Complete Guide To Relieving Shoulder Trigger Points Pain
If you have pain in the shoulder or pain in the shoulder blades, there’s a good chance that you have shoulder pain pressure points (also known as ‘muscle knots’ or trigger points).
These muscle knots may not even be coming from the shoulder. (If you've seen some trigger point pdf or charts, you'll see how the pain spreads from other areas. For example, wrist pain can come from carpal tunnel trigger points). That’s why most people with pain in the shoulders are frustrated. Lack of improvement in their pain, no matter how many therapies they try, can cause quite a headache.
This article is going to answer all the questions you may have about causes of shoulder pain, shoulder pain treatment, and prevention strategies. You’ll be able to know what a trigger point is without getting over technical (like using words like rhomboid muscle trigger points!), how you can find it, and what you can do to get long lasting pain relief.
Want to learn more about trigger points first? You can read our article 'Introduction to Myofascial Trigger Points'. It will provide you with all the information you need to know what a trigger point is. Simply click here to go to that article. If you want to learn more about neck pain pressure points, click here.
Why Are Shoulder Pain Trigger Points So Difficult To Treat?
Trigger points (pressure points), neck pain or back pain causes, are quite common. In fact, nearly 85% of all muscular pain can have some presence of these pesky muscle knots. If these pressure points for neck and shoulder pain are so common, then why are they so difficult to treat? Here are two of the most common reasons why this happens:
Your muscle knots may not be located in the shoulder area
Trigger points can develop in any muscle around the shoulder and also in muscles that are a short distance away. Pressure points for arm pain can come from the neck. For shoulder pressure points, the may may also go into the arm. This is why it's sometimes difficult to understand where the pain is coming from. The shoulder pressure points may sometimes then be overlooked. Just like thigh trigger points can refer pain into the knee, shoulder points can go somewhere else.
Most people don’t know that they should look in the mid back or even in the chest (pectoral trigger points). They continue getting the shoulder treated, with no change in their pain.
Want to know how many muscles can give you shoulder pain? (We did a similar list for trigger points in buttocks and low back in another article) Here, we break it down into direct shoulder muscles, and non-direct shoulder muscles. The names of the muscles are not important for now. What you want to take away is the surprising number of non shoulder muscles that can cause you pain, and what we can do to treat these pressure points to relieve shoulder pain:
As you can see, there are more non-direct shoulder muscles that cause shoulder pain (trap trigger points weren't included since they usually send pain up to the neck, jaw and forehead). As we begin talking about treatments, we’ll show you how you can target all these areas for pain relief (without resorting to an injection shot for muscle pain).
Being labeled with a 'diagnosis' may distract someone from looking for trigger points
I’ve treated patients for over 20 years, and I am also guilty of focusing so much on the diagnosis that I sometimes miss the most obvious cause – a simple muscle knot.
As a health professional, I am required to provide a diagnosis for every complaint a patient has.
The problem with a diagnosis is that it sometimes distracts us from looking at the muscle knot. Pressure points in the back may mistakenly lead to a diagnosis of sciatica. Trigger points in chest muscles can actually mimic angina! If you were given a diagnosis for your shoulder pain (like rotator cuff tendonitis), rotator cuff referred pain pattern from trigger points may be a main contributor. Here are a list of conditions that can have shoulder knots:
Common Trigger Point Shoulder Pain Symptoms
You’ve just learned that your shoulder pain may not be coming from the shoulder. You’ve also learned that a wide number of shoulder ‘diseases’ can have pain coming from trigger points. For example, in a bicep, trigger points may be disguised as a muscle strain.
No wonder they’re overlooked! The type of shoulder pain that you can feel from these muscle knots can also be quite different. Deltoid trigger points can be aching or deep and throbbing. However, there’s a few things you should know about the pain so you’re better able to figure out whether it’s coming from knots in your shoulder:
- Pain is mostly felt as an ache. If you have numbness over the shoulder area, that has more to do with a nerve. The achiness can also be quite different. One muscle can give you a dull ache, while another can feel like a deep ache. Although some may think they have a frozen shoulder, trigger points may be the cause of the underlying pain.
