Shoulder, Upper Back, and Upper Arm
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Chapter 5—Shoulder, Upper Back, and Upper Arm Pain 95
Anterior deltoid pain
pattern (p. 116) Teres major trigger points and referred pain pattern (p. 117)
Latissimus dorsi trigger points and referred pain pattern (p. 117)
Coracobrachialis trigger points and anterior referred pain pattern (p. 119)
Coracobrachialis posterior referred pain pattern (p. 119)
Biceps trigger points and referred pain pattern (p. 120)
Triceps number 1 trigger points and
referred pain pattern (p. 121) Triceps number 2 trigger points and referred pain pattern (p. 121)
Triceps number 3 trigger points and
Shoulder, Upper Back, and Upper Arm Pain
Muscles whose trigger points cause shoulder, upper arm, and upper back pain can be divided into five groups: sca- lenes, shoulder blade suspension muscles, rotator cuff muscles, upper arm muscles, and spinal muscles.
Although the scalenes are neck muscles, their trigger points cause a surprising amount of pain in the upper back, shoulder, and upper arm. Scalene trigger points also contribute significantly to pain and other symptoms in the forearm and hand. The scalenes are so important that they should always come first in troubleshooting pain in all these areas.
The shoulder blade suspension muscles are the rhomboids, levator scapulae, and trapezius. They suspend the shoulder blade from the spinal column, and their function is to help move the shoulder blade into position for all actions of the arm and hand. Their trigger points send pain mainly to the upper back and neck, referring only a minor amount to the shoulder. The trapezius and levator scapulae are discussed in chapter 4.
The four rotator cuff muscles are the supraspinatus, infraspinatus, teres minor, and subscapularis. They attach the shoulder blade to the top of the humerus, the upper arm bone. They rotate the arm and keep the shoulder joint together. Trigger points in the rotator cuff muscles cause a major portion of the pain in the shoulder, along with clicks and grinding noises and loss of mobility. They’re indirectly responsible for physical deterioration of the shoul- der joint and can predispose it to serious physical injury, including rotator cuff tears and dislocation (Simons, Travell, and Simons 1999).
Muscles that move the upper arm include the deltoids, teres major, latissimus dorsi, coracobrachialis, biceps, and triceps. Only the last three are actually part of the arm. In addition to pain in the shoulder, back, and upper arm, trigger points in these muscles can send pain and other symptoms to the forearm, hand, and fingers.
The spinal muscles interconnect the vertebrae and have no direct connection to the shoulder. While they’re a common source of upper back pain, they’re discussed in chapter 8 along with similar muscles of the mid- and low back.
Scalenes
The scalenes (SKAY- leenz) are a group of three, sometimes four, small muscles in each side of the neck. The word “scalene” comes from a Greek word meaning “uneven.” The scalene muscles are all of different lengths, like the sides of a scalene triangle. In addition, each scalene muscle divides to attach to several vertebrae, resulting in sets of muscle fibers of varying lengths. The scalenes can have many trigger points in many different locations. The following case histories are a sampling of the broad diversity of problems that can originate in the scalene muscles. In each case, self- applied trigger point massage solved the problem.
Betsy, age thirty- two, worked for the post office until someone rear- ended the vehicle she was driving. It was only a minor accident, but it left her with periodic disabling spasms in the right side of her neck. Almost any little strain would set it off. When she had a flare- up, she typically needed several days to recover. In the meantime, she was unable to work.
Hong Sun, age thirty- one, a ballet dancer, complained of a constant ache in his upper back at the inner edge of his left shoulder blade. It felt good to reach over his shoulder and massage the place with his fingers, but it didn’t stop the pain. He had had the pain for several years.
Amy, age seventeen, had been a serious student of the cello, but she quit playing because of weakness and numb- ness in her shoulders, arms, and hands. Her parents believed the problem might be related to an accident in the swimming pool that had strained her neck. Thousands of dollars’ worth of medical tests had turned up nothing.
