Arm and Shoulder Trigger Points for Massage Therapists

Trigger points can be active or latent.

Arm and shoulder trigger points are discrete, focal, hyperirritable spots in a taut band of skeletal muscle in the upper extremities. The spots are painful on compression and can produce referred pain, referred tenderness, and even motor dysfunction. Trigger points can be active or latent. Active trigger points cause pain while the muscles are at rest. A latent trigger point does not cause spontaneous pain but may restrict movement or cause muscle weakness. Patients only feel a latent trigger point when you press on it.

Recommended course: Trigger Point Therapy 

Musculoskeletal pain syndromes

According to studies, about 23 million people, or 10 percent of the U.S. population, have one or more chronic disorders of the musculoskeletal system. Musculoskeletal disorders are the main cause of disability in the working-age population. They are also among the leading causes of disability in other age groups. Myofascial pain syndrome is a common painful muscle disorder caused by myofascial trigger points. This is different fibromyalgia syndrome, which involves multiple, typically bilateral, tender points. These pain syndromes are often concomitant and may interact with one another.

Pain in the shoulders and arms can be referred pain from the cervical spine, from the thoracic spine, or from the shoulder joint. Even then the Acromio-Clavicular (AC) joint can refer pain to the shoulder region. 

Examining the upper quadrant

It’s important to conduct a comprehensive movement exam of the entire upper quadrant to differentiate if the pain is referred from the joint(s) or if it is more of a myofascial type of pain. If both Active and Passive Range of Motion (ROM) — for example in the Cervical Spine — reproduces the patient’s pain, it’s likely that the Cervical Spine is the primary source of pain. 

Treatment should focus on regaining pain-free ROM of the cervical spine. If Active is restricted but Passive ROM examination is negative, consider the pain primarily myofascial in nature.

Shoulder trigger points in the upper Trapezius

Trigger points from the Trapezius muscle are usually present along the top of the Upper Trapezius muscle in the superior Gleno-Humeral joint (GHJ) region. They also occur along the medial border of the scapula. Most patients with shoulder trigger points in the Trapezius also complain of neck pain and stiffness, and sometimes pain in the jaw. Often, they present with tension headaches.

Trigger points of the Levator Scapula overlap with trigger points of the Trapezius. They are typically more intense along the superior-medial angle of the scapula. Patients with trigger points in the Levator Scapula also report neck pain and neck stiffness. 

Differentiating trigger point pain in the Trapezius and Levator Scapula

It’s very common for patients to have trigger points in both the Trapezius and the Levator Scapula at the same time. The easiest way to differentiate between pain from either Trapezius is stretching both muscles. Assess which of the stretches is more painful, or more restricted. Stretch the Trapezius with contralateral sidebending and stretch the Levator Scapula with a combination of contralateral sidebending and contralateral rotation. 

Pain in the Posterior Cervical muscles

Another group of muscles that can cause pain into the shoulder area are the Posterior Cervical muscles: the Splenius and Semispinalis often have trigger points that refer pain very similar to the Levator Scapula into the side of the neck and along the angle of the scapula. They also typically cause pain towards the base of the skull, which is less common with the Levator Scapula.

Pectoral muscle pain and shoulder trigger points

Massage therapists often overlook the role of the Pectoral muscles as a cause of shoulder and arm pain. Trigger points from the Pectoral muscles typically cause anterior shoulder pain, or deep below the acromion if the Pectoral Minor is involved. Because of the biomechanical relationship between the Pecs and the interscapular muscles, you can get secondary trigger points in the Trapezius and Rhomboids. 

Lastly, therapists often see trigger points from the Scalenes. Trigger points in the Scalenes do not usually cause neck pain. However, they do commonly cause pain the upper Thoracic area.

Facial, rotator cuff, and deltoid muscles

One other group of muscles that therapists often overlook as a source for neck and arm pain are muscles in the face, like the Masseter. Typically, most pain from Masseter trigger points focusses on the jaw, but it can refer to the neck and the arm.

Pain in the arm is typically referred from the rotator cuff muscles. Trigger points in the infraspinatus can cause arm pain. Pain typically appears in anterior and posterior deltoid and travels down the arm into hand and fingers. The supraspinatus can have some trigger points as well and refer the pain more around the shoulder joint itself. Of course, the Deltoid muscle itself can have trigger points and pain caused by that muscle typically remains in the Deltoid region.

Treating arm and shoulder trigger points

There are many different techniques to treat trigger points. Acupressure is just one of several Asian bodywork therapies (ABT) with roots in traditional Chinese medicine (TCM) that has been used to treat trigger points. 

Traditional Chinese medical theory describes special acupoints, or acupressure points, that lie along meridians, or channels, in your body. According to this theory, when one of these meridians is blocked or out of balance, illness can occur. Acupressure and acupuncture are among the types of TCM that are thought to help restore balance. As the balance is restored trigger points are no longer painful. 

Instrument-Assisted Soft Tissue Mobilization (IASTM) and Cupping can also be used to treat trigger points. IASTM is a skilled myofascial intervention used for soft-tissue treatment. It is based on the principles of James Cyriax’s cross-friction massage and is commonly used by Massage Therapists and Physical Therapists to treat trigger points. 

Recommended course for physical therapists: Instrument-Assisted Soft Tissue Mobilization (IASTM) to the Upper Quarter 

Cupping is a practice in which the therapist puts special cups on the skin to create suction. This causes the tissue beneath the cup to be drawn up and swell causing an increase in blood flow to the affected area, which can help reduce pain from trigger points.

A comprehensive pain assessment

When treating pain from trigger points in shoulders and arms, it’s helpful to treat the neck area, the upper back and down the arm (at least up to the elbow). Pain is complex, and nociception is only a part of the patient’s pain experience. Many factors influence the patient’s pain: biomechanical factors, but also psychosocial factors can increase the patient’s pain intensity. 

Lifestyle choices, and health behaviors also influence pain sensitivity. Lack of proper sleep, physical activity, stress, and diet significantly impact a patient’s pain. That is why your examination of your patient needs to be comprehensive. By treating the entire region and not just focusing on the exact location of the pain, you have a much better chance of making long term changes. These can be especially effective if you also educate your patient on different sources that can affect the pain experience.