Saturday 24th July, 2021
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Can (myofascial) trigger points cause shoulder pain

Man with painful shoulder
(myofascial) trigger points are a common cause of shoulder pain

(myofascial) trigger points are a very large cause of shoulder pain. They have been found to be extremely common in sufferers of shoulder pain, and cause pain either directly by referring pain, or indirectly by altering the posture and function of the shoulder joint creating abnormal stresses and pinching (impingement syndromes).

The treatment of these trigger points has been shown to successfully relieve shoulder pain. However, despite this trigger points are largely ignored by the medical profession, and when they are identified they are too often treated inadequately. Therefore they are arguably the biggest reason shoulder pain keeps coming back.

In this article we will discuss what trigger points are, how they cause shoulder pain, how failure to diagnose and treat them properly results in inappropriate treatments and continuing problems, and most importantly what you can do about it.

What are trigger points

Trigger points are those tender lumps in muscles that massage therapists find. Scientists have found that they are parts of the muscle that have gone into spasm or cramp and causes a chain reaction which causes them to “lock on” and continue to develop. They start as small lumps that are only evident when a therapist presses upon them and causes pain, but they can continue to develop until they can hurt all the time. For more information about trigger points please see our article Trigger point basics.

How trigger points cause shoulder pain

It is clear that trigger points are a big cause of shoulder pain. Studies have found that compared with people who have no pain, the shoulder muscles of shoulder pain sufferers are usually riddled with trigger points (1–4)⁠, and many clinical trials have shown that massage or trigger point therapy relieves this pain (1,5–9)⁠. Lets look at the way trigger points can cause this pain: directly and indirectly (commonly both).

Shoulder trigger point chart
Shoulder muscle trigger point referral: "x" marks the trigger points, the red is the pain

How trigger points directly cause shoulder pain.

Initially trigger points only shoot pain when pressed upon, but as they develop or are aggravated they can shoot pain without being provoked. Scientists have extensively mapped where individual trigger points shoot (refer) pain to. A large number of these refer pain to the shoulder, and as part of one clinical trial trial the researchers mapped the pain produced by pressing on the trigger points and sound it matched the shoulder pain experienced by the patients (3)⁠. The accompanying picture is a diagram of trigger points and their pain referral patterns taken from one journal article (10)⁠, and we have placed a list of muscles whose trigger points cause shoulder pain from the same study in Appendix One below.

How trigger points indirectly cause shoulder pain

The basic principles

Your nervous system uses muscles to maintain a balanced posture and control movement. However, and discussed in our articles Trigger point basics and Functional rehabilitation when a muscle contains a trigger point it becomes both tight and week. When this happens your nervous system needs to make adjustments to compensate. This can cause abnormal stress on tissues and even parts to pinch together. Because it’s easy to visualise we’ll illustrate this using pictures of the spine, but trigger points cause two main issues affecting shoulder joints:

  • altering the (bio)mechanics of the shoulder joint
  • creating a head and shoulder forward posture which alters the angle the shoulder joint sits at.

This creates abnormal stress on the supporting structures of the shoulder and can cause a pinching in the shoulder joint known as shoulder impingement syndrome.

Head and shoulders forward posture
Head and shoulder forward posture- from trial by Alizadhkaiyat

The head and shoulders forward posture

Your head is designed to sit balanced on top of your shoulders and your arms hang straight down by your side. However, if your head and shoulders sit forward as in this picture your head and shoulders are no longer balanced, and your arms hang down at an un-natural angle. This creates abnormal stress on muscles trying to support the unbalanced structures, and places your shoulder joint at the wrong angle. Trigger points can be an important cause of head and shoulder forward posture. The constant tension in muscles caused by this posture can also cause trigger points to develop, which of course can also directly refer pain.

Control of shoulder joint movement

As you can see on the diagram the shoulder joint has a fairly large ball sitting on a very shallow socket which makes it incredibly unstable. The way your shoulder joint keeps that large ball sitting in that shallow socket is by having muscles hold it there and control the movement. The most important of these muscles are the rotator cuff muscles. When trigger points are present control of this movement can become compromised.

Shoulder impingement

Earlier we mentioned impingement syndrome of the shoulder. This is where the normal smooth coordinated movement of the shoulder joint is altered, causing parts of the joint to be abnormally stressed or pinched. This normal smooth movement of the shoulder joint can be altered by the changes in the activity of muscles controlling the joint, and also by the abnormal stresses and angles created by having a head forward posture (11–17)⁠. The pinching and other abnormal stresses caused by impingement causes secondary inflammation and degeneration of the tendons and other structures.

Why shoulder pain keeps coming back

There are two main trigger point related reasons shoulder pain keeps coming back.

