SHOULDER
Medial shoulder blade Pain: “It Hurts Here!”
While caring for multiple conditions that manifest as “shoulder pain” I have often seen patients with severe pain emanating from the medial border of the shoulder blade, or Scapula. Often this is a result of local pathology of scarring and tender nodularity in the deep substance of the multiple small stabilizing muscles on the medial and superior Scapula. These include the Rhomboids (major and minor), and the Levator Scapulae. The pain associated with these muscles are often a result of pathomechanics (over working the muscles to compensate for another injury like a shoulder joint injury) but are often due to an overlooked and underappreciated contribution from pathology or entrapment of the Dorsal Scapular Nerve, which serves these important muscles.
The Dorsal Scapular Nerve is primarily a motor nerve, providing innervation to the Rhomboids and Levator Scapulae muscles. It emanates in part from the 5th cervical root and emerges from the Brachial plexus, passing through the middle scalene muscle and dives deep to the Levator Scapulae and Rhomboid muscles. Often there is no or only subtle scapular “winging” (elevation of the scapula off the rib cage) as pain precedes motor dysfunction severe enough to produce winging.
“The eye sees only what the mind is prepared to comprehend”
Originally published by Roberston Davies in his 1951 novel Tempest-Tost, this phrase summarizes the philosophy of Rene Descartes “We do not describe the world we see, we see the world we can describe”. Awareness of Dorsal Scapular nerve pathology and a high index of suspicion is required to identify this commonly missed diagnosis and source of frustrating and often severe medial scapular border pain.
Manifesting initially as a dull ache or sharp pain between the shoulder blade and spine, potentially radiating to the neck or shoulder, this problem can lead to weakness of these supportive muscles causing “winging” where, in severe cases, the shoulder blade may appear to stick out or wing away from the body, especially when raising the arm.
Multifactorial Causes
The most common cause of Dorsal Scapular Nerve Entrapment syndrome is from hypertrophy or tightness of the middle scalene muscle which can compress the nerve as it passes through that region. In addition, tightness, nodularity or spasm of the Levator Scapulae muscles can cause acute pressure on the nerve. The frustrating thing is that these causes for nerve pressure are also exacerbated by pathology or pressure on the nerve.
Poor posture or compensatory mechanics over a prolonged period (particularly forward head and rounded shoulders, poor sitting ergonomics, repetitive overhead activity/weightlifting or carrying heavy bags on one shoulder) can also cause pressure on the Dorsal Scapular Nerve, causing pain and further poor mechanics.
Management/Treatment
Conservative Management is the first, second, and third choices which need meticulous attention to protocol schedules with repetition, patience, and time. Like Sisyphus rolling his rock up the hill, one must apply constant, repetitive, tedious, and often unpleasant effort over a long duration to achieve results. This includes physical therapy, stretching and strengthening exercises (like scapular retraction exercises), physical mobilization of the medial scapular muscles with direct compression (massage or pulsatile impact), stretching medial scapular muscles (difficult to achieve and requires either online or in person instruction) and posture/mechanical compensation correction. In addition, attention to the cervical spine, particularly at the C5 level to reduce nerve compression or inflammation. Oral anti-inflammatories (NSAIDS or oral steroids) can synergize with the physical therapy efforts by mitigating the inflammatory contribution to this multifactorial challenge.
Corticosteroid or nerve block injections may be used to reduce pain and inflammation as well. injection of the dorsal scapular nerve under ultrasound guidance can be diagnostic as well as therapeutic. Pulsed radiofrequency ablation of the dorsal scapular nerve may provide sustained pain relief as well.
The key for us as clinicians, is to be aware of and to look out for this condition. It has seen you, even if you have not seen it. For patients struggling with medial scapular pain, you can get guidance, but you must put the consistent work and have patience to endure long often unpleasant “tough love” treatments. Only you can do that hard work.
