Expert: Dr. J. Shawn Leatherman - 4/29/2008

Question
My wife(age 36) has been experiencing ongoing issues with her neck and head for almost a year and the cause remains a mystery.  About a year ago, our car door accidentally hit her in the back of the head.  About a month later she began experiencing headaches, tingling and numbness in her extremities and face, and a tingling in her head which she explains as a "buzzing" feeling.  She had originally been diagnosed with protruding discs in her neck which were putting pressure on her spinal column.  After trying numerous conservative treatments, spinal fusion was done on two sections of her neck(I believe they were c3/c4 or c4/c5).  There was no relief and her symptoms continue as severe as the original onset.  She repeatedly advises her physicians that there is a very tender area right at the bottom of her neck and parallel to her shoulder region.(It's the bulging area where your neck meets your torso.)  If you press this area it immediately sends pain throughout her head and sometimes into her extremities.  However, if you massage around it and on her shoulders, she says that it relieves some of the pressure.  Any ideas what this might be caused from?  We are looking for some relief, even if temporary as she is continuously in pain.

Answer
Dear Mark,

What you have described are the classic symptoms of trigger point referral pain.  Trigger points are common in our population and can be the result of acute trauma or chronic overuse syndromes and poor posture.  With the mechanism of injury you described, the formation of trigger points in the neck musculature should be suspected.  Please read the American Academy of Family Physicians definition in the below paragraph.

Trigger points are discrete, focal, hyperirritable spots located in a taut band of skeletal muscle. They produce pain locally and in a referred pattern and often accompany chronic musculoskeletal disorders. Acute trauma or repetitive microtrauma may lead to the development of stress on muscle fibers and the formation of trigger points. Patients may have regional, persistent pain resulting in a decreased range of motion in the affected muscles. These include muscles used to maintain body posture, such as those in the neck, shoulders, and pelvic girdle. Trigger points may also manifest as tension headache, tinnitus (ringing in the ears), temporomandibular joint pain (jaw pain), decreased range of motion in the legs, and low back pain. Palpation of a hypersensitive bundle or nodule of muscle fiber of harder than normal consistency is the physical finding typically associated with a trigger point. Palpation of the trigger point will elicit pain directly over the affected area and/or cause radiation of pain toward a zone of reference and a local twitch response. Various modalities, such as the Spray and Stretch technique, ultrasonography, manipulative therapy and injection, are used to inactivate trigger points. Trigger-point injection has been shown to be one of the most effective treatment modalities to inactivate trigger points and provide prompt relief of symptoms. (Am Fam Physician 2002;65:653-60. Copyright© 2002 American Academy of Family Physicians.)

With the pain patterns that you have described, I would opine that the muscles responsible for your wife's pain are the upper trapezius muscle, the scalene muscles, and the sternocleidomastoid muscle. The levator scapulae muscle may also be affected. These are all located around the base of the neck and shoulder.  For a better representation of the pain patterns, I would suggest that you check out a book from your local library:  Myofascial Pain and Dysfunction:  The Trigger Point Manual (Volume 1), written by JG Travell and DG Simons, 1983.  This is the best referenc text on the subject and is widely quoted in other textbooks and clinical research.  

Frankly I am suprised that none of your other healthcare professionals have addressed this issue.  The fact that your wife's symptoms immediately improve with manual therapy around the neck just further corroborates the fact that trigger points are the most likely cause.  Hope this helps Mark.

Respectfully,
Dr. J. Shawn Leatherman
www.suncoasthealthcare.net