The good news about the confusing conglomeration of symptoms generated by sternocleidomastoid trigger points is that you can fix them yourself in the simplest way.
One of the first rules of massage therapy is “never massage a pulse.” That simple rule will keep you out of trouble. First, let’s locate the carotid artery so you can avoid massaging it. While sitting or lying down, use your fingertips to gently feel for the pulse on one side of your
neck just under the jaw and to the outside of the windpipe. This place is okay to touch if done gently, but deeper pressure can potentially cause big problems. On both sides of the windpipe, this is the location of not only the carotid artery but also the carotid sinus with it. The carotid sinuses house baroreceptors that sense and regulate blood pressure. Massage or compression of one of the carotid sinuses can cause a sudden uncontrollable drop in blood pressure leading to dizziness, fainting, and falling. Aggressive pressure to other areas of the carotid arteries can loosen plaque and lead to a stroke. It is also possible that if one artery is blocked with plaque (arteriosclerosis) and you massage the opposite or good artery, you can cut off blood to the brain, also causing sudden dizziness, fainting, and falling. The body has multiple blood vessels that take blood to the brain just in case one is blocked or damaged, but it is always wise to avoid pressing on them. If you feel dizzy while checking your pulse or massaging this muscle, stop immediately and consult a doctor. If you cannot feel your own pulse because your fingers are not sensitive enough (due to calluses, diabetes, or lack of sensation), stay off the front of the neck.
While being cautious of the arteries, it is possible to massage this important muscle safely. After finding the carotid artery, simply replace the fingers with your thumb, move the thumb to the outside slightly, and grasp all of the tissue to the outside of the pulse. If you pinch the sternocleidomastoid, rather than press it against the side of the neck, you will stay off of the arteries. Treat only one side at a time and remain alert to the necessity of avoiding the pulse.
Turn your head to the opposite side while looking in the mirror, and you will see the sternal branch contract. Grasp it with your fingers and thumb in a pinch and turn your head back to a neutral position
to relax the muscle for massage. Press only hard enough so that it feels comfortable as you try to discriminate between the two branches of the muscle. The sternal branch is superficial to the clavicular branch. Each is about as big around as your index finger. If you pay close attention, you should be able to feel them separately. To squeeze the deeper, or clavicular, branch, take a bigger grasp of the side of the neck. Many people make the mistake of moving their fingers too
Treatment Tips
First, gently identify and then avoid the pulse in the neck, as directed in the text. Grasp this muscle with your thumb and fingers curled into a “C” shape rather than straightened in a “V” shape. You should use only the tips of your fingers.
Milk the SCM with short, repeated up-and- down strokes. Lighten your pressure if you slip off and strum the muscle.
Keeping your face looking forward, tilt your head slightly down and to the same side as you massage the SCM.
The first rule of massage therapy is “never massage a pulse.”
far back to include the back of the neck. Think of the clavicular head as “deep to” not “behind” the sternal branch. To make sure you are still on the SCM, turn your head to the opposite side again. The SCM is nearly everything you can pinch on the side of your neck. As you pull forward with your grip, you will roll off the deep branch. As you do this you may be able to feel a slight trough between it and the superficial, or sternal, branch. After popping off the sternal branch, you will feel only skin and the platysma muscle. To search for trigger points in each branch, start in the middle and work your way up behind your earlobe, and then all the way down to your collarbone (figures 4.4, 4.5, and 4.6). Use your same side hand to best access the deeper clavicular branch. As you work, your other arm can support your elbow and make this technique easy and relaxing.
If your sternocleidomastoid muscles hurt when squeezed, they’re almost certain to be involved in that chronic headache or whatever other symptom you may be having in your head, face, or jaws. When sternocleidomastoid trigger points are bad enough, a little squeeze will actually reproduce or accentuate a frontal headache, giving you a very convincing demonstration of what trigger points do.
Don’t be afraid of these muscles. They may be very tender to massage initially, but you can’t do them any harm. To the contrary, every gentle squeeze you give them will be of benefit. It may seem like a dumb idea to massage such tender areas. Just go easy at first, and work at a pressure level that feels good, or “therapeutically delicious.” Your symptoms may disappear in a very short time, but continue working the trigger points repeatedly and patiently over several days until you can no longer find a place that hurts. Sternocleidomastoid massage often makes a headache better almost immediately. The same is true for dizziness and many other sternocleidomastoid symptoms.
Trapezius
The word trapezius (truh- PEE- zee- us) comes from the Greek word for “small table,” a reflection of the muscle’s relative flatness and four- cornered shape. Although the trapezius is located on the upper back and functions mainly to move the shoulder, it appears in this chapter because its trigger points are a primary source of headaches and neck pain.
Sternocleidomastoid massage between fingers and thumb (Important! Read “Treatment” section first.)
