Chronic muscle strain refers to a painful condition resulting from gradual and continuous tension on a muscle.  Though it typically develops over a period of time, its symptoms can occur quite suddenly, and if not managed well it can lead to significant functional limitations in local and even more remote areas of the body. 
 
The upper back and shoulders are among the main areas you can find this condition to occur.
Populations most commonly at risk are those who:​

• Spend hours sitting at a desk or computer, especially if positioned in less than ideal postures (eg. accountants), where unfortunately, accuracy and focus on the task at hand often trump focus on ergonomics.
• Have occupations requiring continuous movements with the arms in a forward position (eg. piano players), leading to overstretching of the muscles over time.
• Have roles requiring positions that are sustained for an extended period of time (ie. dental professionals), leading to increased risk of muscle fatigue.
• Perform heavy lifting, carrying or pulling activities, (eg. student’s heavy back pack, parents and their infants, etc.), which if done repetitively, can set you up for a combination of both overstretching and fatigue.
• Have shoulders being pulled forward by overdeveloped short anterior shoulder-girdle muscles, resulting from an imbalanced upper body strengthening program (eg. power lifters), when often extremely important regional stability exercises can be missed.
• It can even occur by simply adopting habitual postures over a period of time that promotes this type of shoulders rolled forward position (eg. Favoring a sleep posture on the same side for years).

I think it’s safe to say this condition can affect pretty much anyone at one point or another, including myself.

Though definitely not the only muscle that has the potential to be affected in this condition, the trapezius muscle certainly can be one of the most common.  Even if not directly affected, it can at the very least have a significant role to play in the development of chronic upper back and shoulder strain. Two of the main reasons why, may likely be because of the muscle’s size and its location. The trapezius is a large muscle, originating from the base of the skull, throughout the back of the neck, with attachments to each of the vertebra in the entire upper back.  It goes on to attach to the outer third of the collar bone and along the width of the shoulder blade, extending from the tip of the shoulder all the way along the length of its spine.
By way of these extensive attachments, it functions as both a postural and an active movement muscle, used to tilt and turn the head and neck, shrug, steady the shoulders, and twist the arms.  More specifically, the upper trapezius elevates, the lower trapezius depresses, the upper and lower trapezius work together to rotate, and the middle trapezius retracts the scapula, or shoulder blade.

One of the most challenging issues in regards to a strain of the trapezius muscle, is that the underlying weakness which gradually progresses over time, can be present for some time without any or many complaints before it results in significant functional limitations.  Initially, you may feel a local sore spot while in certain positions or while performing certain tasks. Or, perhaps you might first notice it when applying pressure to the areas where the muscle attaches to the vertebrae or shoulder blade. It may appear as an acute pain or tenderness not otherwise obvious with typical daily tasks.  One reason for this development of pain is as a result of repetitive unopposed traction by the muscle on its bony attachments along the spine.  This eventually leads to a point where the tissues have reached their limit, a type of warning system if you will.  With all the research and development in pain science over the recent years however, we know of course that this may not be the only factor, but it is still nonetheless an important one. 

​The good news is that if the onset is relatively recent, simply modifying your posture to gently engage these muscles or resting in a position that supports your upper back can offer relief as it removes the element of continuous tension on the tissues.   However, if adaptive tightness in the muscles through the front of the shoulders has developed, or if significant weakness throughout the trapezius is present in the case of more longstanding symptoms, a simple change in posture may not be enough. 

The best course of action in this case, will require a fair bit more effort, particularly if effective long term management is the goal.  However, the final results will definitely be worth it in the end. 
A comprehensive management plan should include:

• Modifying the position or activity that has caused the pain
• Use of ice or anti-inflammatory medication in cases where pain is of a continuous nature, at least initially where management of the symptoms aids in rest and recovery
• In cases where marked weakness of the middle and lower trapezius is present, regardless of whether opposing tightness exists, a shoulder support may occasionally be indicated to consistently relieve tension on the muscles for a period of time
• A carefully prescribed exercise program that isolates stretching the tight muscles and specifically targets progressive strengthening of the weak muscles, again typically the middle and lower trapezius muscles are the ones in need of strengthening
• re-education of functional movement patterns that have more than likely been altered as a result of pain and muscles learning to compensate over time

​Not only can this type of program assist with management of upper back pain, but it can also help aide in the recovery of several shoulder conditions that can result from the presence of underlying trapezius muscle strength imbalances.  In fact, focus on optimizing trapezius mechanics can be appropriate in the rehabilitation of most rotator cuff conditions.  One study has even indicated complete resolve of chronic elbow symptoms, solely by focusing on resolving underlying strength deficits of the middle and lower trapezius.  Though more research is still needed, what is apparent is that the benefits of adding more focus on the trapezius muscle to your workout routine will clearly outweigh the risks of putting in the extra time.  Enjoy your workout!

If you have any questions regarding this or any other blog posted, please feel free to contact the clinic.  We’re here to help.