- A deep aching feeling deep inside the joint can mimic arthritis, but is most likely due to pressure points for shoulder pain, like an infraspinatus trigger point
- Clicking over the shoulder joint can also be caused by supraspinatus trigger points
- For some pressure points, shoulder pain from lifting can be due to a deltoid or supraspinatus trigger point
- Pain brought on my hunched over posture all day can be due to several different muscle knots in shoulder, and can even be brought on by tightness in the chest muscles
- Deep pain at night can make one think they have ‘bursitis’, but it can be due to the infraspinatus muscle
How To Relieve Shoulder Pain
Whatever tool you use, always begin applying pressure in the area of pain.
Acupuncture trigger points are no different, except you are using acupuncture needles. In fact, the majority of acupuncture points are very similar to where the trigger points are.
To better learn how to treat muscle knots, ask yourself the following questions: Do you feel any tenderness there? Does it recreate your pain?
If it doesn’t, then begin to move in circles around the area. If you still don’t feel any pain, then increase the size of that circle. It’s important to be patient when you do this (larger areas, like trigger point in glutes, takes more time and patience). Its very easy to miss a trigger point if you are too quick to find a spot, so slow down and treat the pressure points for shoulder blade pain the right way. Lot of my patients are shocked how easy it is to use the hands, when they thought they'd have to resort to aggressive things like an injection trigger shot for pain.
The next thing to do is divide the areas into sections. For example, in forearm trigger points, we divide it into the anterior and posterior forearm and even into the wrist and upper arm (because knots from these other areas can cause forearm pain). For pressure points on back or front of the shoulder, here are the areas that I’ve found to be helpful. Make sure you don’t overlook any of these areas, especially shoulder blade trigger points. The following video gives you a detailed description of how to find these trigger points. We outline each section following the video:
Trigger Points On The Side of The Shoulder:
This is the area of the shoulder that is at the top of the upper arm. I always start here because most of the pain is usually in this area. If you can recreate your pain locally, it will be much easier to treat those trigger points. That's unlike trigger points for hip pain, where the pain is usually from the back or the front hip flexors.
One word of caution though.
There is a high likelihood that you will have pain here. Most people find that spot and then forget to look everywhere else, like for mid back trigger points. We may think that this is the only spot we need to be releasing muscle knots at. If you find that treating this area for shoulder knot pain relieves all your pain, you won't need to look anywhere else.
However, if you find that the relief is temporary, you may want to look into the other areas described below.
Note: This is similar to back pain pressure points. The pain can actually come from the stomach area and radiate to the back. Trigger points in hip muscles rarely go up to the back.
Trigger Point Pain In The Back Of The Shoulder:
The back of the shoulder has most of the ‘shoulder’ muscles that are causing the knot in shoulder muscle. Here we will find the supraspinatus, infraspinatus, teres major, teres minor, and lats.
The goal of treatment for muscle knots is to look for trigger points above the shoulder blade, over the shoulder blade, along the outside of the shoulder blade, and along the medial part of the blade, closest to the spine. Once you have assessed all these trigger points in hand, you'll have a better idea on the best strategy to use to get to these shoulder muscle knots.
The best way to target massaging knots is with a trigger point ball, cane shaped tools or the Muscle Wizard. We demonstrated that in the above video. Notice that there is no mention of injection for muscle pain. Just like lidocaine injection for back pain, aggressive treatments like those are rarely used.
Trigger Points In The Neck Area:
The neck area is often overlooked. If someone does poke around the neck, they will most likely forget the front of the neck. In order to learn how to relieve muscle knots in this area, never overlook the neck.
The front of the neck is where the main neck muscles refer pain into the shoulder. This is called the scalene muscle. You can easily poke around these muscles with your own fingers. If you find the right spot, you’ll be able to recreate the pain that’s in the shoulder. Relieving muscle knots in these areas where you have myofascial neck pain, can be tricky, but still better than a dry needle injection.
Muscle Trigger Points In The Chest Area:
The chest muscles can also develop trigger points, mostly from being in a slouched position, like sitting at your desk all day (thoracic trigger points, in the mid back, are also quite common from this slouched position). You can usually tell from both chest and shoulder pain. These muscles can be treated by your hands, a trigger point ball, or a Muscle Wizard.
