The patient was in a severe motor vehicle accident 6 years prior and fractured C5 and C6 and dislocated C6 and C7. He experienced upper motor neuron lesions as well as lower motor neuron lesions as a result of this accident. Hospitalized for 4 months, he was placed in a cervical halo which was screwed into his skull and posterior shoulder region. Once the halo was removed, rehabilitation ensued for 6 months. His treatment allowed him functionality and he was classified as a functional quadriplegic. He was ambulatory using a cane.
This patient walked into my office with a severe scoliosis, neck and back pain, limitation of movement to his upper and lower extremities, positive Babinski and altered muscular stretch reflexes. There were severe myofascial restrictions and adhesions as well as severe tendon contractures and atrophy in his upper and lower extremities. Distinctly noticeable was an apparent round hole (descriptive) two inches in diameter, one half inch deep into his left upper trapezius muscle just superior to the medial scapula spine. The patient indicated that this hole (descriptive) in his muscle was caused by the screw of the cervical halo. There were also severe constrictions in his Deltopectoral fascia at the anterior shoulder. Shoulder ROM was limited.
Question: What are some possible diagnoses for the loss of muscle tissue in the trapezius?