Levator Scapulae Trigger Point Referred Pain Patterns

Before your read about levator scapulae trigger points and their referred pain you may want to find out more about the levator scapulae muscles.

Levator Scapulae Trigger Point Causes and Symptoms

The levator scapulae is the neck muscle frequently responsible for a stiff neck. Trigger points in this muscle cause pain in the angle of the neck and the superior border of the scapula (inner edge of scapula). When you wake up with a stiff neck because you “slept wrong” the levator scapulae is likely the culprit. Some pain from levator scapulae trigger points may also spill over to the back of the shoulder. The primary area, however, is the angle of the neck. Some studies have shown this muscle to be the neck muscle most affected by trigger points besides the upper trapezius.

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Long periods holding a telephone pinned between the ear and the shoulder can severely aggravate the levator scapulae, similar to the upper trapezius. This and other habits must be eliminated or all the treatment in the world will do not good, and one long phone conversation with the phone held this way can undo months of treatment.

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Trigger points are most likely to occur because of keeping the shoulders elevated so that the muscle stays in a shortened position and fatigued. Periods of distress, of course cause us to hold tension in our shoulders and chronic distress equals chronically sore scapula elevators and trigger points. Long hours spent driving where the hands are held at the top of the steering wheel in the “10 and 2” position can overload the muscle as the shoulders tend to hunch up.

Note: The 9 o’clock and 3 o’clock position, which corresponds with the cross brace on most modern cars, is actually more proper. This also brings the arms down so that the shoulders and arms are at a more natural and comfortable level, reducing levator scapulae and trapezius strain. However, this is not fool-proof and even with the hands at the sides of the wheel instead of near the top some strain to the trapezius and levator scapulae is likely to occur from long periods of driving. Travell and Simmons recommend that one hand be held at the bottom of the steering with the forearm supinated so that the upper arm can rest on the thigh in order to relieve strain to the muscles. They claim that this position “allows emergency maneuvering”. while it is true that this rests the trapezius and is a more comfortable position for prolonged driving (the upper and lower arms would be alternated) whether is “as safe” as the traditional hand position(s) we are taught to drive with is questionable. The language “allows emergency maneuvering” is ambiguous at best since driving with your hands in any number of different position can be said to allow emergency maneuvering, depending on the parameters that we use to define “emergency” and “maneuvering”.

Long periods spent looking down to read a book or write can put strain on the levator scapulae through its role in controlling forward flexion of the head. Working at a computer keyboard with the keyboard too high can also cause problems since the elbows tend to be held up to keep the forearms more in line with the typing fingers. In this case the keyboard is too high and should be brought down or the seat should be brought up. Looking down to the side and back to the screen repeatedly while copying from a document can also put strain on the muscle. Besides a painful and stiff neck with the primary symptom is restriction of head rotation to the same side. If the problem is severe enough one may be unable to turn the head toward the affected side at all. Pain, when you turn your head to look behind you while backing up your care, is very likely due to levator scapulae trigger points. Since the muscle may be short and stiff it will resist rotation of the head to the opposite side as well. When the trigger points are active enough pain may be present even at rest. This restriction of neck rotation should be considered a primary sign of levator scapulae TrP’s. There may be some restriction of flexion at an extreme range of motion and extension will probably be unaffected. But if there is no restriction to rotation levator scapulae TrP’s are not likely.

There may be some pain upon full shoulder abduction since this requires full upward rotation of the scapula but in general shoulder movement is unrestricted.

Shoulder abduction
Shoulder Abduction and lateral flexion

When upper trapezius trigger points are present then related trigger points can form in the levator scapulae so expect concomitant trigger points in the upper trapezius if you have them in the levator scapulae. Also possible are trigger points in the rhomboid and supraspinatus muscles on the same side. Treatment of the levator scapulae TrP’s may be unsuccessful if these muscles are not treated as well. By the same token, it is possible that upper trapezius trigger points could remain active because of failure to treat TrP’s in the levator scapulae.

