What is the appropriate management for an adult patient with no significant past medical history presenting with pain or cramps in the trapezius muscle accompanied by a moveable muscle mass?

Management of Trapezius Pain with Moveable Muscle Mass

Before attributing trapezius pain to a benign musculoskeletal cause, you must systematically exclude life-threatening visceral pathology, as left-sided trapezius pain can represent cardiac ischemia, aortic dissection, pancreatitis, or malignancy. 1

Immediate Red Flag Assessment

You need to urgently evaluate for these conditions before proceeding with musculoskeletal management:

• Cardiac ischemia: Left trapezius pain can be an anginal equivalent, particularly in adults over 40 years old 1
• Aortic pathology: Aortic aneurysm or dissection commonly refers pain to the interscapular and trapezius region 1
• Pancreatitis: Frequently causes referred pain between the scapulae through viscero-somatic convergent neurons 1
• Renal pathology: Nephrolithiasis or pyelonephritis can refer pain to the upper back 1
• Intrathoracic disease: Pleural irritation causes referred trapezius pain 1
• Malignancy: Thoracic spine neoplasms present with constant, unremitting pain 1

Required Physical Examination Components

Perform a comprehensive examination targeting visceral causes before assuming musculoskeletal origin:

• Cardiovascular examination to assess for cardiac ischemia 1
• Abdominal palpation to evaluate for pancreatitis or renal pathology 1
• Chest auscultation to detect pulmonary abnormalities 1
• Thoracic spine palpation for midline tenderness suggesting vertebral pathology 1
• Trapezius palpation for localized tenderness, which should reproduce the patient's pain if musculoskeletal 2
• Assessment for muscle atrophy, which indicates chronicity of the condition 2

Characterization of the "Moveable Mass"

The moveable muscle mass you describe requires specific evaluation:

• Accessory nerve (CN XI) palsy causes weakness and atrophy of the trapezius muscle, creating visible asymmetry and cosmetic disfiguration 2
• If true weakness or atrophy is present, MRI head without and with IV contrast, MRI orbits/face/neck without and with IV contrast, or CT neck with IV contrast is appropriate for initial imaging to evaluate the accessory nerve pathway 2
• The moveable mass may represent myofascial trigger points, which are palpable taut bands within the muscle that refer pain in characteristic patterns 3

Imaging Strategy

Do not order imaging for uncomplicated trapezius pain without red flags, as it provides no clinical benefit and increases costs. 2, 1, 4

However, imaging is indicated if:

• Red flags are present suggesting visceral pathology: order chest radiograph or CT chest based on clinical suspicion 1
• Accessory nerve palsy is suspected with true weakness/atrophy: order MRI or CT as described above 2
• Symptoms persist beyond 4-6 weeks of conservative management: consider MRI thoracic spine without contrast 1
• Neurologic deficits develop: obtain urgent MRI 5, 4

Conservative Management Algorithm

Once serious pathology is excluded, initiate this treatment sequence:

First-Line Treatment (0-6 weeks)

• Activity modification to minimize repetitive stresses and prolonged static postures 1
• NSAIDs for short-term pain relief, though they do not alter long-term outcomes or address underlying microcirculatory dysfunction 2, 1
• Relative rest by reducing activities that load the damaged tendon repetitively 2
• Physical therapy focused on eccentric strengthening, which is effective for tendinopathy and may reverse degenerative changes 2

Second-Line Options (After 4-6 weeks if no improvement)

• Trigger point therapy if myofascial trigger points are identified, as these share characteristics with chronic pain patterns 3
• Consider epidural steroid injections if radicular symptoms develop 5
• Extracorporeal shock wave therapy is safe and effective but expensive for chronic tendinopathies 2

Refractory Cases (After 3-6 months)

• Surgical consultation is appropriate for carefully selected patients who have failed conservative therapy 2

Critical Pitfalls to Avoid

• Never assume all trapezius pain is musculoskeletal without systematically excluding cardiac, aortic, pancreatic, renal, and pulmonary causes 1
• Do not order routine imaging for chronic uncomplicated pain without red flags, as this provides no benefit 2, 1, 4
• Recognize that corticosteroid injections may provide short-term pain relief but do not alter long-term outcomes 2
• Understand that NSAIDs are effective for acute pain but have no effect on long-term outcomes 2

Follow-Up Timing

• Reevaluate at 4-6 weeks if symptoms persist or worsen 4
• Seek urgent evaluation if myelopathy signs develop (spasticity, hyperreflexia, gait disturbance) or progressive motor weakness occurs 5
• Most patients improve within 4-12 weeks with conservative management alone 5