  1. The medical profession largely ignores trigger points, meaning that the real cause of shoulder pain is not addressed and in-appropriate treatment is given instead.
  2. If trigger points are identified they are usually treated so as to stop them hurting but not eliminate them, so of course they eventually start causing pain again.

Trigger points are largely ignored by the medical profession

Despite all the evidence to the contrary trigger points are barely mentioned in medical journals.
Example One:
The article Clinical evaluation of non-arthritic shoulder pain: diagnosis and management (18)⁠ in medical journal Physician and Sports Medicine makes no mention of trigger points

Example Two:
The articles Chronic shoulder pain: part I Evaluation and Diagnosis and part II treatment (19,20)⁠ in the journal American Family Physician tells doctors that if they do notice a trigger point it is probably fibromyalgia instead.

We can only speculate why that is, but basically every source of information for doctors relies on money from drug companies, and if you wanted to sell lots of pain killers and other drugs you couldn’t come up with a much better plan than not telling doctors about trigger points.

Providing the wrong treatment

With trigger points omitted from medical journals doctors most commonly just detect the pinching and secondary issues it causes and make the diagnosis of shoulder impingement syndrome (10)⁠. Of course treating impingement should include treating those trigger points that are shortening and weakening muscles causing the abnormal function. Instead doctors are instructed to prescribe remedial exercises, analgesics, anti-inflammatory drugs and cortisone needles, plus of course surgery when the secondary damage gets worse (18,20)⁠.

Superficially the prescription of exercises sounds sensible, but as discussed in our article on functional rehabilitation function of the shoulder joint cannot return to normal as long as the things that cause it to be abnormal remain. This means that so called corrective exercises usually do not return function to normal. This has been demonstrated by several trials that found that using therapies directed at the underlying muscular issues combined with exercises gave much better results than when exercises alone were used (21–24)⁠. Further, scientists have been able to detect and monitor the abnormal programming of shoulder muscles. They have found that exercises fail to change this programming (25)⁠, whereas the treatment of trigger points returns it to normal (26)⁠.

Trigger points inadequately treated

The second issue that typically causes shoulder pain to keep coming back is that most treatments for trigger points merely stop them from referring pain, not eliminate them. This is discussed in our article Trigger point treatment: deactivation or elimination, but in summary trigger points start as small lumps that are only detected when a therapist presses on them and they shoot pain. Over time they develop, becoming much larger and having considerable adverse effects on muscle function, then eventually they may be aggravated and cause pain. Trigger point therapies are typically used and tested to just revert the trigger points back to as they were before shooting pain. You feel much better, but of course they still inhibit muscle function and are usually re-aggravated to shoot pain again.

Residual trigger points after treatment
Residual trigger points after treatment

Confirming that trigger point therapies usually only temporarily relieve pain

So there can be no doubt that even though trigger point therapy might make you feel better the trigger points will still be there please allow me to share the results of a trial that used 12 very thorough weekly treatment sessions (10). So you can understand these results these are two terms the scientists use.

  • Latent trigger points: ones that are not shooting pain
  • Active trigger points: ones that are shooting pain

Of course they are the same trigger points: it’s just that at some stage they shoot pain and other times they don’t. As this chart shows, after 12 treatment sessions many of the active trigger points had (temporarily) stopped shooting pain and a few had been eliminated, but overall the total number of trigger points had only reduced slightly. Most were still there.

The solution

If you have shoulder pain we’ve seen that trigger points are a large and important cause of shoulder pain that is largely ignored by medicine and too often inadequately treated. If trigger points are causing or contributing to your shoulder pain typical treatments like anti-inflammatory drugs and exercises will not fix the problem, and your session of trigger point therapy or the trigger point release you saw on Youtube will only provide temporary relief. To properly eliminate shoulder pain we recommend you consult a professional who deals with shoulder problems and is knowledgeable about trigger points, and discuss incorporating the strategy below to eliminate trigger points in your management.

Why you need professional help

Unless it is a very simple problem there will likely be factors other than trigger points contributing to your shoulder pain. Some examples may include:

  • If you have a head and shoulder forward posture contributing to your problems this will need to be addressed
  • If the problem has been there a while there may be some weakening of muscles and stiffening of joints due to disuse.
  • There may be some activity you are doing that is contributing to the problem.

The treatment of trigger points

In this section we will give an overview of how trigger points are treated. We will first discuss how trigger point therapies work, then how these can be incorporated into a plan to eliminate your trigger points and keep yourself trigger point free.

