What could cause a constant pain in the trapezius region near the spine?

Constant Trapezius Pain Near Spine: Causes and Clinical Approach

Constant trapezius pain near the spine is most commonly caused by myofascial trigger points in the trapezius muscle, which are hyperirritable nodules within taut bands of muscle fibers that produce localized tenderness and characteristic referred pain patterns. 1, 2

Primary Musculoskeletal Causes

Myofascial Trigger Points (Most Common)

• Myofascial trigger points are present in 30-93% of patients seeking treatment for musculoskeletal pain, with the trapezius descendens being one of the most prevalent locations for active trigger points in patients with neck and upper back pain. 1, 2
• These trigger points consist of hypercontracted muscle fibers that form palpable taut bands, producing deep aching pain when compressed with 2-4 kg/cm² of pressure for 10-20 seconds. 3, 4
• The pathophysiology involves a spinal reflex disorder with sustained neural activity creating a reverberating circuit in specific spinal cord segments, resulting in an acidic environment, high concentrations of inflammatory substances, stiffer muscle tissue, and spontaneous muscle activity at rest. 1, 2
• Muscles with trigger points are abnormally shortened with increased tone and tension, often related to biomechanical overloading from single or recurrent episodes of injury. 1, 5

Mechanical and Postural Factors

• Muscular imbalances, poor posture, and repetitive biomechanical stress contribute to trigger point development and perpetuation. 5
• Cervical muscle trigger points (key trigger points) often incite and perpetuate satellite trigger points in adjacent muscles, creating regional pain patterns. 3

Serious Pathology to Exclude (Red Flags)

Before attributing pain to benign musculoskeletal causes, you must systematically screen for red flags that indicate serious underlying pathology requiring urgent imaging.

Constitutional Symptoms

• Fever, unexplained weight loss, or night sweats suggest infection, malignancy, or inflammatory disease and mandate urgent MRI cervical/thoracic spine without contrast. 6, 7
• Elevated inflammatory markers (ESR, CRP, leukocytosis) warrant urgent evaluation for vertebral osteomyelitis, discitis, or inflammatory arthritis. 6, 7

High-Risk Patient Factors

• History of malignancy requires immediate MRI to assess for metastatic disease to the thoracic spine, which commonly presents with intractable pain and vertebral body tenderness. 6, 7
• Immunosuppression (HIV, chronic steroids, chemotherapy) or current/past IV drug use markedly increases risk of spinal infection. 6, 7
• Age >65 years or chronic steroid use raises concern for osteoporotic compression fractures, which are common in the thoracic spine. 6

Neurological Red Flags

• Progressive neurological deficits (weakness, sensory changes, gait disturbance, bowel/bladder dysfunction) indicate possible myelopathy or cord compression requiring urgent MRI within 12-24 hours. 6, 7
• Radicular pain radiating in a dermatomal distribution suggests nerve root compression. 6

Pain Characteristics

• Intractable pain despite 6 weeks of appropriate conservative therapy (medical management and physical therapy) warrants imaging evaluation. 6
• Constant pain, night pain, or pain lasting >4 weeks in pediatric patients requires advanced imaging. 6

Diagnostic Algorithm

Step 1: Red Flag Assessment

If ANY red flag is present: Order urgent MRI cervical/thoracic spine without contrast immediately. Do not delay imaging while trialing conservative therapy. 6, 7

If NO red flags and duration <6 weeks: Imaging is not warranted; proceed with conservative management as uncomplicated thoracic/cervical paraspinous pain is typically self-limited and responsive to conservative treatment. 6

Step 2: Physical Examination for Myofascial Trigger Points

• Palpate the trapezius muscle with 2-4 kg/cm² of pressure for 10-20 seconds to identify firm, tender nodules within taut bands. 3, 4
• Assess for reproduction of the patient's characteristic pain pattern with palpation (referred pain). 1, 3
• Evaluate for local twitch response when mechanically stimulating the trigger point. 3, 4
• Examine cervical range of motion and assess for restricted movement with pain provocation. 7, 8

Step 3: Imaging Considerations (When Indicated)

• MRI is superior to all other modalities for evaluating soft tissue abnormalities, nerve root impingement, inflammatory processes, infection, tumor, or vascular pathology. 7, 9
• Plain radiographs rarely change management in the absence of red flags, as degenerative changes are present in 85% of asymptomatic individuals over 30 years and correlate poorly with symptoms. 7
• Imaging may be considered after 6 weeks of conservative management with little or no improvement. 6

Management of Myofascial Trigger Points

Identify and Control Perpetuating Factors

• Correct postural abnormalities and body mechanics that create biomechanical stress. 3, 5
• Address psychological stress, depression, poor sleep quality, and nutritional deficiencies. 1, 3
• Implement ergonomic workplace modifications to reduce sustained awkward positions. 7

Trigger Point-Specific Therapies

• Spray and stretch techniques or trigger point injections serve as adjunctive therapy to denervate the neural loop. 1, 3
• Avoid repeated trigger point injections and never inject corticosteroids into trigger points. 5
• Manual therapy, massage, and physical therapy focusing on restoring normal muscle length and proper biomechanical orientation. 1, 5

Pharmacological Management

• NSAIDs (ibuprofen, naproxen) for anti-inflammatory effects and pain control. 9
• Acetaminophen when NSAIDs are contraindicated. 9
• Short-term muscle relaxants for severe muscle spasm, with caution regarding sedation. 9
• Avoid opioids for mechanical musculoskeletal pain due to unfavorable risk-benefit profile. 9

Comprehensive Rehabilitation Program

• Structured physical therapy emphasizing strengthening and stretching of affected muscles after trigger point treatment. 1, 5
• Gradual return to normal activities as tolerated. 9

Critical Pitfalls to Avoid

• Do not attribute constant pain to benign myofascial causes without first excluding red flags through systematic screening. 6, 7
• Do not order imaging immediately for acute pain (<6 weeks) without red flags, as this leads to overdiagnosis of incidental degenerative changes. 6, 7
• Do not interpret degenerative changes on imaging as causative without clinical correlation, as 85% of asymptomatic adults over 30 have cervical spondylotic changes. 7
• Do not use repeated trigger point injections or inject corticosteroids into trigger points. 5
• Do not delay MRI when red flags are present while awaiting specialist consultation or trialing conservative therapy. 7