The best way to target this large muscle is to use my 'plow the field' technique. Using a ball or just your hand, trigger points can all be found and addressed with this method for treating muscle knots. Start at either corner of the muscle and go across or down in a straight line. Then come back to the original area, move slightly to the side of it, and repeat. That way, you're never going to miss a trigger point. You can use the same method with trigger points in shoulder muscles.
Side Note: I keep mentioning the hands to press into the points. Some have others help them with getting into the spots. If someone else uses an elbow, trigger points may become bruised and you can end up with more pain. Be careful when someone else works on your own muscles. Make sure they go slow and with the least amount of pressure possible. Being too aggressive, as in trigger shot injection, may feel like it will help the pain faster, but it usually will set you back.
Trigger Points Pain In Front Of Shoulder And Upper Arm Area:
The arm contains the biceps and coracobrachialis muscle .If none of the other areas (like subscapularis trigger points) can recreate your shoulder pain, this is an area that you can target.
The best way I’ve been able to target these muscles is with a trigger point ball, preferably leaning against a wall.
If you begin to get relief from your shoulder pain, you may want to progress to lying down, where you can apply more body pressure.
The key is to apply just enough pressure that you can recreate your pain. Pressing too hard or treating too vigorously can leave you bruised and sore. For example hip pain trigger points can sometimes refer pain down the leg or give feelings of being 'swollen' if you go too hard.
Trigger Points In The Mid To Low Back Area:
This is the last area I look at if all other options fail to recreate my shoulder pain. From all these diagrams, you may wonder what muscles do NOT refer pain to the shoulder! Well, sinus trigger points don't, but the point is to never discount any muscle area. Now back to the muscle knot treatment in hand. There’s a muscle that attaches to the upper arm that actually goes all the way down to the low back.
It’s called the latissimus dorsi. It’s the muscle that gives a bodybuilder the ‘V’ shape. On rare occasions, this is the muscle that ends up referring the pain.
How To Treat Shoulder Pain
By now, you should have an idea on how to find your neck and shoulder trigger points. The goal is to find tender spots in your shoulder muscles pain that recreate the type of pain you feel. One thing to note is that trigger points are quite common. Mostly everyone will be able to find tender spots in muscles. As mentioned before, acupressure points for shoulder pain are very similar to the location of trigger points.
The real trick is to find the spots that can make you safely say ‘THAT is what’s causing my pain!’ That leads us into the best ways to treat these muscle knots. Here are some key points to remember as you treat your shoulder trigger points
- Don’t press too hard. Press just enough that you can feel the tenderness and the referred pain. If you are grimacing or tensing up, you are pressing too hard. For trigger points head pain, there are spots in the back of the head that provide great relief, which makes it tempting to press as hard as possible. The goal is to apply just enough pressure that you’re comfortable. Once the pain starts to reduce, you can apply more pressure. For trigger points in head muscles, all pressure can be done with the fingers to avoid going to hard on trigger points on head pain.
- Don’t over treat one area. It’s a common habit that all my patients have. They’re so relieved to find that first spot that they tend to think that the more they treat it, the better it will become. For trigger points for knee pain, there is usually one or two spots that they just can't seem to stop pressing. However, you’re more likely to get bruised and feel more pain if you did this. It’s better to target several trigger points during one session than it is to spend all that time on one spot.
- Look for a referral of pain. If you press into the midback (rhomboid trigger points), does it radiate into the shoulder? If so, that’s a sign of a trigger point. Also make sure you can tell the difference between hitting a nerve or a trigger point. A nerve will feel like a numbness or tingling sensation. Some of us may never have had nerve pain so it may be difficult to tell. If that’s the case, there’s one simple way to tell the difference: a trigger point pain should begin to ease off after a few seconds of pressure. A nerve pain will stay at the same intensity and may even increase the more you press into it. For example, with head trigger points, one may get a throbbing or deep pain. At first you may be worried. But after a few seconds, if the pain decreases, then you most likely are on a trigger point.
Best Shoulder Stretches To Treat Trigger Points
When my patients see me for the first time, they tell me that they already stretch often without any improvement in pain. This is common. The second thing they always ask is whether they'll need trigger shots for back pain. You should now know that you won't, even for the trigger points for shoulder pain that we are discussing here.