Chapter 5—Shoulder, Upper Back, and Upper Arm Pain 97
Connie, forty- nine, a potter, experienced pain in her shoulder and all down her right arm. It was always worse in the morning and often awakened her in the night. Her forearm and hand were vaguely numb most of the time, and the hand often felt swollen. She was concerned that she wasn’t going to be able to continue her work and support herself if the trouble got any worse.
Symptoms
Trigger points in the scalenes cause an impressively wide distribution of pain, numbness, and other abnormal sensations in the chest, upper back, shoulder, arm, and hand (figures 5.1, 5.2, and 5.3). Pain may occasionally occur in the back of the neck (not shown). Any of the trigger points in the scalene muscles can cause symptoms in any part of the referral areas, though certain trigger points may favor certain areas. Trigger points low in the middle and posterior scalenes, for instance, are more often the ones that cause chest pain. Trigger points high in the ante- rior scalene and in the entire middle scalene are often the cause of pain in the shoulder, upper arm, forearm, thumb, and first finger. There is a fourth scalene that is only sometimes present. It creates pain in the upper arm, back of the forearm, wrist, hand, and all five fingers, especially in the thumb (Simons, Travell, and Simons 1999).
The scalenes are rarely suspected as the source of the trouble because they’re almost entirely hidden by the sternocleidomastoid muscles (figure 5.4). Pain is hardly ever felt in the scalenes themselves, but scalene trigger points can be the primary source of pain in their referral areas. Unsuspected scalene trigger points are often the critical element in the failure of conventional therapies. Satellite trigger points are likely to be created in scalene referral areas, which make scalene trigger points quite frequently the ultimate source of pain in the chest, upper back, shoulder, arm, and hand (Simons, Travell, and Simons 1999; Lindgren, Manninen, and Rytkonen 1996).
Symptoms created by the scalenes are easily misdiagnosed. Upper back pain evoked by scalene trigger points is almost always wrongly blamed on the rhomboid muscles. Restlessness in the neck and shoulder, a classic sign of scalene trigger points, is written off as a nervous tic. Pain referred from the scalenes to the chest is mistaken for
Figure 5.1 Scalene trigger points Figure 5.2 Scalene referred pain
angina. Pain sent to the shoulder by the scalenes is often mislabeled bursitis or tendinitis. Scalene- referred pain down the front and back of the upper arm is mistakenly treated as muscle strain. The pattern of scalene referral in the shoulder, arm, and hand may make a neurologist infer that a degenerated vertebra or collapsed disk is causing compression of a cervical nerve root (Simons, Travell, and Simons 1999; Long 1956). The scalenes will also reduce your ability to tilt your head to the side.
When trigger points shorten the scalene muscles, they tend to keep the first rib pulled up against the collar- bone. The collarbone squeezes the blood vessels and nerves that pass through the area on their way to the arm; this is termed neurovascular entrapment. This impeded blood flow and disturbance of nerve impulses causes pain, swelling, and burning in the arm, and numbness and tingling in the little finger side of the hand. The collection of symptoms caused by this compression of the nerves and vessels is properly termed thoracic outlet syndrome, although it is very often incorrectly diagnosed as carpal tunnel syndrome. Scalene- induced weakness in the forearms and hands that makes you unexpectedly drop things is likely to be ascribed to a neurological defect. Unexplained “phantom pain” in an amputated arm or hand can actually be coming from scalene trigger points (Simons, Travell, and Simons 1999; Sherman 1980).
Given that all these effects occur so far from their source and are so variable, it’s no wonder that their cause is misunderstood. Fortunately, once you do understand that all these things can be coming from the scalene muscles in your neck, the solution is remarkably simple and quick (Simons, Travell, and Simons 1999).
Causes
The scalene muscles attach to the sides of your neck vertebrae and to your top two ribs. The scalenes help stabilize, flex, laterally flex, and rotate the neck, though their main job is to raise the upper two ribs on each side when you inhale. They’re active to some degree in every inhalation, and they work extremely hard when your breathing is labored during vigorous activity, or during coughing and sneezing.