Trigger point: positive feedback loop

Effective treatments

To understand effective trigger point treatments we need to have a basic understanding of what they are and how they form. As this diagram shows they start with part of the muscle going into spasm, which causes tightness restricting blood flow. This causes a build up of toxic wastes which causes further spasm. This keeps going around in circles getting gradually worse over time. To break this loop an effective treatment needs to address one or more of these issues. It is for this reason that there so many different therapies used to treat trigger points and trigger point related pain. We have massage techniques, dry needling, lasers, stretch and freeze therapy, and the list goes on. As long as they address at least one issue they will have some effect (27,28)

Number of treatments

Our example above and other clinical trials show that courses of 3-12 sessions of therapy reduce pain but eliminate less than one third of trigger points (10,29,30). Therefore a very large number of treatments are necessary to eliminate trigger points properly. Because of this it is best if some therapy can be self applied, it it will become very expensive.

Our choice of therapy

Vibration massage has been scientifically proven to address all the major issues of a trigger point. It disrupts spasm, relaxes muscles, increases blood flow, and the increased blood flow flushes the build up of wastes. For more details please see our article: The scientific effects of vibration massage with clinical applications.
Further, it takes no special skill or knowledge to apply vibration massage, so it is ideal for home use. Because of the large number of therapy applications needed effective treatment needs to include some home treatment, otherwise it becomes unaffordable and inconvenient.

Getting started treating your trigger points

Although self treatment with a vibration massager is very simple, trigger points can be part of more complex issues. It is also good to have a professional advise how to find them and where to apply the therapy. To get started you will need to find a good professional who understands trigger points. If you go to our get a massager page then select your country you should find near the top a link to a list of clinics that may be able to help. Alternatively, you can find a qualified professional such as a Chiropractor, Osteopath or Physiotherapist and discuss this with him or her.

Getting a suitable vibration massager.

You will need an effective vibration massager. There is a lot of miss-information and ineffective machines available. I’ve linked some information below to help you choose, or you can use the safe option and get one of ours.
Video: How to choose a massager
Article: Percussion vs vibration massage
Video: Our highly effective vibration massager

Professional at desk
Professionals: click image to find out more and possibly trial vibration massage

Professionals

DrGraeme massagers were originally built by Dr Graeme for use in his clinic, and to prescribe to his patients for additional self use at home. Now these are used by colleagues and other professionals for similar purposes. If you are a professional and wish to know more about this therapy, or possibly get a sample massager to trial please check out our practitioner page.

Apendix: the muscles found to directly cause shoulder pain

Upper trapezius muscle
Middle trapezius muscle
Lower trapezius muscle
Infraspinatus muscle
Supraspinatus muscle
Subscapularis muscle
Teres minor muscle
Teres major muscle
Anterior deltoid muscle
Middle deltoid muscle
Posterior deltoid muscle
Pectoralis major muscle
Pectoralis minor muscle
Biceps brachii muscle
Triceps brachii muscle