~ Elizabeth Stefanyshyn-Alonso BScPT, FCAMPT

​References: 

1. Kendall, F.P., Kendall McCreary, E. & Provance P.G., Muscles: Testing and Function with Posture and Pain, 5th Ed., Lippincott Williams &Wilkins, 2005.
2. Bhatt, J.B., Randal, G., Chavez, A. & Yung, E., 2013, Middle and Lower Trapezius Strengthening for the Management of Lateral Epicondylalgia: A Case Report, Journal of Orthopaedic & Sports Physical Therapy, Vol 43, No 11, pp 841-847.
3. https://www.physio-pedia.com/Trapezius
4. http://www.howtorelief.com/trapezius-muscle-origin-insertion-nerve-supply-action/
5. https://nypost.com/2018/03/05/tech-is-turning-millennials-into-a-generation-of-hunchbacks/

Colleagues of mine recently shared an article regarding the general misuse of MRI and Xray for management of low back pain, claiming they produce so many “false alarms”, are globally far over used, interpreted without clinical context and by in large presented to patients AS A DIAGNOSIS.

In my practice I like to think of ANY imaging that I am requesting as a way to CONFIRM my diagnosis OR it is ordered pre-operatively by the surgeons that I work with in order for them to better determine surgical management moving forward. It is certainly never used by the team I work with as a sole means to determine a diagnosis or treatment approach. In fact, we often suspect a pathology, and choose not to proceed with imaging because the imaging would not change the treatment approach and is therefore irrelevant regardless of the findings.

For many patients they do not understand the nuances of MRI machines or MRI protocols, X-ray protocols or the differences between CTscan and MRI for example. They feel justified in asking for imaging because they want to ensure that nothing is missed and that they receive the proper diagnosis. FAIR, but imaging for the sake of imaging is not the right approach and could even be detrimental in the treatment and management of your injury.

My caseload is predominately made of young adult hip/sport hip pathologies. I meet most of my patients in a surgeons office who specializes in young adult hip pathologies or through his referral. MOST OF MY PATIENTS ARE NOT SURGICAL.

​The unfortunate reality is that a large portion of my clients have been seeking a diagnosis and appropriate treatment for a significant amount of time before they have met our team. Many of these clients have already received X-rays and MRI’s before they have met us, even more unfortunate is that often these xray's and MRI’s are somewhat useless to us because they are NOT the right protocol for the pathology, meaning sometimes they DON’T EVEN SHOW WHAT IS GOING ON. Furthermore, if the person interpreting the images is not familiar with the pathology or aware of the clinical presentation, a diagnosis is ENTIRELY MISSED.

Xray and MRI imaging show the history of your life in a few snap shots. It may show the current soft tissue findings or bone injuries and abnormalities that are causing your current pain, but it also shows old “scars” that you have sustained over your life time. These images should always be interpreted WITH your subjective and objective exams in mind. Meaning the person interpreting your imaging should be aware of your pain presentation and your clinical exam. Failure to interpret this information together may lead to unnecessary interventions or general mismanagement for your presentation.

For example, someone with generalized hip OA will show “wear” on the hip joint differently than someone who has femoral acetabular hip impingement. Someone who has hip impingement from a giant cam lesion will have a labral tear in a different position than someone who has hip impingement from retroversion. Retroversion cannot be diagnosed via Xray and we require a special MRI protocol or CT scan to confirm its diagnosis but we don’t need an MRI or CT scan to pick up the retroversion if we already suspect that from your clinical exam. We may choose to order the MRI or CT to confirm the retroversion or investigate as to the amount of retroversion and whether or not you are a surgical candidate, but clinically it won't change your management strategy much.

Furthermore, we may suspect that you have sustained a labral tear in your hip. In order to confirm this we could order an MRI arthrogram (a painful procedure where dye is injected into the hip and you are run through the MRI machine) but if we suspect that you have the tear, and it won't change the conservative management approach offered - why bother?
Imaging does not give the entire picture, and there is significant information that can be gained from a great objective clinical exam. In addition, imaging that shows “something is wrong” generally freaks people out, causing fear and anxiety and these factors perpetuate the pain cycle.

​Moving forward I encourage clinicians and patients to really ask themselves, is this imaging needed? Am I the best person to be ordering this and interpreting this, and how will the information change my treatment or management?

​What can you do as a patient to help the problem? Ask questions!
      - When discussing imaging with your physician ASK WHY the images are being ordered. What
         do they expect to find and how will the information be used to further improve your
         pain presentation.
      - Ask if the results will change the management plan
      - Clarify why those specific images are being requested
      - Clarify who will be interpreting the images.

If you are being referred on to another practitioner or specialist are they going to need different images, if so, do you need both?

We have a great team of diverse practitioners with all kinds of clinical experience at Donald Physiotherapy. If you have questions, or need some help navigating the muddy waters of imaging reach out to us! We are here to help!

~ Lindsay Tysdal, PT