The World Health Organisation has more than 100 classifications for headaches. The usual ones that musculoskeletal specialists (physiotherapists, osteopaths, chiropractors, musculoskeletal physicians) deal with are 'tension' headaches and 'cervicogenic' headaches.

Tension headaches can be attributed to increased muscle tension in the muscles found at the back of the neck (upper trapezius, splenius capitus, semispinalis capitus). Tension in these muscles may increase for a number of reasons, including physical and emotional stress, sustained postures (such as in computer work) as an occupational hazard or sustained neck extension in cyclists as a sporting hazard. It is thought that as tension in these muscles increases, the nerve supply (via the greater occipital nerve) and blood supply to the back of the scalp are obstructed. This causes widespread pain in the skin and muscles at the back of the head and base of the skull and can often radiate to the front in a 'tension band'.

Cervicogenic headaches, on the other hand, are usually caused by pathology in the joints, joint structures, muscles or nerve elements in the first three cervical joints (C1-C3). Pathology in these areas sets up a referred-pain phenomenon so that pain is felt in the head, jaw or face. These headaches are characteristically felt on one side only and are almost always preceded by neck pain.

This case study focuses on another unusual type of one-sided headaches - trigger point headaches.

The problem
A 28-year-old former Rugby League player presented to the clinic based on recommendation from another physiotherapist. This athlete was a fit-looking, well-built, active man who no longer played Rugby League (last game at 25). He ran 3-4 times per week, both interval-type training and longer endurance training, and still participated in gym training 3-4 times per week.
His major complaint was long-term discomfort and ache felt on the right side of the neck, extending from the base of the skull to the point of the shoulder (through the upper trapezius muscle). He also had intermittent 'full' uncomfortable sensations in the right cheek, behind the right eye and in the right side of his mouth. He also complained of intermittent right-jaw pain. He had consulted a dentist, and an OPG (an X-ray for the teeth) indicated that his wisdom teeth were not the cause of the jaw pain. When particularly bad, the pain radiated into the temple and was 'pulsing' or 'throbbing' in nature. The pain seemed to come and go without any real precipitating causes. He would have periods of real discomfort through the face and eyes for weeks on end, then everything would be fine for several more weeks. He could not detect any particular patterns.

The neck ache and facial sensations had been present for about five years. He had consulted numerous physiotherapists and shopped around for a solution to the problem with no success. He had at various stages had his neck mobilised, manipulated, massaged, electrotherapied,
X-rayed, CT-scanned and exercised, all to no avail. He was resigned to the fact that he would have this problem for a long time and would just have to put up with it.

The background

When questioned about possible trauma to his neck, the player recalled that when he was about 21 he had suffered a 'stinger' type injury to his right shoulder during a game of football, which had caused him considerable problems for about three weeks. The mechanism of the injury was a direct blow (from a knee) into the shoulder and collarbone area while making a tackle. It had caused immediate pins-and-needles and numbness into the whole arm, and he had been unable to lift the arm for about five minutes. When he did regain function, the arm was heavy and felt like 'lead'. This sensation of heaviness lasted for about three days and gradually resolved. Nothing was particularly painful. When questioned about other problems around the right shoulder, he indicated that he had experienced ongoing problems with his right shoulder when bench pressing anything over 130kg. This had continued on and off for about three years. He had treated it with stability-type exercises, and after six months it had resolved.

What I found very interesting about this patient's story was the stinger injury he had received five years earlier. I hypothesised that he had possibly received a significant brachial plexus neuropraxia (a type of nerve bruising that affects the conduction of nerve impulses) that had caused a temporary sensation change and a longer-standing problem with the conduction to the muscles - hence the heavy-arm syndrome. If the nerve 'damage' was located where the nerve roots exit the spinal column, then this would have affected not only the muscles of the upper limb but also all the elevating muscles of the scapula (such as the upper trapezius, levator scapulae and, indirectly, the scalenus and sternocleidomastoid). My reasoning brought me to the conclusion that he had long-standing dysfunction (due to a conduction problem) in the muscles that may have caused some mild atrophy and weakness over time.