References

  1. Sergienko S, Kalichman L. Myofascial origin of shoulder pain: A literature review. J Bodyw Mov Ther [Internet]. 2015;19(1):91–101. Available from: http://dx.doi.org/10.1016/j.jbmt.2014.05.004
  2. Bron C. High prevalence of shoulder girdle muscles with myofascial trigger points in patients with shoulder pain. BMC Musculoskelet Disord . 2011;12.
  3. Hidalgo-Lozano A. Muscle trigger points and pressure pain hyperalgesia in shoulder muscles in patients with unilateral shoulder inpingement: a blinded controlled study. Exp Brain Res. 2010;202:915–25.
  4. McEvoy J, Dommerholt J. Myofascial Trigger Points of the Shoulder. Phys Ther Shoulder. 2012;351–79.
  5. Gordon CM, Andrasik F, Schleip R, Birbaumer N, Rea M. Myofascial triggerpoint release (MTR) for treating chronic shoulder pain: A novel approach. J Bodyw Mov Ther . 2016;20(3):614–22.
  6. Van Den Dolder PA, Roberts DL. A trial into the effectiveness of soft tissue massage in the treatment of shoulder pain. Aust J Physiother . 2003;49(3):183–8.
  7. Shih YF, Liao PW, Lee CS. The immediate effect of muscle release intervention on muscle activity and shoulder kinematics in patients with frozen shoulder: A cross-sectional, exploratory study. BMC Musculoskelet Disord. 2017;18(1):1–10.
  8. Van Den Dolder PA, Ferreira PH, Refshauge KM. Effectiveness of soft tissue massage and exercise for the treatment of non-specific shoulder pain: A systematic review with meta-analysis. Br J Sports Med. 2014;48(16):1216–26.
  9. Hains G, Descarreaux M, Hains F. Chronic Shoulder Pain of Myofascial Origin: A Randomized Clinical Trial Using Ischemic Compression Therapy. J Manipulative Physiol Ther. 2010;33(5):362–9.
  10. Bron C, De Gast A, Dommerholt J, Stegenga B, Wensing M, Oostendorp RAB. Treatment of myofascial trigger points in patients with chronic shoulder pain: A randomized, controlled trial. BMC Med. 2011;9.
  11. Lucas KR, Rich PA, Polus BI. How common are latent myofascial trigger points in the scapular positioning muscles? J Musculoskelet Pain. 2008;16(4):279–86.
  12. Jcu R, Sakthi D. Clinical assessment of subacromial impingement-which factors differ from asymptomatic population. Musculoskeltal Sci Pract. 2017;27:49–56.
  13. Alizadehkhaiyat O, Roebuck MM, Makki AT, Frostick SP. Postural alterations in patients with subacromial impingement syndrome. Int J Sports Phys Ther. 2017;12(7):1111–20.
  14. Skolimowskil J, Barczyk K, Dudek K, Skolimowska B, Demczuk-Włodarczyk E, Anwajler J. Posture in people with shoulder impingement syndrome. Ortop Traumatol Rehabil. 2007;9(5):484–48498.
  15. Otoshi K, Takegami M, Sekiguchi M, Onishi Y, Yamazaki S, Otani K, et al. Association between kyphosis and subacromial impingement syndrome: LOHAS study. J Shoulder Elb Surg . 2014;23(12):e300–7.
  16. Hunter DJ, Rivett DA, McKeirnan S, Smith L, Snodgrass SJ. Relationship between Shoulder Impingement Syndrome and Thoracic Posture. Phys Ther. 2020;100(4):677–86.
  17. Land H. Clinical assessment of subacromial shoulder impingement – which factors differ from the asymptomatic population? Musculoskeltal Sci Pract. 2017;70:429–40.
  18. Holmes RE, Barfield WR, Woolf SK. Clinical evaluation of nonarthritic shoulder pain: Diagnosis and treatment. Phys Sportsmed. 2015;43(3):262–8.
  19. Burbank KM, Stevenson JH, Czarnecki GR, Dorfman J. Chronic shoulder pain: Part I. Evaluation and diagnosis. Am Fam Physician. 2008;77(4):453–60.
  20. Burbank KM, Stevenson JH, Czarneck GR, Dorfman J. Chronic shoulder pain: Part II. Treatment. Am Fam Physician. 2008;77(4):493–7.
  21. Arias-Buría JL, Fernández-de-las-Peñas C, Palacios-Ceña M, Koppenhaver SL, Salom-Moreno J. Exercises and Dry Needling for Subacromial Pain Syndrome: A Randomized Parallel-Group Trial. J Pain. 2017;18(1):11–8.
  22. Senbursa G, Baltacı G, Atay A.Comparison of conservative treatment with and without manual physical therapy for patients with shoulder impingement syndrome: A prospective, randomized clinical trial. Knee Surgery, Sport Traumatol Arthrosc. 2007;15(7):915–21.
  23. Yemul SR. COMPARISON OF SUPERVISED EXERCISE WITH AND WITHOUT MANUAL PHYSICAL THERAPY FOR PATIENTS WITH SHOULDER IMPINGEMENT SYNDROME. J Cur Res Rev . 2013;05(05):5.
  24. Bang MD, Deyle GD. Comparison of supervised exercise with and without manual physical therapy for patients with shoulder impingement syndrome. J Orthop Sports Phys Ther. 2000;
  25. De Mey K, Danneels L, Cagnie B, Cools AM. Scapular muscle rehabilitation exercises in overhead athletes with impingement symptoms: Effect of a 6-week training program on muscle recruitment and functional outcome. Am J Sports Med. 2012;40(8):1906–15.
  26. Lucas KR, Rich PA, Polus BI. the Effects of Latent Myofascial Trigger Points on Muscle Activation Patterns During Scapular Plane Elevation. Jclb . 2007;25(8):765–70.
  27. Simons DG. Understanding effective treatments of myofascial trigger points. J Bodyw Mov Ther. 2002;6(2):81–8.
  28. Dommerholt J, Bron C, Franssen J. Myofascial Trigger Points: An Evidence-Informed Review. J Man Manip Ther. 2006;14(4):203–21.
  29. Shah JP, Phillips TM, Danoff J V., Gerber LH. An in vivo microanalytical technique for measuring the local biochemical milieu of human skeletal muscle. J Appl Physiol. 2005;99(5):1977–84.
  30. Grieve R, Barnett S, Coghill N, Cramp F. Original article: Myofascial trigger point therapy for triceps surae dysfunction: A case series. Man Ther . 2013;18:519–25.

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Dr Graeme

About Dr Graeme

Several years ago Dr Graeme, a Chiropractor practicing in Victoria, Australia was looking for a serious hand held massager his patients could use at home to get the extra quality massage they needed. The ones he found in the shops and on-line for home use looked nice but were not serious, and... read more



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