I have talked about the upper traps a couple of years ago here and how I think they are arguably one of the most misunderstood, mistreated and mismanaged areas in our profession. How they are surrounded by so many misconceptions and misunderstandings about them being not involved or an issue in shoulder or neck pains, or if they are, that they’re tight, knotted or over active, and how they need to be stretched, massaged or reduced in activity.
I disagree with all of this!
Yet I see and hear many therapists discussing and doing all of the above. So I thought I would have another go at defending the poor old upper traps from all of you who are still adamant in pulling, poking and pummelling them to death, and why I think this is totally the wrong way to manage them!
In my experience, all the painful, sore, tight and tense upper traps I encounter are lengthened and weakened. They may be painful to poke and press. They may respond to a bit of a stretch or a rub for a while. But that doesn’t mean this is what they need.
Therapists love poking around in upper traps. They seem to think it will tell them something useful. When they find a sore spot, they think they have found the problem, they believe they have found a muscle knot, commonly referred to as a trigger point, they think they are caused by over activity or poor posture, and they have just the thing to ‘fix’ that, normally a thumb, an elbow, or a needle!
There is no muscle knot!
I have discussed the flaws and pitfalls that therapists face when poking around in soft tissues before. I have demonstrated the lack of reliability of any therapist to be able to locate these so called muscle knots or taut bands no matter their skill or experience here, and in my recent article in the British Journal of Sports Medicine I discuss how these soft tissue sore spots are not muscle knots but possibly something else here.
There is also a rather interesting study here that further questions the belief that soft tissue sore spots in the upper traps are knots of tight muscle tissue. It actually demonstrates that the most painful areas to palpate in the upper traps for people are in fact the softest when measured with pressure algometry, and this does NOT change after 20 mins of fatiguing exercise.
Yes, ok it was conducted on healthy volunteers so we cannot say the same is seen in those with pain. But it does, blow some more holes in the muscle knots theory. Which by the way, as theory’s go, looks like a slice of Emmental cheese it has that many holes in it.
Poor posture!
Poor posture is also often blamed for upper trap pain. Upper crossed syndrome, anteriorly translated and protracted shoulder girdles, downward rotated scapulas. All these postures are associated with neck and shoulder pain yet there is no robust evidence that shows those with these postures, suffer more pains or problems than others.
For example this paper here looks at the effect of upper back and shoulder posture on the incidence of rotator cuff tears. They checked the shoulders of 525 residents of a small village in Japan with ultrasound and compared what they saw with the subjects posture. They concluded that poor posture IS a predictor for both symptomatic and asymptomatic rotator cuff tears, defining ideal and poor posture as shown in the picture below.
However, this study did not compare the subjects age, occupations, sporting and recreational activities, or any past history of trauma. Nor was other health conditions such as diabetes looked at. Also the rotator cuff tears in 146 subjects whom the examiners were unable to determine their spinal postures were excluded from the study. So with these flaws it is simply impossible to blame upper back or shoulder posture alone.
Over active?
Finally many upper traps are thought to be ‘over active’ when you stick some EMG units on them, and many suggest that we should be giving exercises that reduce their activity such as recommended here and here
But before we start to think about ways to reduce upper traps over activity, which seems to be an all too common treatment and management strategy, perhaps we should be asking why are the Upper Traps over active in the first place?
Maybe upper traps over active simply because they are struggling under the loads and the forces they encounter. Are the upper traps over active because lack of strength, endurance, capacity, or because something else is not working as it should be, such as the rotator cuff.
I’d argue thats exactly why Upper Traps are over active. I’d argue most painful upper traps need strengthening not further reduction in their activity.
So in summary please STOP rubbing and stretching those painful upper traps, and start strengthening them more!
As always thanks for reading.
Adam
Your thoughts on Janda’s upper cross syndrome Adam?
Out dated and a flawed and simplistic way of thinking.
Many, many people could be classed as suffering upper crossed syndrome, not all, in fact probably most don’t suffer any ill effects, so how can we blame the posture!
Simply put we cant, but many do!
But surely you would agree that poor posture increases the chances of MSK pain? Of course not all people with bad posture have problems, this is because the body naturally is a great adaptor/compensator.