Habitual chest breathing instead of diaphragmatic breathing will overtax the scalene muscles. Simple nervous hyperventilation stresses them, too. People who are prone to emotional tension should expect to find tender trigger points in their scalene muscles. The struggle for breath in people who suffer from asthma or emphysema can promote scalene trigger points, as can a bad cough from pneumonia, bronchitis, allergies, or a common cold. Playing a wind instrument commonly fosters scalene trouble (Simons, Travell, and Simons 1999).
Many ordinary activities cause scalene trouble when overdone to the point of strain. Working for long hours with the arms out in front of the body can be very stressful for them, including working at the computer or driving a car. Pulling, lifting, and carrying heavy loads can be bad. Carrying a heavy backpack is especially rough for the scalenes and for several other muscles not designed for mule duty, such as the trapezius, pectoralis minor, and ster- nocleidomastoid. The scalenes are among the muscles most abused in sports activities. They are also very likely to initiate and perpetuate satellite trigger points in other muscles (Simons, Travell, and Simons 1999).
You can expect the violent movement of the head during a fall or an auto accident to bring about trigger points in the scalenes. Most of the muscles of the neck are severely affected by whiplash and are often overlooked in the treatment of pain from this type of injury. Apparent neurological symptoms in the upper back, shoulders, arms, and hands that mysteriously persist after an auto accident can often be traced to the scalenes (Simons, Travell, and Simons 1999).
Scalene muscles help manage the weight of the head. Anything that creates an imbalance puts an additional burden on them. For this reason, it’s wise to work to improve posture that may be holding the head off center. Slouching or habitually carrying your head forward is sure to keep trigger points going in these muscles (Simons, Travell, and Simons 1999).
Chapter 5—Shoulder, Upper Back, and Upper Arm Pain 99
Treatment
The front of the neck should be treated carefully, with awareness of the lymph nodes, arteries, and nerves. Read and follow the advice in chapter 3, Treatment Guidelines, before beginning, including the section “Contraindications: Reasons to Be Cautious,” which includes information on lymph nodes. The brachial plexus nerves and subclavian artery pass between the anterior and middle scalene muscles on the lower half of the neck. Don’t let yourself get too aggressive in this area by treating more than three times a day at first, and don’t press beyond a comfortable 5 on a scale of 1–10. It is possible to irritate the nerves and cause neuritis or inflammation of the nerves. Remember to stay off the pulse of the subclavian artery near the collarbone and familiarize yourself with the location of the carotid arteries as discussed under the sternocleidomastoid muscle section. The front-of- the-neck muscles are very important and doing the massage techniques correctly and with confidence will serve you well throughout your life. Follow the directions in this section to find and accurately massage the muscles.
When trigger points are present, scalene massage feels a little nervy and weird. So how do you know you are not pressing on a nerve? Well, you likely are. There are nerves everywhere throughout the body. You are sitting or standing on some right now. Nerves don’t usually cause intense sensation unless there is problem such as being pinched by a muscle or bone. If you press into a nerve that is severely entrapped (pinched by a muscle) or impinged (pinched by a bone), the sensation goes immediately from a 0 to a 10 on the pain scale. There is no middle ground and you can’t make the massage feel nice. If that happens in the neck, avoid the area and consult a physician, chiropractor, or physical therapist. There may be a bulging disk in the spine that’s causing trouble. Stimulating a less severely pinched nerve can cause numbness and tingling further down the nerves’ path, such as into the hand. Massage can help to release entrapped nerves.
Success in finding and dealing with the scalenes depends on your understanding of their relationship to the sternocleidomastoid muscle (figure 5.4). The anterior scalene, the front- most scalene muscle, lies between the ster- nocleidomastoid and the neck vertebrae and is almost completely hidden. The middle scalene is behind the anterior scalene, more on the side of the neck, with its lower half free of the sternocleidomastoid. The posterior scalene lies almost horizontally behind the middle scalene in the soft triangular depression just above the collarbone and below the front edge of the trapezius. A fourth scalene muscle, the
vertically oriented scalenus minimus, is found behind the lower portion of the anterior scalene. Not everyone has a scalenus minimus; it’s a normal human variation. You likely won’t be able to notice a difference between the anterior scalene and the scalenus minimus.
