Trapezius myalgia: Making dentistry a pain in the neck—or head!

By midmorning, it starts … again; the all-too-familiar “tension headache” that soon evolves into a headache behind the dentist’s right eye and pain in his right temple. In an adjacent operatory, the hygienist experiences burning pain on the left side of her neck. Why does this happen? Both clinicians recently embarked upon diligent exercise programs with their personal trainers in an effort to improve their musculoskeletal health and avoid such painful episodes.

Does this sound familiar? If so, you’re in good company—the incidence of neck pain among dentists and hygienists has been reported as high as 71% and 82% respectively. The causes of headaches and neck pain are multifactorial; however, in dentistry, the upper trapezius muscle is the culprit in a myriad of head and neck pain syndromes.

The delivery of dental care places high demands on this muscle and can result in a painful condition called trapezius myalgia. Symptoms include pain, spasms, or tenderness in the upper trapezius muscle, often on the side of the mirror, or retracting arm (figure 1). Trigger points in this muscle result in headaches behind the eye, into the temple, and in back of the neck.

Figure 1 The left upper trapezius muscle

The upper trapezius muscles are responsible for elevating the shoulders and rotating the neck. In rounded shoulder posture, the upper trapezius and neck muscles largely support the arm’s weight, increasing muscular strain on the neck and shoulder. In dentistry, trapezius myalgia is caused by static, prolonged elevation of the shoulders, mental stress, infrequent breaks, and poor head posture.

CAUSES OF TRAPEZIUS MYALGIA

Positioning the patient too high. When the patient is positioned too high (Fig 1)  the operator is forced to assume one of two postures—working with the shoulders elevated (which leads to trapezius myalgia), or shoulder abduction (which leads to rotator cuff impingement). Patients should be positioned so the oral cavity is at elbow level or 4 cm above elbow level. When the patient is higher than this, arm abduction or shoulder elevation typically occurs, especially when working between the 8 o’clock and 10 o’clock positions. Working in the correct clock position for a specific tooth surface & quadrant, while preserving your optimal posture AND patient comfort, is critical for preventing upper trapezius pain.  This is covered in Dr. Valachi’s online CE course: “Treat & Beat your Upper Trapezius Pain”.

Figure 2 Positioning the patient too high & working in the wrong clock position can lead to trapezius myalgia.

Non-ergonomic magnification.  Poor head posture is commonly observed in the operatory and strains the upper trapezius muscles. Loupes with poor declination angles are one of the biggest culprits I’ve seen that can cause or worsen trapezius myalgia.  About 70% of the loupes on the market today don’t offer a steep enough declination angle to prevent trapezius myalgia.  For more information on proper loupe selection and brand recommendations, see Dr. Valachi’s online CE course: “Treat & Beat your Upper Trapezius Pain”   No armrests/Improper height. Supporting the arm weight is especially important for trapezius myalgia sufferers. Clinicians should make sure their armrest height is adjusted properly. Adjusting the armrests too high can cause neck stiffness and pain at the crook of the neck and shoulder, however adjusting them too low can also lead to neck pain.

Infrequent breaks/tightness. One EMG study of the neck, shoulders, and arms showed that the highest muscular activity during dental work occurs in the trapezius muscles. Sustained low-level contraction of these muscles with few breaks greatly increases susceptibility to pain. With insufficient rest periods or dynamic movement (i.e., chairside stretching), tension can accumulate in these muscles, and by the end of the day you may be wearing your shoulders as “earrings” without realizing it. Chairside stretching every 45 minutes is important to prevent trapezius myalgia.  Stretches to prevent trapezius myalgia are in Dr. Valachi’s online CE Course, “Treat & Beat Your Upper Trapezius Pain” 

Stress. Common clichés such as “pain in the neck” allude to stress as a cause of pain. This association is actually quite true. High levels of emotional stress and working at complex tasks can elicit muscular contraction in the upper trapezius muscle. This subconscious muscular contraction in response to stress is called neuromuscular hypertension. If the stress response is not followed by dynamic muscular activity, the blood pressure has no outlet and continues to rise. The statically contracted muscle becomes ischemic and painful while the blood pressure remains high. Therefore, stress management strategies that specifically target muscular-type pain are helpful in prevention. Numerous techniques to manage this physiological reaction to stress are in Dr. Valachi’s online CE course, “Treat & Beat your Upper Trapezius Pain”

Improper exercises. Training the upper trapezius muscle with heavy weight resistance is one of the most common exercise mistakes dental professionals make.  Fig. 3.

Figure 3 Certain exercises ( that aren’t a problem for the general public) can throw dental professionals into the ‘viscious pain cycle’, causing trapzius myalgia.

This can worsen the unique muscle imbalance to which they are already prone, create trigger points, and worsen neck pain.   Dental professionals are prone to a unique muscle imbalance which causes and worsens trapezius myalgia.  Team members should target this imbalance with shoulder stabilization exercises and very specific aerobic exercises, which are in Dr. Valachi’s online CE course, “Treat & Beat your Upper Trapezius Pain”

Wardrobe risk factors. Narrow bra straps can compress the upper trapezius muscles, worsen neck pain, and create headaches, especially among female dental professionals with large chests. Racer-back sports bras have wider straps and are a better choice. A purse slung over one shoulder can also perpetuate muscle imbalances to which female dental professionals are prone, since the trapezius muscle must contract unilaterally to support the weight.

Trigger points. Trigger points in the upper trapezius muscles can refer pain to the temple, cause a “headache behind the eye”, or cause pain in the back of the neck.(Fig 4)  Once the diagnosis is determined to be myofascial or muscular in nature, consider self-treating your own trigger points. An effective combination is moist heat, then trigger point self-treatment, followed by a sustained stretch of the affected muscle.