The idea is that when compensation fails, pain presents. As the body has to compensate more when deviating from the plumb line ant/posteriorly… this is a reason to blame the posture.
Jandas approach did also take into account morphological muscle fiber changes for tonic muscles such as the upper traps. These ‘slow twitch’ fibers had properties which allowed for enhanced endurance.
So when you say you think the upper traps should be trained more for strength. I would differ and say the posture should be looked at to reduce muscular demand (in a biomechanical sense with AP deviations from the plumb line giving leverage) in the body. If any training I would say not strength but endurance should be trained, unless by strengthening you meant in an endurance sense?
Hi Jason
Thanks for your comments, but I’m afraid I have to disagree in that I haven’t seen ANY evidence nor is it my clinical experience that poor posture causes any increased risk of pain or injury. And this systematic review also says the same http://www.ncbi.nlm.nih.gov/pubmed/19028253
Posture is posture, injury is injury, they have little to do with each other.
Next plumb line assessments of posture are flawed, who says we have to be this way aligned, i’m not, most if not all my friends and family are not, and my patients aren’t either, rarely do I see someone plumb line straight
Next, muscle fibre types within the body are pretty much equally spread between type 1 and type 2, and yes there is a little shifting with activity, but not as much as believed. Check out http://www.strengthandconditionresearch.com for more info on this
Finally the difference between strength and endurance training isn’t as different as many believe. Strength training a muscle to fatigue regardless of rep ranges has similar results in all measurements, although using loads between 8-15RM seem to be most effective for most things.
Cheers
Adam
Nice article and response.
I love how in physiotherapy opinions and certainty can turn round in a discussion! Good points you mentioned. There are indeed some bizarre postures out there which are complaint free, which are the flag ships of your point made.
What you said on endurance and strength remind me of a friend of mine who does nothing but surfs, yet he has great strength purely from his functional and endurance training. Heavy bench press being of particular example, even though he only trains body weight.
Good food for more thought.
Thanks.
Jason
Only one other reason – are they ‘over active’ because something else is not active enough?’ So find the primary under activation rather than trying to inhibit the over recruitment.
Okay, this is totally anecdote and probably not that helpful. But my traps always seemed to be “tight” and sore, probably related to carrying around kids all day in the same position, or maybe not, who knows. Anyway, I tried tons of stretching routines, relaxation routines, or whatever to make them feel better. But honestly the only thing that helped with pain there and in my lower back was all around strength training. In other words, I starting working out. I couldn’t pinpoint a specific exercise that did it, but all I know is overall fitness and resistance training somehow made my pain mostly disappear, so based on purely anecdotal experience, what you say resonates with me.
Although my traps still become sore at times from intense exercise, i have drastically reduced daily pain from stress and tension by increasing my exercise. Sounds like a pickle but it is much better to have occasional muscle soreness from healthy exercise than to have daily pain without physical activity.
Hi Adam,
Very interested in your comments (in a few articles I believe) that suggest “tight” muscles are often weak and need strengthening. Was curious if there is any research on this? I know this may be hard to research as “tightness” is quite a subjective complaint!
Cheers
Chris
Hi Chris
Sorry for delay in reply. Not aware of any, as you say the issue is the measurement of tightness would be difficult. I speak more from clinical experience, in that many of the tight feeling my patients report get less with exercises that don’t include static stretching, be it upper traps or knees or shoulders.
And putting that together with the lack of structural change we ‘see’ in the literature with weeks/months of stretching and what we know of the mechanoreceptors and the central nervous system it seems a plausible explanation
Cheers
Adam
this was an interesting post…. next time, I err… won’t call the muscle knots, and tell the spa people that their grammatically and technically incorrect 😀 I guess muscle knots have always been a big thing with women. But know was always a favorite woman-word… ‘I’m in knots’ my work in knots, my life in knots… 😀
http://www.ayeshajamal.com
Hey Adam,
Have been very interested in this post and the last one on upper traps. Have doing a bit of testing and experimenting myself over the last 6 months or so, with patients with neck pain. I have found more often than not that the lower traps is weaker (with the prone y lift -like test) but will still continue to be open minded to your suggestion.
