Student Work: Case study - Tight shoulder with many "knots" by Brenda Woudenberg

Michelle Burns
October 31, 2017

During the course of attending massage school at A New Beginning School of Massage, students are given a number of assignments that requiring research and writing. Some of these assignments result in very insightful and well-thought-out information and decision-making outcomes. I am happy to share some of their assignments for you to enjoy.

The condition my client reported on the intake form during the interview was extremely tight shoulders with many "knots" in them. This is my own private client that I have brought in for internships.

I chose this condition because I have seen it over ten times in internships. I see multiple trigger points in the upper and middle trap and cervical spinal muscles. These seem to be a very common condition. I also have many trigger points in these areas.

In writing a brief summary of her condition and history, it appears that most of her trouble is coming from the middle fibers of the trapezius. My client has her own pastry chef business. So, she spends at least 6 hours a day on her feet mixing various batters and then decorating the pastries. I have watched her do her job (she's my dear friend). I have observed her leaning over her work (flexing the neck) and elevating the scapula adducting the shoulder, flexing the elbow and flexing the digits. So this position is fine for a few minutes but she may be in this position for hours. Now, she is not complaining of back, hip, elbow, or wrist pain. She only complains of pain in that upper and middle trap area. There she presents with multiple trigger points.

My understanding of the condition of myofascial trigger points. Trigger points are defined as a focus of hyperirritability in a tissue that, when compressed, are tender. This gives rise to referred pain and tenderness. Trigger points are typically caused by three types of muscle overload: acute, sustained and repetitive. Muscle overload causes an abnormal release of acetylcholine. This release causes an influx of calcium into the sarcomeres in the affected area, which, in turn, causes sarcomeres to contract. Because of the sarcomere contraction, there is an increase in the tension of the muscle fiber. This tension creates contraction that shortens sarcomeres, and these knots evolved into trigger points. There are several different types of trigger points: active trigger points that actively refer pain, latent trigger points that are present and don't refer pain but may limit ROM and are tender when you press on them. Central trigger points are commonly found in the center of the muscles. These can make the muscle weaker. Attachment trigger points can be found where muscle fibers blend into the tendon and they can increase tension. Satellite trigger points develop in the pain referral zone of an active trigger point. It develops in response to the pain felt by the original trigger point. If you don't find and treat the original active trigger points, the satellite ones will tend to return no matter how many times you get them treated (Myofascial Pain and Dysfunction. The Trigger Point Manual. Janet Travell, MD and David G. Simons, MD. Williams & Wilkins. Baltimore, MD.)

This is my treatment plan for my client.

Goal #1  client will verbalize decreased pain from a level 9 to a 2                                          Goal #2  client will sleep 7-8 hours per night                                                                            Goal #3  client will have full AROM in shoulder flexion and outward rotation                  Goal #4  client will identify possible causes of trigger points and identify new postures for cake decorating

  • Locate trigger points by palpating tight bands, find the most tender spot.
  • Most tender spot usually found in the muscle belly. Apply pressure to this spot for 30-90 seconds
  • Muscle stripping through taut band
  • Stretch muscle
  • Try to identify the cause of the trigger point to prevent the trigger point from returning
  • This procedure may need to be repeated

The explanation for why I chose this particular type of treatment. First of all, trigger points will not resolve on their own. Muscle fibers are chronically stuck in a contraction. This particular protocol is said to deactivate the trigger point by causing myosin heads to release the actin filaments. This best happens by increasing blood circulation, O2 and energy to that muscle. It's very important to treat that taut band as well. Referral pain is thought to be in the same location and share the spinal nerve root.

My expected outcome from following this trigger point treatment plan was significant pain reduction. My client reported pain at a level 7-9 out of a 1-10 scale. She had increased pain following 8 hours of cake decorating. Her ROM was within functional limits but was decreased from what it had been in previous years, particularly in shoulder flexion and outward rotation. I expected treatment to enable her to regain full ROM. Due to the pain intensity, this affected the client's sleep, so my goal was for her to have decreased pain so she could sleep 8 hours per night. I also believed much of the trigger point formation was a result of muscle overload and repetitive use. So identifying repetitive movement so adaptive techniques to decorate cakes that might reduce the load on her upper trapezius muscle was a focus.

I found two legitimate and recent research studies on myofascial trigger points and successful methods in treating them. Unfortunately, they both related to headaches which my client didn't have. However, her trigger points were in the same place.

The first one, called Trigger Point Massage Offers Headache Help, published in the Clinical Journal of Pain. I want to talk about their specific treatment and the outcome. They started with 15 minutes of myofascial release to back, shoulders, chest, and neck. Followed by 20 minutes of trigger point release to upper traps, suboccipitals, and the SCM. The last 10 minutes of each massage consisted of post-isometric relaxation, directed right and left lateral cervical flexion, circular or cross fiber friction at the masseter, temporalis and occipitofrontalis muscles as well as gentle effleurage and petrissage to neck and shoulders. I was not able to find specific numbers in the research paper. However, the results published was a greater perceived reduction in head pain among those who received massage as compared to those in the placebo group.


The next study also focused on headaches as it relates to trigger points. This was a four-week study, each participant receiving a 30-minute massage twice a week. This was the procedure:

  • Three minutes preparatory tissue warm up lower cervical to occiput
  • Five minutes myofascial release included: three Palmar glide passes over deltoid & pectorals, three passes with soft fist from the occiput to the lateral shoulder and upper trapezius
  • Two minutes of axle cervical traction
  • Trigger point therapy of holding pressure points up to two minutes
  • Five minutes including relaxing effleurage and petrissage

The conclusion of this study was that the massage techniques significantly reduced the headaches people were experiencing. The researchers also hypothesized that the massage techniques, particularly the trigger point release, was the main factor in the reduction of pain.

I treated my client 3 times, three weeks in a row. I followed the procedure as above. I always took time to warm up her tissues before performing trigger point release. By the third session, her pain was reduced to a level five. She was sleeping eight hours a night. Her shoulder flexion had improved significantly. The shoulder external rotation was still somewhat limited. We talked about several adaptive techniques that she could use to change her position. I really don't think she seriously considered any of my suggestions.


Reference articles I used for my paper:!po=50.0000







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