What is the cause and management of left trapezius muscle pain?

Left Trapezius Muscle Pain: Causes and Management

For uncomplicated left trapezius muscle pain without red flags, initiate conservative treatment immediately with NSAIDs, activity modification, and therapeutic exercises—imaging is not indicated and provides no clinical benefit. 1

Causes of Left Trapezius Pain

Left trapezius muscle pain typically arises from musculoskeletal origins, though serious pathology must be excluded:

Common Musculoskeletal Causes

• Myofascial pain/trapezius myalgia: Characterized by focal muscle tenderness, restricted range of motion, and local twitch response on palpation 1
• Delayed onset muscle soreness (DOMS): Results from eccentric muscle loading or unaccustomed activity 2, 3
• Postural strain: Prolonged static loading during seated work or repetitive shoulder activities 4, 5
• Muscle overuse: Elevated habitual trapezius activity can perpetuate pain cycles 4

Pathophysiology

• Impaired microcirculation: Chronic trapezius myalgia involves consistently low local blood flow in the painful muscle, with slightly elevated muscle tension 5
• Central sensitization: Muscle soreness can enhance temporal summation of pain and increase central nervous system excitability 3

Red Flags Requiring Urgent Evaluation

You must exclude serious underlying conditions before proceeding with conservative management 1:

• Myelopathy: Progressive neurological deficits, gait disturbance, bowel/bladder dysfunction
• Malignancy: Unexplained weight loss, night pain, history of cancer
• Infection: Fever, immunosuppression, recent spinal procedure
• Fracture: Significant trauma, age >65 years, chronic steroid use, known osteoporosis
• Inflammatory arthritis: Morning stiffness >30 minutes, systemic symptoms

Management Algorithm

Step 1: Initial Assessment (No Imaging Required)

• Clinical diagnosis is sufficient for uncomplicated trapezius pain without red flags 1
• Identify trigger points by focal tenderness on palpation and restricted cervical range of motion 1, 2
• Assess pain characteristics, functional limitations, and psychosocial factors 1
• Do not order imaging in the absence of red flags—routine imaging provides no clinical benefit and increases unnecessary healthcare utilization 1

Step 2: First-Line Conservative Treatment (0-6 Weeks)

Pharmacological Management:

• Topical NSAIDs are preferred over systemic treatments due to superior safety profile 1
• Oral NSAIDs (e.g., ibuprofen, naproxen, diclofenac) for limited duration if topical agents insufficient 1
• Avoid paracetamol as monotherapy—it is ineffective for musculoskeletal pain 1
• Avoid opioids—they provide no additional benefit over NSAIDs for musculoskeletal pain and carry significant harm risk 1

Non-Pharmacological Interventions (Core Treatment):

• Exercise therapy: Strengthening and range-of-motion exercises to improve function and reduce pain 1
• Muscle energy techniques: Reciprocal inhibition technique (5-second contraction, 5-second rest, 10-60 second stretch, 5 repetitions) significantly improves pain, cervical ROM, and functional activities 2
• Activity modification: Stay active rather than complete rest, but pace activities to avoid overload 1, 6
• Heat or cold therapy: Apply as needed for symptomatic relief 6
• Patient education: Explain the generally favorable prognosis and self-management principles 1

Step 3: Adjunctive Therapies (If Inadequate Response)

Manual Therapy:

• Trigger point therapy: Direct pressure or dry needling may provide relief, though evidence shows dry needling (63% response) may be more effective than drug injection (42% response) 1
• Ergonomic training: Education on proper posture and use of assistive devices 1

Psychological Support:

• Address anxiety, fear-avoidance behaviors, and psychological distress through education in relaxation techniques and coping strategies 1
• Refer to mental health specialist if significant psychological distress persists 1

Step 4: When to Consider Imaging (After 6 Weeks)

Imaging may be considered only if 1, 6:

• Conservative treatment for 6 weeks has failed AND
• Symptoms significantly limit function AND
• Patient is a potential candidate for interventional procedures

Preferred imaging: MRI without contrast of the cervical/thoracic spine if radiculopathy suspected 6

Step 5: Interventions to Avoid

Do not use 1:

• Facet joint injections (ineffective in 90% of patients with back pain)
• Trigger point injections with steroids (no superior benefit over dry needling)
• Glucosamine or chondroitin
• Selective serotonin reuptake inhibitors, tricyclic antidepressants, or anticonvulsants for isolated muscle pain
• Spinal injections (facet joint injections, trigger point injections with medication)

Common Pitfalls

• Ordering premature imaging: Imaging before 6 weeks of conservative treatment provides no benefit and increases costs 1
• Prescribing opioids: No evidence supports opioid use for musculoskeletal pain; risks outweigh benefits 1
• Passive treatment reliance: Patients must engage in active exercise and self-management rather than depending solely on passive modalities 1
• Ignoring psychosocial factors: Pain catastrophizing and fear-avoidance behaviors perpetuate disability and must be addressed 1
• Missing red flags: Always screen for serious pathology before initiating conservative care 1