Chapter 4—Head, Face, and Neck Pain 67
Symptoms
Trapezius number 1 (figures 4.7 and 4.8) is located in the very topmost fibers of the thick roll of muscle on top of the shoulder. It’s not deep in the body of the muscle. Most people can find it only by pinching a tiny roll of tissue right where the shoulder joins the neck (the angle of the neck). On heavier or more muscled bodies, this roll of muscle can be as big as a magic marker. Nearly everyone has trapezius number 1 trigger points. It’s the primary cause of a temple headache but may also send pain to the masseter muscle at the angle of the jaw, up the side of the neck behind the ear, and deep behind the eye. Occasionally, pain occurs in the back of the head and in an arch over the ear (not shown). Their effects are most often identified as a tension neck ache. This point can restrict rotation and sideways flexion of the head to the opposite side. Additionally, it’s capable of inducing satellite trigger points in muscles in the temple and jaw, making it an indirect cause of jaw pain and toothache (Simons, Travell, and Simons 1999).
Trapezius number 2 (figure 4.9) is actually a pair of trigger points an inch or two apart deep in the roll of muscle on top of the shoulder. You may have either one or both. These two are a primary cause of pain in the back of the neck and the base of the skull, which may be felt as either a headache or a sore neck. This referred pain very often induces satellite trigger points in the muscles of the back of the neck. When neck massage feels good but doesn’t get rid of the pain, the problem may be in the trapezius muscles, not in the neck. This point can also restrict rotation and sideways flexion of the head to the opposite side.
Figure 4.7 Trapezius number 1 trigger
point and referred pain pattern: front view Figure 4.8 Upper trapezius number 1 trigger point and referred pain pattern: side view
Figure 4.9 Upper trapezius number 2 trigger points and referred pain pattern
Trapezius number 3 (figure 4.10) trigger points can be found along the inner (or medial) border of the shoulder blade, just down from where the edge of muscle crosses onto the shoulder blade, about halfway up from the inferior angle.
The upper trigger point is an extremely common primary trigger point. It refers pain to back of the neck and base of the skull like the trigger points in the upper trapezius. It’s one of the many causes of a stiff neck. It can also send referred pain to the upper trape- zius itself. Satellite trigger points produced in these two places can in turn be the cause of headache. This cascade, or domino effect, of myofascial trigger points is one reason headaches have been so hard to under- stand and treat effectively. The lower point can also cause an oppressive ache or burning pain in the midback and an aching pain in the top of the shoul- der. This top of shoulder pain can also be coming from local trigger point number 6 (see figure 4.13). When trigger points weaken the lower trapezius muscles, they may contribute to making the shoulder blades stick out in back, a condition called “winging” (Simons, Travell, and Simons 1999).
Trapezius number 4 (figure 4.11) trigger point is located on the shoulder blade itself, overlying the infraspinatus muscle. This trigger point can create an aching pain just off the inner edge of the shoulder blade.
Trapezius number 5 (figure 4.12) trigger point occurs next to the inner border of the shoulder blade in the broad middle part of the trapezius. It causes a burning kind of pain nearby, alongside the spine. Superficial trigger points in this area can cause goose bumps on the back of the upper arm and sometimes, oddly, on the thighs (Simons, Travell, and Simons 1999).
Figure 4.10 Lower trapezius number 3 trigger points and referred pain pattern
Figure 4.11 Trapezius number 4 trigger point and referred pain pattern
Figure 4.12 Middle trapezius number 5 trigger point and referred pain pattern
Eventually you will feel so good that you will begin to forget to do your self-care. This is a good sign but watch out. The pain may come back because of unreleased latent trigger points.
Chapter 4—Head, Face, and Neck Pain 69 Trapezius number 6 (figure 4.13) is a trigger point
located on the upper shoulder at the acromion, the outer part of the shoulder blade. This point may be over trigger point 1 in the supraspinatus muscle or can appear independently. Note that this trigger point causes local pain and can be a satellite of the lower trapezius number 3 point.
The symptoms generated by trapezius trigger points are widely misinterpreted, producing a whole catalog of misdiagnoses and misdirected treatments. You may be told your symptoms are from spinal disk compression, spinal stenosis, bursitis of the shoulder, or neuralgia. Headaches caused by trapezius trigger points may be labeled as tension, cervicogenic, vascular, cluster, or migraine when their true cause is not understood. Although there are serious medical causes of head- aches, an examination for trigger points should be near the top of any doctor’s list (Simons, Travell, and Simons 1999).
Causes
The trapezius covers most of the upper half of the back, extending upward to cover the central part of the back of the neck. This uppermost part of the trapezius is what gives the back of the neck its shape. The muscle attaches to the base of the skull, the spine, the collarbone, and the shoulder blades. The trapezius supports the weight of the shoulders and must contract strongly to rotate the shoulder blade every time you raise your arm above shoulder height. Another primary function is to hold the shoulder blade solidly in place as a base for the finer operations of the arm and hand.
The uppermost part of the trapezius helps support the weight of the head and neck when you bend your head forward or to the side. It also contracts when you raise the shoulder toward the ear or the ear down to the shoulder, as when lying down on the opposite side. Faulty posture, such as slouching while seated or habitually carrying your head forward, places an unnecessary burden on your trapezius muscles, generating trigger points. Shortened pec- toral muscles, indicated by a round- shouldered posture, exert a steady pull on the shoulders that the trapezius muscles must constantly counteract. This can perpetuate an overstretched and weakened trapezius that is suscep- tible to developing satellite trigger points from the mechanical strain produced by short, tight pectoral muscles. Shortened abdominal muscles can also pull the torso down, creating a rounded-shoulder, forward- head posture. The trigger points in the rectus abdominis can thus be the primary points leading to a headache! Sounds crazy doesn’t it? Massage and stretch your abdominal and pectoral muscles to treat your headache if the trapezius massage does not give you lasting relief.