Anyone who has trigger points often ‘craves’ stretching. You may have several knots in a muscle that may feel tight. Stretches for shoulder pain usually provides temporary relief.
If feels as though you need to stretch all day. For example, hip trigger points are some of the more common ones where for the trigger points, hip pain often feels 'temporarily' better after stretching. If that describes you, here are some ways for you to add stretching to your program:
- Try first focusing on self trigger point treatments or get trigger point therapy through a health professional. Once the pain begins to improve, you can slowly add a stretching program, like stretching the trapezius shoulder pain muscles.
- If you want to continue stretching, try doing it after you’ve worked on the trigger points in upper back and shoulders through self trigger point treatments.
- One of the most effective ways I see my patients add stretching to their self trigger point treatments for upper back trigger points is to warm up the muscle first, apply pressure to the trigger points with any of the tools we mention, and then stretch out afterwards.
- For all these trigger points (upper back, shoulder, chest, etc.), try doing your stretching program while taking a hot shower. The muscles will be relaxed enough for you to get a good stretch
- Hold the stretch for at least 30 seconds, and sometimes up to 2 minutes. As you can see, we still haven't had to rely on muscle injections for pain.
Now that you know how to add stretching to your program, the following video gives you some of the good ways to stretch, and some positions to avoid:
Strengthening Exercises For Shoulder Muscles With Trigger Points
Strengthening Exercises For Shoulder Muscles With Trigger Points
For most trigger points (legs, back, shoulders, neck), most of you should be able to get muscle knot relief through self-treatments, which don't even require you to ask 'what do muscle knots feel like' if you're using my 'plowing the field' method. For others, you’ll need to strengthen the shoulder muscles (without any triggerpoint injections).
Do you sit slouched over all day (where you may also have other things like headache trigger points)? Or does your job involve using your shoulder muscles, where there's a chance of getting rotator cuff trigger points?
If that’s the case, your muscles need to be strong, or have the endurance to handle repetitive tasks or positions where your muscles are being constantly worked. Whether its trigger points in calf muscles or shoulder muscles, that’s where strengthening programs come in, primarily focusing on the rotator cuff muscles. Here are a few points to remember when starting a strengthening program after you've learned how to release muscle knots from self treatments:
- The goal of strengthening is not to develop ‘big muscles’. The goal is to build up muscle endurance (even with low back trigger points). That means you’re not going to be lifting anything heavy. In fact, the less amount of weight or resistance the better. We’re going to focus on higher repetition exercises. If you can do any of these exercises more than 15 times at a time, you’re doing good. If you can’t, slowly build up to it. It may sometimes be difficult and slow but it's better than a lidocaine injection for neck pain or shoulder pain.
- I usually recommend that you treat the trigger points in neck and shoulder first. Once you begin to see some pain relief, you can begin strengthening exercises twice per week. If at any time you’re feeling more pain (trigger points neck or shoulder pain), or no change in the pain, then stop the strengthening and go back to self trigger point treatments. Once you begin to feel better again, slowly begin strengthening to see if you can maintain the improvements. Sometimes you'll go one step back and 2 steps forward so be patient. No need to think you need any tpi injections.
- You don’t have to do all the strengthening exercises that we recommend. Start with one exercise first. Do that for a week or two. If you still feel good, you can add another exercise, or you can increase the frequency of your exercise to 3 times per week. Sometimes other areas can limit you, like trigger points in arm, tension headache trigger points or trigger points in the neck. If this is the case, make sure you begin addressing them also.
