Tight Upper Traps: Fed Up Patients, Frustrated Physiotherapists, and A Magic Bullet
In the course of seeking the truth of acupuncture science through deeply digging the history from ancient to modern times, I found that the deeper I excavate, the more puzzles popping up which can not be resolved easily without grasping a big and clear picture of the entire world of medicine.
To Many, Acupuncture Is Still An “Unknown”
Acupuncture (including dry needling) is making inroad into almost every corner of modern medicine, either conventional or alternative, in some cases with an impact that could turn some non-acupuncturist clinicians' status quo perspective upside down.
At the same time, acupuncture is still an “unknown” to many healthcare practitioners who could have been more successful in their practice if only they had learned even as little as 1% of the truth of acupuncture science.
Recently, I read a post by physiotherapist Nick Ilic who, in my view, is a penetrating critical thinker. His insight is very inspiring, not only to me, but, as I see, to all clinicians who are struggling with how to manage a very common complaint from patients – tight upper traps.
Stretching & Massage Not Work
According to Functional Performance Physical Therapy (FPPT):
However, the critical thinker Nick Ilic has a different opinion on whether correct movement or posture is the key or not.
"I'v Seen 4 - 5 Physios", Fed up Patients Say
In his post titled “Some Ideas On The Management of Tight Upper Traps”, he shared his experience in handling the tight upper trap after the patients have been "unsuccessfully stretched, poked, zapped, taped, stabbed, scrapped and cupped”. His post goes:
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.
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” ...
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). ...
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”.
Can Clinicians Feel The “Tightness”?
Nick Ilic continues:
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.
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.
Neck Is The Root
Nick Ilic further argued:
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)
Don't Pretend to Be A Hero, Patients Need NSAIDS
Nick Ilic also advised:
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.
“BAD Posture”?
Nick Ilic questioned "Bad Posture".
“What about Posture? I’ve been told by….” (list of HCPs and also also non-professionals) “…that my posture is terrible”.
领英推荐
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).
“Weak” Neck Flexors?
He further questioned "Weak 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.
One of The Profession's Capital Assets
The critical thinker further articulated his voice on one of the two PT profession's most important stock of trades (manual therapy and passive movement):
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?
Nick Ilic finally asked his PT fellows this question: Can we do better in this area, as a trade? His answer:
We can always do 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.
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.
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”.
The Most Valued Service?
The critical thinker shared his trump card:
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.
Now My Question: Can We Do Even Better?
I admire Nick Ilic's penetrating insight into the “tight upper trap" mystery and the frustration of his PT colleagues, the concerned GPs, and all other concerned masculoskeletal HCPs confronted by this mystery. I also believe his approach of handling the “tight upper trap" mystery would be very inspiring at least to his PT fellows.
But for tight upper traps, do we have a more tangibly effective solution? The answer is definitely YES. All clinicians in the world who have the chance to see tight trap patients can do far far far better if only they knew a little bit about the truth of acupuncture science.
A Magic Bullet: Truth of Acupuncture Science
Once you know the truth, the acupuncture needles in your hand will become a magic bullet, which can kill any pain or any abnormal sensation of a patients instantly at 95% certainty.
In Nick Ilic's case, if he had learned the truth, he should have not needed to waste his valuable time in performing all those rituals (chatting about life with patients, advising patients, following up emailing etc), which anyway may end up in throwing patients back to their GPs for pain killers.
Trapezius myalgia, trap spasm, trap pain, trap tightness, trap strain, no matter what the “mystery” is called, 99% for sure it will subside or even completely melt away just in 5 seconds upon your needle in (not into the traps!), if you know the truth and how to turn a needle into a magic bullet. Permanent cure will eventually follow with at least 85% of certainty after a period of continuing treatment. My next post will talk about the “secrets” of acupuncture science for clearing up the “mystery”, stay tuned.
Epilogue
Nick Ilic is an Australian physiotherapist. He describes himself as Physio Clinician — Patient-Centred Injury Management || Tennis Physio, Player and Coach at www.thetennisphysio.com. My thanks go to him for his penetrating insight on the “tight upper trap" mystery which inspired me to write this post.
References
FPPT, Stretching and Massage Does NOT Get Rid of Upper Trap Pain. https://fpphysicaltherapy.com/upper-trap-neck-pain-treatment-prevention/ (Accessed on Apr. 4, 2023)
Nick Ilic, Some ideas on the management of Tight Upper Traps. Aug 12, 2021 https://physioclinician.medium.com