Satellite trigger points of the levator scapulae can also be caused by trigger points in the lower trapezius because the levator scapulae is part of the referred pain pattern of the lower traps. If this is the case then excess tension may be involved in the pectoralis major and minor, which are antagonistic to the lower trapezius. Gentle stretching and perhaps myofascial release may be necessary to restore the resting length of these muscles and relax them.

Alterations in gait such as limping on one leg can cause the levator scapulae to be overly active in trying to compensate for the gait alterations. This can be accompanied by trigger points in the sternocleidomastoid and scalenes as well.

Headaches are not usually associated with levator scapulae trigger points through their typical referred pain patterns. However, a shortened levator scapulae due to trigger points can pull the ipsilateral cervical vertebrae laterally causing painful and tender cervical joints and possible causing referred pain from the joints to the head. 1Ferguson, Lucy Whyte., and Robert Gerwin. Clinical Mastery in the Treatment of Myofascial Pain. Philadelphia: Lippincott Williams & Wilkins, 2005. Print.

Levator Scapulae Trigger Point Release

There are two trigger point locations on the levator scapulae. Perhaps the most tender is the one located just above the attachment to the upper angle of the shoulder blade. This is the spot that people habitually want to massage when they have levator scapulae and trapezius problems. Attachment trigger points tend to be the most painful in general so it is natural to hone in on them. Additional bursa in this area may also be a further source of tenderness in this area for some and inflammation resulting from this kind of attachment trigger point, known as enthesitis (inflammation at the point where a muscles inserts onto bone, caused by chronic stress and tension in the area). This may give rise to constant pain in the area and ice application may be useful in this instance. Due to the presence of this inflammation, it may be best to avoid applying pressure to the area through self-massage and concentrate instead on the central trigger point, which, as explained below, is the real trouble maker.

levator scapulae trigger points
Levator Scapulae Trigger Points and Referred Pain Pattern

This attachment TrP is located by palpating about one-half inch above the superior angle of the scapula. The “superior angle” of the scapula is the inside edge along its top, closest to the spine. Feel along this area for a very tender spot. You may be able to feel the knot and even get it to rock back and forth between two fingers. The muscle fibers in this area may be indurated, which means they will feel hard. This is the most easily found and identified trigger point although beside pain and tenderness it is unlikely to cause a jump or twitch response when palpated since it is buried beneath the trapezius.

Levator Scapulae Diagram with Trigger Points Marked
Levator Scapulae Diagram with Trigger Points Marked

Although the attachment trigger point at the muscles insertion to the scapula border may the most tender the most important trigger point occurs centrally just as the levator scapula emerges from underneath the trapezius, right at the angle of the neck and is probably the origin of the attachment TrP. This TrP may be difficult to locate but it is crucial for success in treating the levator scapulae.

The central trigger point is difficult to locate and treat because the trapezius must be dealt with. In the image above and to the left can see where the levator scapulae emerge from underneath the large upper trapezius, which looks like the hood of a cobra. Notice the point where the pointer locates the levator scapulae. Just below this, but shrouded somewhat by the trapezius will be the problematic trigger point. It should be somewhere right at the border of the trapezius just as the levator scapulae emerges.

To locate is sit back in a chair so your upper body rests against the backrest allowing the shoulders to relax. On the side you are working on, let the forearm rest gently and naturally on your belly. You may want to use a cushion to support the arm. This way, the trapezius and levator scapulae can relax somewhat. It the trapezius is tensed it will be that much more difficult to find the trigger point. If it is relaxed you can push it back to help reveal the TrP you are looking for.

With the opposite hand locate the upper edge of the trapezius right around the angle of the neck. From there roll your fingers forward, while pushing back on the trapezius, until they make contact with the side of the neck, thus the levator scapulae. The trigger point you are looking for should be right around this area. Palpate until you feel the knot, a hard area of tight tissue, and most of all tenderness an pain. It may help to gently turn your head toward the opposite side in order to tense the muscle and bring it up against the fingers. This may increase the sensitivity of the trigger point and illicit the referred pain symptoms when it is pressed.