- There’s a lot of strengthening exercises out there that you can use. Let’s just say that you won’t run out of any shoulder strengthening exercises to do! However, the focus is to keep it simple. Do one or 2 exercises that will help maintain proper shoulder strength. Once you achieve pain relief and are motivated to do more, you can explore more exercises. (For example, when we find trigger points in neck symptoms, there are many strengthening exercises for the front, side and back of the neck, including the upper back, chest and even to the low back. We don't only concentrate on trigger points on neck muscles. Our strengthening program is comprehensive). For now, I like to provide the basic exercises that you will need. Here is a short video on the best strengthening exercises for trigger points in the shoulder (we also have another article for trigger points in lower back pain, neck pain, and headaches):
Prevention Strategies For Future Shoulder Trigger Points
Prevention Strategies For Future Shoulder Trigger Points
Self treatments with any of the tools out there will be the best option to reduce shoulder and cervical trigger point pain. Stretching and strengthening exercises for trigger points in neck and shoulders will help you maintain the strength and flexibility you need to keep your muscles from going back to being in pain. Stretch and strengthen the trigger point, neck and shoulder pain will most often feel better.
However, if you can’t fix the original cause of the trigger points in shoulder and neck muscles, you’ll be fighting an uphill battle. The good news is that most of the causes can be addressed and changed. Fix these issues and you’ll be able to reduce the stresses that are causing your shoulder pain.
Note: Most people ask me 'what does a muscle knot feel like?' It's often because they think there is something they can feel so they can relieve it. They are sometimes suspicious of simple prevention strategies since you aren't exactly pressing into something but seeing benefits. Whether it's the back, shoulder or leg, trigger points are not 'usually tight'. The most tight feeling muscles may have no pain, while the most relaxing muscles, like trigger points for lower back pain, can be the most painful.
You can watch the video below that outlines some of the prevention strategies, without the need to complicate things like getting trigger point injections:
Here are a list of some of the things that tend to increase shoulder trigger point pain. The shoulder is only second to lumbar trigger points when it comes to complaining of certain positions that lead to pain in the shoulder or pressure points for upper back pain. Do any of these relate to you? If so, you will want to focus on these while you’re taking charge of your health:
Avoid keeping your arms raised for periods of time: Anytime your arms are raised, you’re working your shoulder muscles, not to mention probably aggravating neck muscle trigger points. If you keep this position for long periods of time, you’re basically overworking these muscles. That leads to a tug of war where your muscles are constantly contracting to keep the arms up. This can lead to trigger points. Examples include the following:
- Avoid working overhead (electrician, painter, etc.). Instead of working with the arms above shoulder level, use a small stool to raise yourself up so your arms are brought closer to you and are at shoulder level
- Avoid computer desks that are too high or a chair that is too short for you: proper ergonomics in the work place is important. You should be sitting at a desk where your arms are at a 90 degree angle with the keyboard or desk. See if your desk or computer is too high, or if your chair is too low. Its easier to adjust the chair to fit your position. Rhomboid muscle knot in the mid back is a common complaint for those that are hunched over or using a computer desk like this.
- Avoid having your computer or work too far in front of you. If you are reaching overhead and out, or your keyboard and desk work is so far that you are always reaching forward, bring your chair in more or your work closer to your body. The further you work on something, the more work your shoulders will have to do. Notice how easy these prevention strategies are compared to invasive things like muscle pain injection.
- Avoid chairs with no arm rests: Arm rests are more important than you think. It’s impact on trigger points are usually not felt right away. Over time, your body is going to work hard to keep your arms up. Not only will you begin to develop shoulder pain, but you’ll end up getting muscle knots in the neck, which will often refer pain to the shoulder area. If you’re working at a desk for long periods of time, it’s best to get a chair with arm rests. For some, they slouch forward, tightening their chest muscles and giving rise to chest trigger points.
Carrying objects with the arm hanging down:
Do you carry a briefcase or purse in one hand with your arm hanging down?
Is it heavier than usual?
Most often, this can lead to an overstretching of the shoulder muscles. Again, this is something that’s not usually noticeable right away.
If you’re doing this on a regular basis, try changing up arms.
The best prevention techniques is to get a briefcase with wheels or use a back pack that you can place across both shoulders. If you’re travelling, make sure you always use a cart to carry your luggage. I have had patients that could never figure out why they always saw me for treatments after business trips! I've even had someone that was getting lidocaine injections for fibromyalgia, when in fact the origin were trigger points, shoulder pain and all. This slight modification actually reduced the pain about 50%.