The scalenes cling closely to the bones of the neck. You may not be able tell that they are muscle tissue unless you contract them by taking several short repeated breaths; use this technique to confirm you are on the scalenes. When massaging the scalenes, you will be pressing them against the bony vertebrae behind them. Use only your fingers to massage the front of the neck.
To massage the anterior scalene, you have to get your fingers between the neck vertebrae and the ster- nocleidomastoid (SCM). See the sternocleido- mastoid section in chapter 4 to learn about how to find this muscle. To massage the anterior
Use only your fingers to massage the front of
the neck. Figure 5.4 Location of anterior, middle, and posterior scalene muscles behind the sternocleidomastoid
sternocleidomastoid anterior scalene middle scalene posterior scalene clavicle first rib second rib
scalene, first grip the SCM between the fingers and thumb, of the opposite hand, as if you were going to massage it. Then let go with your thumb and with your fingers pull the entire SCM about two inches toward the windpipe. The idea is to get your fingertips as far around in front of the vertebral column as you can, with the sternocleidomastoid pulled out of the way. In this posi- tion, you can press the anterior scalene against the vertebral column with the tips of your fingers (figure 5.5). You can also pull the SCM out of the way by turning your head to the opposite side. Then relax your neck by slightly tilting back to the same side you are treating.
This will not hurt unless you encounter a trigger point, in which case it can be extremely tender. Remember to make the massage feel “therapeuti- cally delicious” by experimenting with different amounts of pressure. It will be tender, but it should feel good. Pressure on a scalene trigger point can evoke a spooky kind of pain that will make you duck and cringe: it can feel like you’re pressing on a nerve (see below). At the same time, you may feel the referred pain or other symptom being reproduced or accentuated. This can be a very convincing demonstration of the reality of referred myofascial pain.
The massage stroke is executed by pressing with your fingertips as you push them across the muscle toward the side of the neck. The skin of the neck should move with the fingers. At the end of the stroke, which will be only half an inch long, release the pressure, reset your fingers where you began the stroke, and repeat. This procedure should be carried out all along the back edge of the SCM, from up under your jaw clear down to the collarbone. You may find some of your worst scalene trigger points behind the SCM where it attaches to the collarbone (figure 5.6). If this trigger point is bad enough, multiple angles of pressure might be beneficial. Turn your head to the opposite side to find the lowest part of the SCM. Place your finger just above the collarbone and to the outside of the SCM. Turn your head back to neutral, then press behind the col- larbone down toward your feet. After massaging at this angle, press toward your low back, then toward the upper back. Give each spot a few stokes of massage. Avoid pressing directly on the subclavian artery here by moving slightly up or to the side. Remember the rule: never massage a pulse. Clipping and filing your fingernails will make this more comfortable.
To massage the middle scalene, find the sternocleidomastoid muscle again. Grasp it with a pinch to find it, then let go with your thumb. Starting
just below the ear, press into the side of your neck. The bony knobs under your fingertips will feel bumpy and hard; that is because they are the transverse processes (or sides) of the vertebrae. They almost feel like a row of little midfinger knuckles down your neck. If your fingertips are to the back of these knobs you will be mas- saging the posterior neck muscles; if they are to the front of these knobby bones, you will be touching the middle scalene (figure 5.7). To confirm that you are on the middle scalene, take several short, quick, repeated breaths in a row to contract
it. On the side of the neck here, use Figure 5.7 Middle scalene massage
behind the sternocleidomastoid Figure 5.6 Anterior scalene massage
deep to the sternocleidomastoid attachment to the collarbone Figure 5.5 Anterior scalene
massage. Pull the sternocleidomastoid out of the way, firmly toward the windpipe.
Chapter 5—Shoulder, Upper Back, and Upper Arm Pain 101
Figure 5.8 Posterior scalene