Therapy Notes – Middle trapezius

The middle trapezius is often part of a larger problem with high-tight shoulders. Integrative Neuromuscular Massage involves addressing the other elevators of the shoulder girdle, especially the serratus anterior. Many therapists don’t treat these areas because it is inconvenient, awkward, and difficult on the hands.

The middle trapezius is often part of a larger problem with high-tight shoulders. Integrative Neuromuscular Massage involves restructuring the position of the shoulder blade. Consequently, this approach involves addressing the other elevators of the shoulder girdle, especially the serratus anterior. Many therapists don’t treat these areas because it is inconvenient, awkward, and difficult on the hands.

Innervation of the Trapezius Muscle

The trapezius is a complicated muscle in several ways. First, it is innervated by the spinal accessory nerve, which is, in itself, an unusual structure. In addition, it has three distinct sections. Each section has a very different role in suspending the scapula over the rib cage. Furthermore, irritation of the trapezius is reputable for creating regulatory problems that drive people into anxiety, fight, and flight. It’s trigger points feed the sympathetic ganglion, make tags intolerable, and more.

The spinal accessory nerve innervates the trapezius muscle. Nerve fibers come off of the first 4-5 segments of the spinal cord and travel inside of the spinal canal back to the cranium before they exit via the jugular foramen. As they extend inferiorly, they join with fibers of the first four cervical nerves. Also, some sites report of innervation of the trapezius by the ventral rami of the third and fourth cervical vertebrae.

This structure implies that the first five vertebrae can contribute to the innervation of the trapezius. Consequently, the upper cervical area needs evaluation and treatment before treating the trapezius directly. If you have the training, start by treat the occiput, temporal bones, and fascia around the Jugular foramen. Follow up with the treatment of the suboccipital area, upper cervical vertebrae, and then continue to the more local joints and trigger points.


Start by Understanding the Anatomy.
About the coloring of the illustrations…

Its muscle is a supporting strap that creates deep, nagging pain. Read more about it in this post about the anatomy of the serratus posterior superior.

Evaluating and releasing other elevators of the scapula is important. Make sure that you include the extrinsic chest muscles, especially serratus anterior. Here’s an overview of the extrinsic chest muscles.

In the extrinsic back muscles, rhomboids, levator scapula, middle and upper trapezius also need to be considered.


Treatment Sequencing

Open the Nerve Flow, Release the Upper attachments

Start with cranial work around the jugular foramen. This includes mobilizing the atlas and releasing the suboccipital muscles.

Continue with treating the cervical lamina groove.

The mobilization of those first five vertebrae helps to further work the spinal accessory nerve. Also, some of the nerve feed of the trapezius comes out of the posterior rami fo the mid-cervicals. Consequently, it will make the rest of this treatment more comfortable and effective.

The middle trapezius extends into the upper thoracics. Taking those glides a bit further will make the next steps easier.

Release the Attachments with Gentle Joint Work

You can get the middle trapezius to soften by releasing the local joints before heading to direct treatment./

While you are here, slip your fingers under the SCM and onto the lower vertebrae. Free the lower cervical vertebrae that are sheared forward. They are part of the tension in local joints too.

The classical neuromuscular routine for trapezius does not include the treatment of the medial attachment. So far, the cranial and cervical attachments have been addressed in this sequence. The lamina groove routine addresses the rest. It is also an excellent way to relax the client. This tedious work along the spine releases tension throughout the system.

Remember that this trigger point creates irritation in this area. For this reason, treatment should be firm and calming. In other words, too much rubbing on the skin without proper lubrication can rub them the wrong way.

This is a classic neuromuscular routine for treating the trapezius while the client is prone. If you’ve done the prep work, it should melt under your finger tips.

There is a special technique here for treating the cowl of the trapezius. It offers focused attention to the upper and lower trapezius. Admittedly, it is tedious and takes practice but can be worthwhile when those areas need more than glides.

Self Care tends to be quite beneficial for this problem. The breathing exercises are effective in releasing the elevators of the scapula. As well, those exercises notably comfort and relax the client. Don’t miss out on helping your client with self-care for irritating tags and burning shoulders.



This site is undergoing changes. Starting in early 2020, we began improving the format. We are also adding more extensive self-care, illustrations, therapist notes, anatomy, and protocols. We appreciate your input and feedback. You will see us adding posts and updating older posts as time permits.


Weekly Featured Post

This post shows you how to press out the trigger points and stretch the infraspinatus muscle. It’s a small muscle on the back of the shoulder but creates a number of problems, including:

  • shoulder pain when sleeping
  • loss of grip strength
  • upper neck pain
  • pain along the inside edge of the shoulder blade

Tony Preston has a practice in Atlanta, Georgia where he sees clients. He has written and taught about anatomy, trigger points, and cranial therapies since the mid-90s.

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will include more patterns with better self-care. In the meanwhile, there may be inconsistency in formatting, content presentation, and readability. Until we get older posts updated, please excuse our mess.

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