCTMB

Each week, I treat several clients who complain of “low back pain.” For many patients, however, the primary cause of pain is not the lower back but the gluteus medius muscle. No matter what kind of massage practice you have, a great deal of your success will depend on how quickly you are able to determine the origin of a patient’s complaint and your ability to produce measurable results. This article will review some ways to identify when the gluteus medius muscle is responsible for causing pain.

Anatomy:

The gluteus medius muscle lies superficial to the gluteus minimus muscle and deep to the gluteus maximus muscle. Proximally, it attaches along the external surface of the ilium between the anterior and posterior gluteal lines. Distally, it attaches to the lateral surface of the greater trochanter of the femur (See Photo 1).

The gluteus medius muscle “abducts the hip joint; the anterior fibers medially rotate and may assist in flexion of the hip joint; [and] the posterior fibers laterally rotate and may assist in extension.”1 It also helps to keep the pelvis level when the opposite leg is raised during activities such as walking, running, or standing on one leg.

Intake and History:

The first step to designing and implementing an effective treatment plan is to understand the client’s medical history and current circumstances. Utilizing health history intake forms will help you gather the appropriate information; they will also reveal important factors that could be relevant to a patient’s condition.

Using pain scales to document a client’s pain patterns are beneficial, as well. Ask the client to color the diagram form illustrating where on the body he/she experiences pain. Then ask the client to add modifiers that adequately describe the pain, followed by a number from 1-10 to rate its intensity (See Photo 2 ). This diagram provides a helpful visual tool that you can reference during the session. You will also see how pain patterns often match common trigger point patterns, which are discussed in more detail below.

Ask the client if any of his/her daily activities are affected by the pain. If the answer is yes, ask the client which muscles hurt, what movements aggravate the pain, and what he/she believes caused the pain. Ask if the client has recently started or modified an exercise program. Answers like walking, running, tennis, aerobics and other types of activities may indicate gluteus medius involvement. Has the client had any falls or sustained any hip injuries? What is the client’s occupation? Does the client place a wallet or tools in a back pocket? All of these questions will help you narrow down the origin of pain. (Read “Questions with Direction,”)

Gait & Postural Analysis:

Observe the client as he/she walks. A painful or “weak gluteus medius muscle forces the client to lurch toward the involved side to place the center of gravity over the hip; such movement is called an abduction, or gluteus medius lurch.”2

Show your client the relationship between posture and pain, and describe how you can help. Just like chiropractors advertise free “spinal exams” to attract new patients, you could provide free postural analysis to attract new clients. Market the postural analysis as a value that you include during the initial visit; then include a second postural analysis taken upon completing a series of treatments. This is a great way to sell packages, and it also demonstrates postural progress. (Read “Getting Comfortable with Postural Analysis,”) When conducting a postural analysis, look for signs of gluteus medius muscle involvement. Shortness of the gluteus medius muscle “may be seen as a lateral pelvic tilt, low on the side of tightness, along with some abduction of the extremity.”3

Trigger Points

“Myofascial trigger points (TrPs) in the gluteus medius are a commonly overlooked source of low back pain.”4 There are three trigger points frequently identified in the gluteus medius muscle. TrP1 (See Photo 1) is located lateral and superior to the posterior superior iliac spine (PSIS) just below the iliac crest. TrP1 refers pain and tenderness over the sacrum, above the iliac crest into the lumbar region, and throughout the gluteal region on the same side of the body as the trigger point.

TrP2 (See Photo 1) is positioned midway between the anterior superior iliac spine (ASIS) and the PSIS just below the iliac crest. “Pain referred from TrP2 is projected more laterally and to the midgluteal region; [and] may extend into the upper thigh posteriorly and laterally.”5

TrP3 (See Photo 1) is rarely present and can be located just posterior to the ASIS and just below the iliac crest. Referred pain is primarily produced over the sacrum bilaterally.

Educate your clients about trigger points. Use wall charts or flip charts to demonstrate their location on the body. Using charts and other aids will not only help the client, but it will also build your credibility with the client. This is also an excellent time to explain how the muscle affects posture.

Pain is a symptom. As massage therapists, our job is to address the cause of the pain and work to prevent its return. Educate your clients. Discuss proper ergonomics, stretching and strengthening. Identifying the gluteus medius as a source of back pain is easy once you have the knowledge.

David Kent, LMT, NCTMB

David Kent, LMT, NCTMB, is an international presenter, product innovator and writer. His clinic, Muscular Pain Relief Center, is in Deltona, Florida, where he receives referrals from various healthcare providers. David is President and Founder of Kent Health Systems which teaches Human Dissection, Deep Tissue Medical Massage and Practice Building seminars, and has developed a line of products, including the Postural Analysis Grid Chart™, Trigger Point Charts, Personalized Essential Office Forms™, and DVD programs. Visit www.KentHealth.com or call (888) 574-5600 for more information.

1, 3 Kendell FP, McCreary, et al. Muscle Testing and Function with Posture and Pain, 5th ed.  Lippincott, Williams and Wilkins: 2005.

2 Hoppenfeld S. Physical Examination of the Spine & Extremities. Appleton & Lange: 1976

4 Simons DG, Travell JG. “Myofascial Origins of Low Back Pain, 3: Pelvic and Lower Extremity Muscles,” Postgrad Med 73:99-108, 1983.

5 Simons DG, Travell JG. Myofascial Pain and Dysfunction, The Trigger Point Manual: The Lower Extremities, 2. Lippincott, Williams and Wilkins: 1992

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