Trigger Point Injections
With any form of injection, a small needle is inserted by a qualified health professional, directly into a trigger point. There are different options to use for the needle, such as a local anesthetic like lidocaine injections for trigger points, a saline solution or even including a corticosteroid. Injections can be performed anywhere on the body and not just the shoulder. Like knee pain trigger points, piriformis trigger points, and neck pain trigger points.
Does adding corticosteroids to an injection help with shoulder or neck trigger points? Some new evidence states that just using a lidocaine injection alone produces the same results as using lidocaine plus corticosteroids. (1) This study focused on injections instead of a priformis myofascial release. However, the sample size was relatively small for this study, but it does follow the trend that’s seen with injections of any kind for muscle pain, including shot for muscle spasms. And that is that corticosteroids may be overdoing it when it comes to tpi injections
Using botox (botulinum toxin A) is also something that is being used for trigger points for neck pain, shoulder, headaches, trigger points in legs, etc. Some of my medical colleagues, who are experts on how to get rid of trigger points, perform these and do see some results. The literature also shows that there are benefits on how to get rid of knots in shoulder muscles. However, more studies are needed to minimize the placebo effect, look at how many doses are exactly required and making sure that the injections are actually hitting the trigger points through ultrasound guided treatments.
Injections combined with conservative treatments:
If you’re going to get an injection, whether for foot trigger points or shoulder pain trigger points, using compression of the trigger points (sometimes using a foot trigger point chart to find the right spots)in addition to injections may show better results. A study showed just that by demonstrating that getting injections with ischemic compression (pressing into the trigger point or satellite trigger points) gave better results than just injections alone. (2)
What’s interesting is that they tested pressure with the hands over the spot for 30 seconds and 60 seconds. The longer time didn’t make any difference. This goes back to my earlier point about not needing to hold a spot for a long period of time. For example, if you’re using your fingers on the opposite arm trigger points, pressing for too long will only fatigue you.
Note: With injections, it’s best to have someone used guided ultrasound. With using the hands, using a myofascial pain syndrome trigger points chart may be helpful. A muscle trigger points chart can easily be found online for free.
Should you get treated by an injection or get physical therapy?
The good news is that a recent study actually compared injections on trapezius trigger points with lidocaine to physical therapy treatments, or a combination of treatments for these muscle knots. They found there wasn’t any difference between the lidocaine injection and the physical therapy treatments alone or combined together in treating trigger points. Therefore, an injection may not be the first line of defence. (3)
However, you also need to realize that certain areas with trigger points may be better off with an injection. Another study found that lidocaine injections were better at reducing chronic pelvic pain from trigger points compared to manual ischemic pressure from the hands via physical therapy. (4)
These type of conflicting results reinforce the need to not treat every trigger point the same, or every treatment the same. Fascial trigger points may respond differently than a scalene myofascial pain syndrome.
What is the risk of a trigger point injection?
The most common risk is post-injection pain. In upper trapezius trigger point treatment, you may have some soreness in your shoulders. The pain can last a few days. (What is a muscle knot to do to get any pain relief?!) Most of this occurs when there is no medication that is added to the injection. With an injection that includes a corticosteroid, there is a chance of a fat shrinkage around the area, leaving a small dent in the skin. Other rare results can be infection and bleeding. This can happen anywhere, including scalene trigger points.
In summary, trigger point injections were originally not given much weight, since there was a lack of objective criteria in even defining what a trigger point was! Nowadays, using guided ultrasound can be an effective tool to increase the accuracy of an injection, and may provide better outcomes.
Although we talked about specific treatments for shoulder trigger points, a lot of these principles can apply (sometimes with the help of myofascial trigger points chart) to lower back trigger points, or neck or even headaches. We also looked at injection muscle techniques on how to treat trigger points and shown that there are different types of injections out there, whether you have trigger point foot, trigger points face, or trigger points arm treatments. We also looked at what causes trigger points. Some of these causes of trigger points can actually be treatable through prevention techniques and simple home tools with self treatments. We also looked at different ways on how to relieve trigger points and what causes trigger points to develop. When given the right patience and the right knowledge, it’s not difficult to self treat your shoulder trigger points at home. You can use a simple body trigger points chart to help you find the right areas, use a Muscle wizard to help relieve the trigger point pain and then a stretching, strengthening and prevention program to make sure your relief is permanent.