What is the referral pattern of the upper trapezius?

An interesting case here showing an unusual symptom referral pattern of the upper trapezius.  Read on.

A patient sought medical assistance of her primary care physician due to constant right lateral 5th digit numbness.  Although no specifics of why the symptoms arose, she did say her activity increased a few days prior while participating in a tennis match and coaching volleyball in the same day.  She did state for a few days she had symptoms in the lateral brachium but that did not last and didn’t think anything much of it until numbness arose, which is why she sought medical care.

Upon arrival to me, her main complaint (numbness in 5th digit) was constant even after medical interventions of prednisone series and cortizone shot in the contralateral arm.  She has also had magnetic resonance imaging of the cervical spine that was basically unremarkable (most of the degenerative and stenotic changes were actually shown on the contralateral side of the symptoms).  Otherwise, she was pain-free.  No neck pain but noticed lifting anything over shoulder height was difficult, not symptomatic though.

She had no pain with cervical range of motion and no change in symptoms with a repeated movement exam with and without PT overpressure.  She had full, pain-free active range of motion of the shoulder (yes, full range and no impingement arch) but 3-/5 MMT of the infraspinatus and teres minor tested at neutral by side.  Abduction and flexion were 4-/5 but pain-less, just weak.  No pain to provocation at the subacromial space. Negative impingement test (Neers and Hawkins-Kennedy of the shoulder too).

She did have hypomobility at the cervicothoracic junction and at the C5-6 joint that led to performing joint manipulation but no change in symptoms.  Otherwise, no myofascial trigger points were found through a palpatory examination to elicit concordant symptoms.

Considering no change in symptoms through a movement and arthrogenic approach, and not satisfied with the outcome, I decided to dig further into one of the main findings, weakness of the rotator cuff (but not your typical impingement symptoms).  I hypothesized that she was compensating for altered glenohumeral mechanics due to this motor performance loss by performing a shoulder shrug sign.  This was not visible by the naked eye but made sense.

I opted to perform dry needling to the upper trapezius after finding a myofascial trigger point upon pincer palpation, even though just local discomfort and not concordant.  After entering approximately 30mm, there was reproduction of concordant signs (in addition to local twitch response) that eventually lessened after completion of both a static and dynamic influence.

The symptoms dampened but did not completely abolish after the treatment.  However, upon the following visit, she reported that they were abolished the next day.  Not exactly what I was expecting, but hey it worked.

So the change in symptoms could have come from some of the other interventions, but considering concordant symptoms were found after penetration and not by palpation by hands, this was quite interesting to me and worth sharing.  The referral pattern is quite different from the proposed ones by Travell and Simons.

Have you had any cases of true referral patterns from the upper trapezius, and if so, where?