Trigger points are produced in all parts of the trapezius by a job that requires working with the arms held out in front of the body for extended periods of time. You subject your trapezius muscles to constant strain when you sit without elbow support. At the computer or any other desk job, use a chair with arms whenever possible. It’s not enough to rest your arms on the desk. Heavy- breasted women may be especially vulnerable to any of the many trapezius symptoms. The strain of supporting heavy breasts can make trapezius trigger points hard to get rid of. Carrying a heavy backpack or a heavy purse hanging from a shoulder strap can be the simple explanation for that recurring migraine or chronically stiff neck (Simons, Travell, and Simons 1999).
Another common cause of trapezius trigger points is the emotional tension that keeps your shoulders up. It is a good practice to purposefully let your shoulders drop down multiple times during the day. Put a sticky note where you can see it to remind you. Chapter 12, Muscle Tension and Chronic Pain, has a systematic approach to con- scious relaxation that you incorporate into your daily life.
Figure 4.13 Upper trapezius number 6 trigger point and referred pain pattern
Treatment
Trapezius number 1. It’s important to understand that trapezius number 1 in the angle of the neck is often found right under the skin. The taut band that contains the trigger point feels like a knitting needle between your fingers. It usually takes only a shallow pinch to take hold of it for most folks. Heavily muscled and generously proportioned people will find this trigger point in a larger denser roll of muscle as big as a magic marker at the same junction. Using your opposite hand, massage the trapezius by rolling it between your thumb and first two fingers (figure 4.14). A good, strong squeeze of trape- zius number 1 may reproduce or accentuate a temple headache, which veri- fies it as the cause. Virtually everyone has this trigger point, and it causes an incredible amount of grief. If this technique is too hard on your hands, try using a modified pinch with a ball against a wall (figure 4.15).
Trapezius number 2. These two trigger points (figure 4.9) can also be pinched using the opposite hand. Make sure your thumb is in front of and beneath the big roll of muscle at the top of your shoulder. In other words, pinch with a big bite from the very front, about an inch above the collar- bone. The first, more medial, point is right in the middle, while the second, or lateral, point is an inch or two more toward the outside. Remember that medial means toward the midline and lateral means toward the outside of the body. The medial point is deeper into the body and requires a bigger pinch than the trapezius number 1 point. To find and treat the outer trigger point, search further laterally toward the shoulder using a pinching motion. Go across the trapezius until you run into the collarbone with your thumb. Keep the thumb there, just inside the col- larbone, and with it dig up and outward underneath the roll of trapezius. The fingers will meet the thumb from the other side with a pinch. You will be massaging into the front of the trapezius just before it attaches laterally to the collarbone. The muscle will feel thick and dense here.
Treatment Tips
To make the upper trapezius easier to get ahold of, loosen it by putting your hand in your pocket or waistband. Tilt your head to the same side while massaging to relax this muscle. Use the Thera Cane through a layer of clothing.
Rest your elbows on a desk or table as you reach across the body to massage the trapezius.
Figure 4.14 Massage of trapezius number 1
with fingers and thumb Figure 4.15 Trapezius number 2 massage with supported thumb against a ball on a wall or bed
Chapter 4—Head, Face, and Neck Pain 71
If massage with fingers and thumb is too tiring for your hand, try pressing the upper trapezius trigger points against a ball on the wall with a supported thumb, fingertips, or pointed massage tool (figure 4.15). Any of the trapezius trigger points can be massaged with the Thera Cane, Backnobber, Body Back Buddy, or any hook tool. Figure 4.16 shows how to hold the Thera Cane for massage of trapezius number 2. Maximum pressure and control are obtained when the hand opposite of the side being massaged is in the bow of the cane. This also allows the muscle you are treating to relax. The bottom of the cane is angled across the body, toward the opposite hip. This allows you to keep your head straight rather than tilted away from the tool. See figure 4.21 to see the ideal position of the hands. If you don’t have a hook- type tool, lean forward against a door frame or convex corner to place the ball on the top of your shoulder (figure 4.17). Review the massage guidelines given in chapter 3 (see table 3.1) to be sure that you clearly understand how to correctly execute the massage stroke.
Trapezius number 3. Leaning against a ball (tennis ball size) on a wall is especially effective for trigger point number 3 in the lower trapezius (figure 4.18). Notice that you have a choice of two direc-
tions to move the ball: up the back or across it
toward the spine. Moving up along the edge of the shoulder blade, you may feel the ball bump as it goes over the diagonally oriented edge of the muscle. Moving across from the shoulder blade onto the back, it feels like you’re pushing the muscle ahead of the ball. There’s likely to be more than one trigger point at this site, one on each side of the edge of the shoulder blade.