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So, hi, my name's Jo Gibson and I'm a clinical physiotherapy specialist working at Liverpool in the UK. Those of you who joined us before Christmas know that in conjunction with David Pope at Clinical Edge, we've been running a series of free videos and Facebook Lives really looking at diagnosis of some common shoulder conditions. Now, if you missed out before Christmas, you can still access three free webinars that we did looking specifically at the diagnosis of acute onset shoulder pain, and those are still available at www.clinicaledge.co/shoulder.
So, to start the new year, this is just a quick Facebook Live tonight to whet your appetite, and set the scene for some further events that we'll be doing over the next few weeks. And so, I thought we'd talk about upper fibres of trapezius. Now why is that? I had a guy that came in a few weeks ago who actually was adamant that he needed me to release his upper fibres of trapezius, and if I just massage them two or three times a week, he'd be able to get back to doing what he normally did.
And so, I was kind of left asking him why he thought these muscles were tight or why he thought they were sore and that despite months and months of physiotherapy with some other colleagues, he hadn't got any improvements. But it also got me thinking why is it that we are always saying the upper fibres of trapezius is the bad guy and certainly there seems to be a lot of emphasis on switching them off or choosing exercises that bias middle trapezius and lower trapezius. And also looking at taping techniques to try and inhibit them. Is there really any basis for this, and why do we want to isolate muscles anyway when we know that the brain actually recognises movement rather than individual muscles? But also, unless we've actually had a nerve injury or had some sort of tear of a muscle requiring some specific isolated stretching, actually most of our rehabilitation should be based on getting muscles to work together. So, where have some of these myths come from? Well, there's no doubt that some papers from the early 90s probably started this trend, and probably a little bit before that as well. Certainly, when I started my physio career, which was in the late 80s. There was a study by Paula Ludewig that certainly concluded in the abstract that patients who had what was then referred to a subacromial impingement syndrome did have overactivity in their upper fibres of trapezius compared to some of the other scapular muscles.
Now, that sounds quite convincing until you drill down to the detail and see what Paula actually reported was the upper fibres of trapezius was actually overactive in the later degrees of elevation, and when you looked at onset timing, essentially everything was a bit slow to get going. And so then working at a mechanical disadvantage, and so then potentially upper fibres of trapezius was playing catch up.
We've also had a lot of EMG studies from the lovely Ann Cools’ group, and they've obviously used surface EMG to evaluate upper fibres of trapezius. Now that in itself is not without its potential flaws because as we know with surface EMG particularly, there's a lot of risk of crosstalk. And again, when we look at electrode placements, it can be quite hard to differentiate upper fibres of trapezius from levator scapulae. Now Ann's clearly a very experienced researcher, and I'm sure her methodology will be absolutely rigorous. But what's interesting when we also look to studies looking at patients with shoulder and neck pain as a combination, there is clear evidence that commonly upper fibres of trapezius is actually weak rather than actually overactive.
So again, we have to be honest and recognise the limitations of EMG and actually what increased activation levels tell us. Are they genuinely telling us that a muscle is working harder because it's doing too much work? Is it simply a compensation for the muscles not doing their job? And the other thing that we're not clear about is what's the chicken and what's the egg? When we look at systematic reviews of EMG studies trying to look at key differences in patients with pathology compared to the normal population, the bottom line is there are some key themes, but there's a huge heterogeneity across different populations.
So, who are the groups we might truly expect them to have an overactive upper fibres of trapezius? Well, if we look at some robust studies, there's no doubt if you have somebody with a frozen shoulder because they simply don't have the range, their only strategy is to elevate that shoulder and overuse those scapula muscles. Similarly, if you think of somebody with a massive rotator cuff tear, interestingly, if you look at patients with a massive rotator cuff tear with symptoms who haven't compensated well, a common feature is increased activation in those upper fibres of trapezius. Whereas, when we look at patients with massive rotator cuff tears with less symptoms who are better compensated then interestingly, they have a better-balanced activity in all the scapula muscles, so all the different parts of trapezius. There's no doubt if somebody had a serratus anterior injury or a long thoracic nerve injury compromising serratus function, then again, you'd expect a trapezius to be working harder.
Now, it's interesting if you have a spinal accessory nerve injury that takes out trapezius, actually patients can't compensate and achieve full flexion. Whereas, if people have a long thoracic nerve injury, whilst they'll have a lot of issues with fatigue and sustained overhead use, generally they can achieve good flexion. So, nerve injury, a stiff shoulder, a massive rotator cuff tear would be good reasons that upper fibres of trapezius do work harder purely as a compensatory strategy.