If the trapezius is not relaxed enough and if the levator scapulae is too tensed it will be difficult to differentiate the TrP’s of the muscle belly from the rest of the tense muscle. Much depends on the sensitivity and severity of the TrP for the do-it-yourself patient since the tenderness and pain upon pressing together with the referred pain pattern, is the best way to locate them when one does not have the educated hands of a professional.

Once you have located the TrP it can be worked with the fingers but this is difficult and tiring. Although a massage ball or tennis ball could be used against a wall, your best bet is the Thera Cane® Self Massager. This allows you to reach the area and apply sufficient leverage to it while keeping the muscle somewhat relaxed. The Thera Cane is indispensable for those hard to reach areas of the back or for areas where leverage is bad and it is hard to apply enough pressure. Also, continued daily massage with the fingers, especially given the leverages involved, is very tiring to the hands and fingers.

Thera Cane Massager (Blue)
 Theracane Self-Massage Tool

Notice in the image to the right that the Thera Cane has several knobs that can be used for massage in different areas. The knob on the end of the crooked part will be used for the levator scapula. The two projections at right angles to the shaft of the can be used as handles. When you are working on your levator scapula you will want to have the opposite hand do most of the work and apply the pressure. You can grab the cane wherever is most comfortable and gives you the most control. The hand of the working side should be used lower on the shaft. The “handle” that is furthest away from the crook is a good place to put the non-working hand. It can be used to provide some additional control but if you use this arm too much you will over-tense the muscles of the neck and shoulder.

Shortened Sternocleidomastoid and Forward Head Posture

Some of the same habits that can lead to problems in the levator scapulae can cause the sternocleidomastoid to be chronically shortened thus perpetuating the overload to the levator scapulae and trapezius. Forward head posture should be corrected and the shortened sternocleidomastoid should be returned to its normal resting length. 2Berthoz, A., Werner Graf, and Pierre Paul. Vidal. The Head-neck Sensory Motor System. New York: Oxford UP, 1992. Print.,3Simons, David G., Janet G. Travell, Lois S. Simons, and Janet G. Travell. “Chp. 8: Masseter Muscle.” Travell & Simons’ Myofascial Pain and Dysfunction: The Trigger Point Manual. Baltimore: Williams & Wilkins, 1999. 329. Print.,4Davies, Clair. The Trigger Point Therapy Workbook: Your Self-treatment Guide for Pain Relief. Oakland, CA: New Harbinger Publications, 2004. Print,5Ferguson, Lucy Whyte., and Robert Gerwin. Clinical Mastery in the Treatment of Myofascial Pain. Philadelphia: Lippincott Williams & Wilkins, 2005. Print.

shortened sternocleidomastoid muscle and forward head posture
Effects of shortened sternocleidomastoid The shadowed regions represent normal head position.

Sources   [ + ]

1, 5. Ferguson, Lucy Whyte., and Robert Gerwin. Clinical Mastery in the Treatment of Myofascial Pain. Philadelphia: Lippincott Williams & Wilkins, 2005. Print.
2. Berthoz, A., Werner Graf, and Pierre Paul. Vidal. The Head-neck Sensory Motor System. New York: Oxford UP, 1992. Print.
3. Simons, David G., Janet G. Travell, Lois S. Simons, and Janet G. Travell. “Chp. 8: Masseter Muscle.” Travell & Simons’ Myofascial Pain and Dysfunction: The Trigger Point Manual. Baltimore: Williams & Wilkins, 1999. 329. Print.
4. Davies, Clair. The Trigger Point Therapy Workbook: Your Self-treatment Guide for Pain Relief. Oakland, CA: New Harbinger Publications, 2004. Print