Pain in the upper inner angle of the scapula – the scapulocostal syndrome is an enigma spanning over 70 years . Recent advances in ultrasound technology have highlighted previously unknown cause- dorsal scapular nerve microentrapment, and adhesion between rhonmboid and intercostal muscles.
Both were written up as letters so had no abstract and so would have been lost to perpetuity except for yours truly that came across it and am relating it here. In 1952 in JAMA scapulocostal syndrome was written up:
JAMA. 1952;150(1):25-27
DIAGNOSIS AND TREATMENT OF SCAPULOCOSTAL SYNDROME
Allen S. Russek
https://jamanetwork.com/journals/jama/article-abstract/318037
(they still want you to pay to look at full article – gag)
“The scapulocostal syndrome is manifested by the insidious development of pain in the superior or posterior aspect of the shoulder girdle with radiation into one or more of the following regions: (1) the neck and occiput, often associated with severe headache; (2) the upper arm, particularly in the upper triceps and point of insertion of the deltoid muscle; (3) around the chest to the front of the thoracic wall; and (4) down the medial aspect of the forearm into the hand and fingers. Often there is numbness and tingling of the fingers, most commonly the fourth and fifth. The syndrome is caused by long-standing alteration of the relationship between the scapula and the posterior thoracic wall. It is characterized by remissions and exacerbations and may become acute, but it is more often chronic and can persist for years. It is refractory to the usual forms of physical therapy…”
Here is how I approach the issue: Sometimes the order will change depending on what I find.
1) Levator scap will hurt above angle: – First thing I want to know is if the tenderness is above ( in the levator scapula) or upper angle/medial area.
2)Pect minor/rib issue– If latter, is rib level sore and does this soreness extend to front – in upper rib area, and maybe in armpit. If sore anteriorly I will rub the rib area 120 times and see if soreness comes out. If it is quite tender, I will inject 5% lidocaine (max 2 mls) onto top of ribs into pect minor then see if will rub out.
Once that is better, I will check if it is still tender in back.
3) Third rib impingement – Then, I will check the ribs in the axilla area for tenderness. It is surprisingly very sore if this is the issue. Try to put hand above sore areas to pull down and have patient push head to that side and push arm up against you. Have him breath in and as he exhales try to pull rib down. I do several times and rub the interspaces until the soreness disappears. Then recheck to see if back areas is better.
4) C4/5/6 levels could refer to there. I check the neck movement, facet and vertebral body tenderness at those levels and then use and activator or muscle energy techniques to deal with any facet issues. Then recheck for tenderness. In bad cases, I would inject 5-10 units botulinum without local into tender facet levels then see if issue resolves.
5) Subscapular bursitis – Next is a subtle diagnosis. I check the angle of scapula for tenderness and for my take on whether tenderness extends under the scapula. Excessive tenderness and impression it extends under scapula suggests there is subscapular bursitis in area and I inject 40 mg on triamcinolone thru 3 portals around scapular upper medial tip.
6) –Subclinical Dorsal scapular – including branch that goes over upper inner edge of scapula mislabeled as spinal accessory – but obvious point tenderness there
Tenderness medial to scapula extending down from inner angle and also a little above has been spotted on ultrasound to potentially being subclinical microentrapment of dorsal scapular nerve or spinal accessory nerve which responded to sugar perineural injection.or steroid I saw a case which I thought was a double crunch of c5 and pressure of a bra strap to upper medial angle – got a bit of tinels there and injected triamcinolone into it with benefit.
Tang, Tsung-Yung, and Chueh-Hung Wu. “Identifying the dorsal scapular artery optimizes the safety and precision of the ultrasound-guided 5-in-1 injection.” American journal of physical medicine & rehabilitation 98.7 (2019): e80-e81.
8)Serratus Posterior Superior trigger – this muscle has been considered a prime factor in this problem so much so that surgery to it has been suggested. It has been found when bringing shoulder blade laterally exposes more tenderness: eg:
Piraccini, Emanuele, and Stefano Maitan. “Ultrasound guided rhomboid plane hydrodissection for fascial adhesion.” Journal of clinical anesthesia 59 (2019): 13-13
https://www.sciencedirect.com/science/article/pii/S0952818019305380?via%3Dihub
- “medical examination revealed a tout band along the paravertebral region 2 cm medial to the scapular border”
- US found “adhesion between rhomboid and intercostal muscles.”
- Under US did hydrodissection with “levo-bupivacaine 50 mg and dexamethasone 4 mg within 15 ml of normal saline”.
- separation of tissues on US was associated with immediate and lasting relief