What do you think about this article I just found? (which I think is one of the only ones of its kind I could get hold of). It does only have a study size of 25 but I would be interested to hear your interpretation of it.
‘Comparison of Upper, Middle, and Lower Trapezius Strength in Individuals with Unilateral Neck Pain’.
Cheers mate,
Kieran
Not really a comment, but a request. Please write a shoulder injury prevention guide for weight lifters. I would buy it immediately. Thank you sir.
Hi Adam,
Would you consider repeated/prolonged ischaemic muscle pain (low tissue pH) during everyday tasks which require static musclework as one source of patient complaints in the upper traps area.
How about overuse (in some professions/hobbies) and delayed onset muscle pain?
What do you think about prolonged/often repeated “postures”/movements where the muscle is near individual end-range during static or dynamic tasks? (https://digitum.um.es/xmlui/handle/10201/18835)
How would strenght-training be useful in above situations?
Really enjoy your blog,
br, Teemu
Yep all these factors can cause soft tissue pain, simple way to treat and improve these… Move more!
Hi Adam, absolutely amazing blog and very educational for students like myself.
We are currently examining the case of a patient who presented with a recurrent headache, ‘shortened, tight’ trap muscles and reduced ROM all around, she had difficulty relaxing and letting go of her tension. We’re treating it like a stress-induced tension headache.
Other than looking at all the stressors in life and work that might affect this patient, would you still tend to focus on strengthening the traps rather than stretching/massage in this type of stressed, tense, headache-type presentation?
Regards from Norway,
Jonas
Adam thanks for sharing your insights in both this and the 2013 upper trap blog.
Have had left side upper trap pain (desk worker) and have tried to remedy through the usual posture, stretching and manual therapy with little result over the years.
Have taken your strengthening advice, bought some weights and started with monkey shrugs – this really works on many levels.
Thank you!
Thanks for sharing Rein
Adam for somebody seriously weak, how many sets, reps and weights would take them to fix the levator/Upper trap ratio? I ave constant whiplash pain over my levator area and your upper trap logic seems solid. I am planning to try it out and would appreciate your insight,
Simply do as many as you can tolerate, usually with a weight that is challenging but acceptable to you!
Hi Adam,
Liking your articles. I am not a therapist or strength and conditioning coach. Can you advise any further how I can read the full PubMed article please? I am being denied access to this info……keep up the good work…love it. Hope to hear from you soon
Cliff Graves
Hi Cliff
Im afraid pay walls are an issue with research.
If you want full access you either need an academic access or you have to pay
Sorry
Hi Adam, thank you for taking the time to respond. This is the way of the world. One of greed and I am very disappointed that these organisations feel it necessary to “squeeze” money out of the public.
Keep up YOUR good work. You have a brilliant sense of humour that would placate me if needing physiotherapy treatment. Thank you again
Adam, this may just be the answer to my chronic unrelenting neck and upper back pain ~ more like intense burning sometimes, stiffness, point tenderness and headaches. This all started after taking up regular competitive tennis at the age of 48 ~ 2 years ago. Although a very athletic, active woman I have been told to stretch, do yoga, acupuncture, massage. I’ve done several rounds of PT, neurosurgeon ( who said it was muscular in nature ),accupuncture, trigger point therapy. You name it. Now even swimming causes a horrible flare up of the tightness and headaches. I was told to back off upper back exercises, I gave up any upper body weight training due to the tightness and pain. At the risk of looking like I am self diagnosing to my physical therapist, how many reps and how often should I be doing the exercises? Weakness, not tightness absolutely made sense and when I read I had a huge sense of relief that I can manage this.
Hi Adam, love your work. Physio student here. How would you identify when to use UT strengthening for a shoulder/neck injury compared to cuff strengthening/lower trap/SA? I would ideally strengthen all areas but would focus more on areas that I find need more strength. We learned in school to give exercises that targets a problem list you found, such as the UT being week (decreased MMT). How would you be able to objectively measure if the upper traps are weak, I know you can do resisted MMT for UT by resisting shrugging but that seems subjective and alot of people are able to shrug relatively well, without using a dynamometer to objectively measure strength? I definitely will use UT strengthening exercises for pts, but just want to be able to justify using it and explain why.
Thanks in advance.