Shoulder Blade Pain…Everyone’s Bane

I can’t tell you the number of times I have seen a client and the first thing they say to me is “can you work on my shoulder blades or wings…or whatever they are called?” I don’t know about you but if I had wings back there I would be pretty excited. Also, I don’t remember being trained in wing massage….hmmm. All kidding aside, the upper thoracic and scapular region do get a lot of attention from massage therapist because it is a source or a great deal of discomfort for many clients. This area affects just about every human it seems (which is a lot of people) especially anyone who tends to spend a lot of time in front of a computer. It is also an area where we tend to gather tension related to stress which adds to the discomfort. Combine all of these factors and it is definitely an area most people are going to want work done on.

I would like to take this common treatment area and open up the reasons why it is such a prominent area of pain. I would also like to delve a bit deeper and see if we can figure out why so many people have, not only soreness here, but many times ongoing acute and chronic pain. What is that  “burning” and “aching” feeling that is described to us therapists so often? Also, why does it always seem to come back even after treating it? Hopefully, I can answer those questions and give you a better knowledge of how to treat what seems to be everyone’s bane.

Let us start with some anatomy so we know what we are dealing with. The main area clients seem to describe pain is right along the medial border of the scapula and into the cervicothoracic junction. This area is made up of a number of anatomical structures including layers of muscles, nerves, ribs and the scapula. The main structures I want to focus on are the Rhomboids and Serratus Posterior Superior.  The nerve we are going to talk about is the Dorsal Scapular Nerve. The scapula, well, we will deal with it in a moment.

Rhomboids- Photo Credit Anatomagraphy

Serratus Posterior Superior- Photo Credit Anatomography

The rhomboids and serratus posterior superior are in the intermediate layers of muscles with rhomboids laying on top of serratus. Both muscles run medial to lateral with the rhomboids attaching into the scapula and serratus inserting into the ribs. Although they have very similar paths, their function is VERY different. The rhomboids pull the scapula towards the spine while serratus posterior superior elevates the ribs which assists in breathing.

The strain put on these muscles is also very different. Rhomboids are usually over lengthened and week due to forward shoulder posture with the scapula translating laterally. Serratus posterior superior is usually overused and hypertonic due to elevated shoulders from stress poor posture and, possibly, incorrect breathing technique (a completely different subject). The commonality that CAN be found between these two muscles is more the fact that they are both involved with the dorsal scapular nerve. In between these two muscles is where it lies.

Dorsal Scapular Nerve

The Dorsal Scapular Nerve originates from the C5 level in the cervical spine and courses down the posterior shoulder along the medial border of the scapula. During this course, it pierces the middle scalene, runs deep to levator scapula and in between the layers of serratus posterior superior and the rhomboids (picture only displays general location for discussion purposes).

This proximity and interaction of all three of these structures is where I would like to get into the meat of our subject. To begin this conversation we need to talk about our friend the scapula.  In a healthy body, the scapula is stabilized medially by the rhomboids and trapezius, which helps keep the entire shoulder girdle from moving anterior and creating an anterior shoulder posture.  However, as we know, commonly this is not the case and the shoulder does move anteriorly due to hypertonic pecs, serratus anterior and a number of other muscles. This anterior shoulder posture chronically elongates and weakens the rhomboids and trapezius causing those muscles to become strained and fibrotic. When this happens, adhesive tissue is laid down causing poor circulation and potential trigger points to form within different muscles. This does not just occur within muscles, but more importantly, adhesive tissue can occur in between layers of muscle. In our case, this happens in between the rhomboids and serratus posterior superior exactly where the dorsal scapular nerve courses. This is where we will get problems.