On further inspection
When I examined the patient, I noticed some interesting things. His right shoulder was lower than his left shoulder. He had mild wasting in his infraspinatus and deltoid, and upper trapezius. The area filling in behind his collarbone on the right looked a lot thicker and fuller than on the left side. His head was translated off-centre to the right side. With active elevation movements of the arm, he had poor control of the scapula on the right, with early movement of the scapula on the way up and loss of control on the way down. His neck movements looked full range, though they looked a bit tighter when he was rotating his head to the right.

What gave him real discomfort was a left cervical quadrant, a movement where the head is actively rotated to the left about half way, the left ear is dropped sideways over the left shoulder and the patient then looks up. This is supposed to maximally test the facet joints on the left, but it reproduced the discomfort he felt in his cheek, behind the eye and in the jaw on the right. Aha, I thought, this movement will really stretch the anterior scalenus and, to an extent, the sternomastoid on the right. I had a quick peek at my Travel and Simons trigger point book to look at the referral pattern of these muscles, and, to my excitement, found that they could, in combination, be reproducing some of the pain felt behind the eye, in the jaw and in the cheek.

After having a feel through the cervical joints and satisfying myself that these were not referring pain, I had a good poke and prod through the scalenus and sternomastoid and found spots that directly referred to these areas. Needless to say, this patient was thrilled to bits, while I was happy that I had identified at least part of his problem.

Lugging a massage table
What I didn't yet know, however, was what was setting the whole thing off. I ran through the patient's weight programme with him, thinking that any movements that caused a depression of the scapula or shoulder girdle could potentially cause a problem. He had exercises such as heavy deadlifts and power cleans in his programme. However, he could not say definitely that his problem was worse after doing these exercises. So we probed a bit further. After a lot of questioning, we narrowed things down to the fact that his neck/face/eye problems seemed to be worse on Sundays and early in the week (when he had periods of exacerbation, that is). What, I wondered, did he do on Saturdays?

I then found out that on Saturdays he worked for one of the big Rugby schools as a trainer/masseur. Owing to the popularity of schoolboy rugby in Australia, it is often necessary to park a long way from the ground on match day. What this poor chap had to do was carry his 15kg massage table up to 500 metres on some days, always carrying it on the right side, and then carry it back again afterwards. I suggested that carrying such a weight over such a distance was causing a sustained depression on his scapula/shoulder girdle (along with it his first rib and collarbone) and that this was setting off his trigger points. If he had an underlying weakness in the elevating muscles of his shoulder girdle, then the other muscles around the area would possibly have to work harder, or be inherently more liable to irritation by sustained loads.

Treatment
To prove my theory, I asked him to perform his usual feat on Saturdays and take note of his sensations the next day. He was then to come in on Monday so I could feel around and treat his neck. Sure enough, on Monday he complained that his neck/face/eye felt terrible. We were able to reproduce the pain even more with a left quadrant. Examining the muscles on the right, I could feel they were thickened and tight and certain 'triggers' referred the pain into those areas. So we treated him with trigger-point releases, massage, heat, stretching etc - and he felt great. My next instructions for him were to carry the table on his left side on the following weekend and to come back to see me the next day. In he came on Monday, feeling fantastic!

Now that we knew the cause of his problem, the patient was very easy to manage. He now avoids any sustained carrying on his right, knows how to self-release his trigger points and to self-stretch. He gets the very occasional flare-up if he is obliged to carry anything on the right; for example, on one occasion he was travelling overseas with two bags, and so had to carry one on each side. He has the occasional appointment to have more specific work done to his scalenes, sternomastoid, and also levator scapulae and upper trapezius. We instigated some very specific upper-trapezius exercises to improve their holding capacity as an elevator of the scapula. His pain sensations are comparatively mild now. In retrospect, this patient served as an interesting example of how an earlier injury involving the nervous system could set up many long-term problems.

Chris Mallac