Dr. Zac Morgan // #ClinicalTuesday // www.ptonice.com 

In today's episode of the PT on ICE Daily Show, Spine Division leader Zac Morgan discusses assessing, treating, and loading the upper traps when suspecting their involvement in neck or headache symptoms.

Take a listen or check out our full show notes on our blog at www.ptonice.com/blog.

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EPISODE TRANSCRIPTION

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ZAC MORGAN All right, good morning, PT on Ice Daily Show. I'm Dr. Zac Morgan, lead faculty in the spine division, teaching both cervical and lumbar spine management. And this morning I wanted to bring you all a technique Tuesday, looking at the upper trap, thinking more in that cervical management arena. So I think we all really appreciate that a lot of our patients with neck pain have some upper trap dysfunction. That's a very common muscle to have issues with, whether you're dealing with mechanical neck pain, Maybe you're dealing with cervicogenic headache patients, patients with TMD, temporal mandibular joint dysfunction. We see it a lot in our patients who have an irritated nerve root, something like a radiculopathy. They'll often hold some tension in that upper trap to kind of slacken their brachial plexus over time. Lastly, folks who are just really stressed out, which I think we all can kind of appreciate. That's most of our clientele. Most Americans carry around a ton of stress. I think all of these pathologies really lend themselves to quite a bit of tension in the upper trap. I wanted to talk this morning a little bit about actually like soft tissue assessment and kind of how to progress your vigor throughout that assessment to replicate those symptoms. But then I also wanted to just bleed that straight into treatment because they look quite similar and show you all some things that I find that are very useful for both identifying the symptoms and then eventually eradicating these symptoms doing some soft tissue work. So let's move to the table and we'll talk a little bit about the actual hands-on assessment of the upper trap and some key points to not miss. So we'll go ahead and shift gears over here. I do think having a little bit of soft tissue cream can be helpful when you're assessing the upper traps. So I like the company Deep Prep because Deep Prep is still, you can still get a grip on the muscle, but you get a little bit less friction, which is nice. There are plenty of soft tissue creams on the market. This is just the one that I typically will use. So I'm just going to kind of coat that whole region of the upper trap all the way up into the cervical spine with some lotion just to get it to where I can feel all of those fibers without getting too much grip on the person's skin. So, starting out from an assessment standpoint, the big piece that I don't want you to miss is the anterior side of the upper trap. So, I think a lot of times we feel these things with the person in prone, and we miss that anterior side of the upper trap, and I always like to think of it like a wave that's crashing over the shoulder, and we wanna feel that anterior side, or where the wave's almost curling. And so really, all the way down at the clavicle, I like to find the AC joint, and then start to just gently stress that lateral upper trap. And typically for palpation of the upper trap, I'm going with a grip like this. Kind of a lumbrical grip and avoiding DIP flexion. DIP flexion is what gets really uncomfortable, really pinpoint for the person. So I'm almost trying to sandwich that upper trap like this with my hand. So I'm going to feel that distal anterior upper trap and basically just make a couple of quick passes. I'm going to feel my way up through the anterior side of the upper trap. A couple of passes through there. I'm going to feel it as it connects to the neck right there where it's starting to dive into the actual cervical spine. And then of course the last place is up at the nuchal line where it's proximal insertion is. So you want to feel through all of that just with some really gentle strokes to start. you might pick up that the patient's a little heightened as you're feeling through this and that might be plenty of palpation to kind of elicit the symptoms but if the symptoms are a little less irritable and you want to kind of up the vigor of what you're doing here What I would suggest first is to just hold some tension in the upper trap and then push it straight down towards the table. So you won't be able to see my hand move down towards the table much because it's just bearing in the pillow. But essentially what I'm going to do is find each third of that upper trap, so the clavicular the AC joint attachment, like right there at the end of the clavicle, the middle of the trap, and then up towards the neck. I'm gonna find a tense spot, hold pressure, and drag it straight down towards the table, like this. So I would call that like pinning and then depressing. And then same thing in the middle of the trap, pin and depress. And then same thing up here at the neck, pin and depress. You'll often find that when you drive that trap down towards the table, that tension creates some of those cervicogenic headache symptoms, maybe even just their plain neck pain you might replicate like this. But if you really want to stress it even a little bit more, what I would encourage for the assessment is going to be pinning it, depressing it, then stretching it. So it's a pin and stretch, but we want to make sure we get that depression in as well. So I'm going to hold the bottom of my client's head like this. And so this part of my hand is going to be on one side of their head. Their head's going to lay across my forearm. That way I can add all of the motion that I want through my