When we have adhesive tissue form within these structures, the dorsal scapular nerve can become adhered to the surrounding tissue. Now, this doesn’t mean that we are necessarily going to have horrible nerve symptoms like tingling and numbness. Usually, this sort of condition will present with less extreme symptoms like slight burning or deep aching pain.  This occurs because the nerve is not being fully entrapped or impinged; it is more being irritated by the surrounding tissue and thus sending out “irritated” signals. These symptoms usually come and go, depending on activity levels and different stresses on the area. Sound familiar?

This condition is more common than most people know. Usually, these symptoms are mistaken for serratus posterior superior or levator scapula trigger points. The referral patterns for these two muscles are very much similar to this, and in actuality, clients will probably have these trigger points along with a dorsal scapular nerve entrapment. The conditions for having trigger points form and adhesions along the dorsal scapular nerve are almost exactly the same. So the answer to this is to look for both. Obviously though, if we are only treating one of these problems then we are only treating part of the issue.

So how do we treat adhesions around the dorsal scapular nerve? It may sound complex but in actuality, its very simple. We will start by palpating for the dorsal scapular nerve. It is actually fairly easy to feel when you know what you are feeling for. Probably in the past, you felt it while working on clients and mistook it for trigger points within muscles because of it recreating the same referral symptoms that your client was having. These include referred pain in to the upper shoulder and maybe down the arm( also the same referral as serratus posterior superior). It feels like a band running parallel to the medial border of the scapula and will be slightly tender. Once you have found it, you will realize the path it takes is very similar to the area where many clients complain of their pain.

In order to treat the nerve restrictions, we are going to use the ability of the dorsal scapular nerve to glide and move. You may have heard of a “nerve glide” technique which is going to be halfway similar to our technique. The main theory we need to focus on when treating this nerve is creating differentiation between the serratus posterior superior, rhomboid and the dorsal scapular nerve. In other words, we are trying to break the nerve away from the adhesions that have formed in between these muscle layers around our nerve which will allow for normal free movement. To do this, we will use a pin and stretch technique paired with movement of the neck.

We will start with pressure being applied to the serratus posterior superior right next to the nerve (we do not want to be directly on the nerve…ouch) We will want to work the muscle by directing our pressure in an inferior manner. In other words, we will be pushing the tissue of serratus posterior superior in a cross-fiber or perpendicular direction down, and at the same time being parallel to the nerve. Once we have established our pressure and have loaded the fascia and muscle in this manner, we will flex the neck forward and to the opposite side. This motion pulls the nerve past the pressure we are maintaining, thus pulling the dorsal scapular nerve away from any restrictions which we have pinned under our pressure. This movement should be done a few times in order to move the nerve as much as possible. You will notice neck movement may be limited during the first pass and improve as the passes increase. This treatment usually feels very good for a client who has had this as a chronic issue. It is usually described as good pain. This exact treatment to free the nerve should be applied to the rhomboid as well. The difference in treatment will be your location, and your depth of pressure will not need to be as firm.

Even if we do successfully treat adhesions around the dorsal scapular nerve and release trigger points in the affected muscles, and the client is feeling better, our job is not complete. We have to deal with the chronic anterior shoulder posture which is causing the straining to the area in the first place.  If we don’t, the symptoms will eventually come back and we will have to do the same treatment over again. To do this, we will address all of the muscles which pull the shoulder girdle anteriorly (These include pectorals, subscapularis, and serratus anterior). Once we have treated the anterior shoulder posture, we can expect the shoulder and scapula to function properly and the straining in the upper thoracic/scapular region to not continue.

Couple this specific treatment to the dorsal scapular nerve with trigger point work to the serratus posterior superior, as well as anterior shoulder posture release, and you will most likely help a lot of clients who have had chronic pain for a long time. They will probably sing your praises everywhere they go (hopefully not off key).

Something to be aware of: I would like to mention that chronic scapular pain can come from the cervical spine as well.  When nerve compression occurs in the C5-C6 region due to a disc injury or degeneration, many times pain will be felt down into the upper thoracic and scapular region as well.  Just something to be aware of when assessing your clients.


 

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