The other group that there is some evidence to support are those patients who might have had a neck injury, neck trauma or a whiplash where actually upper fibres of trapezius shows increased activity purely as a protective strategy. So, again, if we have somebody with a history of neck pain who's gone on to develop shoulder pain, and initiates some movement with a very definite shrug, then that might help us narrow down where we're going to target our treatment or does it? Because the bottom line is that actually isolating any muscle doesn't make a tremendous amount of sense. We need to make sure that the cuff, the scapula, the shoulder muscles have sufficient strength to do what that patient needs to do functionally.
So, we've kind of challenged perhaps what we've interpreted for some of those early studies. They were not necessarily telling us what's then been translated into practice. But the other thing that's important to look at is the cohorts that some of those studies had been done on. If we look at some of Ann Cools lovely work, it's been done on volleyball players who obviously spike the ball and arguably may have some adaptation purely because of what they do functionally. We have to be careful about generalising that to the general population.
Now, the other thing that we need to consider is actually the role of upper fibres of trapezius. As I've said already, it doesn't work in isolation. It works as a force couple with serratus and the other parts of trapezius as well as the rotator cuff, and obviously the more superficial shoulder muscles.
But if you actually look at the anatomy of upper fibres of trapezius, rather than having these very vertical fibres that would give you that pure elevation, they're actually quite transverse in their direction. And so, actually upper trapezius doesn't have much of an elevation effect on the scapula in the initial phases of elevation. So, if my arms are down by my side and I elevate, then actually I don't get tremendous upper fibres of trapezius activation. I'm more likely to get levator scapulae, which actually can downwardly rotate that scapula.
Now, what's interesting is if I just bring my arms out to about 30 degrees and then do a shrug, then I get a much better relative contribution of upper fibres of trapezius. So actually, if I had somebody with that really long droopy shoulder type posture who's complaining of neck pain, who's complaining of trigger points, purely because upper fibres of trapezius actually are probably weak and need a bit of encouragement to work harder and do their job better, then actually just bringing the arms out to 30 and getting them to do a shrug is a very nice way of targeting that.
Now, there's also been some other work done by Lee's group. I think the paper was published in 2016 when extensively they looked at not only doing this slight abduction position and shrugging, but also adding craniocervical flexion at the beginning of the movement. But the bottom line is if they added in this craniocervical flexion before they did their shrug, then again, they got an even better effect on trapezius.
Now if we then just do elevation through range, we get really lovely contribution and balanced activity of all the elements of trapezius with serratus anterior. And what's interesting is that we get even more of an effect if we just add in some external rotation through range.
So, Birgit Castelein did a lovely study looking at the ways of targeting trapezius without getting undue activity in levator scapulae, and actually again showed that this elevation through range in the scapular plane, so in scaption, but through that range of movement with external rotation is an extremely effective way of targeting those muscles.
She also showed in the same study that actually if you've got patients do a shrug above head, again, you've got nice activation of upper fibres of trapezius, and again some balanced activity in middle and lower trapezius.
There's been quite a lot of studies that have looked at actually changing the ratios and trying to choose exercises that bias middle and lower trapezius and actually try and decrease the relative contribution of upper fibres of trapezius. But again, we need to be a little bit careful because this really just seems to actually illustrate in those patients who have disproportionate activity in upper traps, a change in onset timing or just not getting everything working at the start of the movement.
So, arguably just exaggerating that initial switch on is a great way of targeting all those scapular muscles through range and external rotation is clearly going to target your rotator cuff as well. But if we're honest, there are lots of different exercises. Scaption itself with a shrug or without, doing movements through elevation, exaggerating a shrug and range, side lying elevation movements, making the patient cognitive about that as they do their range. All these things have been shown to give good activation in the scapular muscles.
Now again, there's been a huge emphasis on using tape to try and inhibit upper fibres of trapezius and clearly tape as a standalone solution is never something we should consider. There is some argument for a sensory effect, some argument for cortical spinal effects.
But I think the important thing to know about taping of the scapula to affect specifically recruitment of the different components of trapezius, there's no doubt that tape has been shown to change onset timing but only immediately after the tape was applied. That was a study by Snodgrass et al.
Mike Smith has also done a study suggesting that what the tape actually does is just change the start position. So, if you think what we've already said about that elevation or that slight abduction position that enhances that initial activation, getting upper traps doing its job, enhances that almost retraction effect that it has on the scapula rather than elevation. And so, the taping is not a mechanical effect. It's purely a sensory effect that changes how that patient starts or as they say from the Snodgrass paper, changes that timing of onset. It just does something to change what the muscles are doing.