arm really easily. So I'm just going to gently slide my hand under their head, swung all the way through. Now I had easy control of her head and neck and I can come in, pinch, depress and stretch. move to the middle of the trap. Pinch, depress, and stretch. Team this technique for assessing the upper trap is the most common way that I'll wind up eliciting a lot of those soft tissue symptoms for the person. It's because it's pretty vigorous. As you pull that tension into the trap and then pull the proximal insertion away from the muscle, that often gets a lot of tension through that big muscle and the person will feel their symptoms. So make sure as you're assessing, pay special attention to the anterior side of the trap build your vigor slowly, start out with just gentle palpation throughout the muscle belly. If that gets the job done, no need to get more vigorous, but if you haven't found those symptoms and you're suspicious of the upper trap, then add a little bit more pinching and depression. If you want to get more vigorous still, pinch, depress, and move the head. Now from a treatment standpoint, thinking about soft tissue techniques that we can do, basically what I will typically do is take the depression out, but still do the pin and stretch. If you really want to get vigorous, you can of course add the depression back, but for most people you won't need that depression to get them a really big stretch and get their soft tissue a bit looser. So for that, it's the same thing that I just showed you from an assessment standpoint. But I'm going to do a lot more passes. And I typically think about the trap, the upper trap in those thirds. So there's like the lateral third, the middle third, and then the medial third. And I probably am going to do 10, 15 reps at each one. So I'm going to hold, side bend 10 times. Hold the middle, side bend 10 times. Hold the proximal, the part closest to the neck, side bend 10 times. Go back through, do the exact same thing with rotation. Go back through, do the exact same thing with flexion. And then the most vigorous or last one that I would do would be like that flexion quadrant where you're getting flexion rotation and side bending all at the same time. Those can look like this. So again, I'm gonna have that same exact grip of their head like this. I'm gonna find whatever that spot is and then just side bend. And it doesn't take much side bending for you to feel a lot of tension between your thumb and like index middle finger where you've got that kind of pincer grip. you will feel quite a bit of tension as you side bend, and I'm just going to loosen that up. Encourage the person to just breathe normally. This can be pretty intense. When I want to look at rotation, same thing. A little less tension and rotation than side bending, so often not quite as big a deal, but can just work rotation right here with the neck, holding just tension through this part of my hand. Last thing that's useful is flexion. Definitely more tension here in flexion. You're going to get a lot of stretch across those anterior fibers. This will often feel a little bit symptomatic for the person as well, but they'll often tell you how it feels like it needs to happen. It's kind of a hurts so good type of thing. And then last thing would be flexion quadrant. So moving into this diagonal. So I'm here and there. That'll be your most vigorous. So I'm thinking about moving her nose towards her armpit each time. That'll be definitely the most vigorous of all of these. So team, all of that is some nice ways to sort of assess and treat the upper trap. A lot of our neck pain clients would benefit from that. A decent amount of them are carrying tension already, whether they even have neck pain or not. Our clients are commonly complaining of tension there. They'll feel tense when you check their range of motion exam. This may not be the first thing you go to throughout their plan of care. There may be some other things that you do to address the local tissue. But throughout a lot of my clients with neck pains plan of care, I'm gonna do that deep dive into the upper trap, feel all the fibers, figure out where it really is the most tense, and then address that with a bunch of reps of soft tissue work. This works great and I think you'll find that it bumps people's symptoms down pretty well. The other thing is people love it. People generally love to feel thoroughly assessed, soft tissue and all, and it's rare that someone doesn't feel some tension here, so often patients just like for you to go ahead and take that nice broad overview of the upper trap. So make sure, whether it's a cervicogenic headache, mechanical neck pain, radiculopathy, you name it, there's a lot of patterns of neck pain that show up. Assess the upper trap. You will often find that you're able to bump those asterisks forward even better when you do so. And so I would really encourage you to make that a part of your practice. SUMMARY If you're looking for an upcoming spine course, if you're looking for cervical specifically, we've got a few coming up. So June 29th and 30th, Kent, Washington. So make sure you check us out there on the west coast. July 13th and 14th, Charlotte, North Carolina. So back over on the east coast. And then July 20th and 21st, Oviedo, Florida. So down south, right next to Orlando. If you're looking for lumbar management, June 8th and 9th in Anchorage, Alaska. So if you're out there in Alaska, join me for lumbar. June 22nd and 23rd in Paoli, Pennsylvania. And then July 13th and 14th in Amarillo, Texas. So several good course offerings upcoming. We'd love to see you out there on the road where we cover full head-to-toe management in spine conditions. Thanks everyone. I will catch you on the next one.

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