Now, interestingly, we're talking about tape, but remember it only works immediately after the tape's been put on. If you look at those patients 24 hours later, it's not having any effect on upper fibres of trapezius at all. We can achieve exactly the same things in session just with some tactile or verbal cues, and again, there is good evidence to support that.
Now, we started this saying, “Is upper trapezius the bad guy?” And the bottom line is no, it isn't. Remember in our massive rotator cuff tear population, it's working harder because I haven't got my rotator cuff, and I need to lose a strategy. What's key is the evidence would suggest that if we can get them using the rest of the scapular muscles at a higher level, balance out that activity, then that seems to correlate with better outcomes. In our stiff shoulder population, then it's a necessary strategy until they have that passive range to be able to get the rest of the muscle system going. And in our neck patients, remember that study by Lee et al that showed that just adding in that craniocervical flexion seemed to significantly improve the effectiveness in influencing scapular position or unloading that upper quadrant and actually getting more normalised ratios of muscle activation around the shoulder, or at least those that mimics the group without pain.
And also remember that if you have somebody with a nerve injury, that's a time when maybe we do want to specifically target an isolated muscle, but probably the only time.
For me, it's really if somebody has got a lot of pain and a lot of tightness in this area, the likelihood is, lots of patients with neck and shoulder pain will have sore bits that we can press whatever you want to call them, but they generally reflect that the muscle probably needs to be a bit stronger and isn't doing its job well or the muscle is working too hard because other muscles aren't doing their job.
But remember, we don't need to really drill down to the detail unless we've had a nerve injury or an actual muscle injury because ostensibly, the brain recognises movement. Muscles are designed to work together. And actually, we just exaggerate that initial onset, if you like, to really help get traps going, then we can select exercises that specifically get all the scapula and cuff muscles strong and actually increase the robustness of the patient.
So, I hope that's given you a little bit of a tip bit about upper fibres of trapezius. Just checking, I've told you everything I wanted to do and just really to reiterate, I talked briefly, I mentioned about this transverse orientation of the fibres as trapezius attaches to the cervical spine, to the superior nuchal line, and the occiput. But essentially, that transverse alignment actually means that it's not a pure elevation, it's more of a retraction and actually contributing to that upward rotation at the start of range. And remember it's having its action on the clavicle. So again, it's a fantastic part of actually transferring load from the upper limb into the trunk.
So again, if you think of the effect it will have on the clavicle and compressing the sternoclavicular joint with that transverse orientation, then again that's a great way of load transfer through that system. So, I think it's fair to say the upper fibres of trapezius isn't the bad guy. It's just an indication of a change in load through that system and potentially a loss of capacity. Your history will tell you that. A disuse, proper elation, somebody who sits all day working at a desk or those sorts of things, and maybe doesn't do any activity. You can sort of work out the groups where weakness is likely to be an issue. But even you guys who go to the gym, there can be a huge emphasis when you watch people in the gym on this up, back and down and almost really depressing the shoulder girdle as a kind of preset to movements, and actually I often show my patients that just by exaggerating a bit of elevation in that abduction position, how much stronger they are as opposed to the position that they think they should start in.
So, it's about understanding the muscles work together. I'll post you some links to all these different studies so that you can have a look at them yourself. Let's not make one muscle the culprit. The bottom line is unless you've had a nerve injury, there is not one muscle that will be totally weak, and even in the case of a spinal accessory nerve injury, it will take out all your trapezius, not just upper fibres. Generally, soreness, trigger points, everything else are just an indication that either we need to get the system more strong or we have a preexisting pathology such as our stiff shoulder, our massive rotator cuff tears, just a very weak shoulder. Those nerve injuries, those neck driven issues that potentially contributes those changes in activation. But the bottom line is let's not be specific. Let's not try and switch something off. Let's just get everything doing its job better.
So, guys, don't forget if you want to access those free diagnosis videos, they're still available at www.clinicaledge.co/shoulder. A little shorty tonight just talking about poor old upper traps, which is much maligned, and actually generally is probably trying to play catch up or do the job the other muscles should be doing. The EMG studies about normalising ratios can be very interesting, but again, it's about just getting that system to work through range, and have the functional strength that that patient needs to do what they're doing. So, remember, don't get too hung up on trying to switch it off. Reassure your patients, and show them how they can change things actively by getting that shoulder system working.
So, look forward to our next Facebook Live. We'll let you know when it is, and let you know what the subject is. We've got a few things lined up. Not so much about the diagnosis line, but looking at some clinical applications.
Thanks to those of you who join us. I'm glad you've enjoyed it. Thanks so much for your feedback, and I look forward to seeing you all again very soon. Bye for now.