Shoulder blade pain

 

Introduction

 

Pain behind the shoulder blade is a common problem and many people around the world suffers from this disabling disease. The real pathology causing this pain is relatively unknown. Therefore the condition is not correctly diagnosed in many circumstances.

Historically this pain has being attributed to fibrositis or other conditions like fibro mialgia. To be very honest  these names are given to conditions where  the physician is unable to make the diagnosis or where the the causing pathology is unknown.

The landmark article describing this condition was published in 1994 by Dr Louis Fourie, a South African general practitioner who has done a lot of research regarding this condition after developing a personal interest in this condition because of a family member suffering from severe pain over the shoulder blade. The condition has previously been known as scapulo thoracic syndrome or scapulo costal syndrome. Unfortunately the real cause of the problem was unknown untill the research were done by Dr Fourie.

The landmark article was published in the South African medical Journal.

Pathology

Thre pathology is localised in this Serratus Posterior Superior muscle. This muscle arises from the Cervical spine  and runs down to the ribs below the shoulder blade. The origin is from the spinious  processes of the seventh cervical vertebrae down to the third thoracic vertebrae. The insertion is on the ribbs 2, 3,4 and 5 below the shoulder blade.

 

This muscle is well-developed in birds and seem to be a respiratory muscle in birds. In the human being the function has been lost and the muscle seem to be of no importance at all. As we go older and get a little bit more kifotic the muscle is tentioned over the ribs and this causes a severe traction  pain over the shoulder blade.

 

Clinical picture

These patients has typical symptoms of pain over the back of the shoulder blade. Usually they have seeked medical attention on many occasions without success. They are usually being told that they suffer from fibrositis or fibro myalgia. They were usually treated with pain medication, anti-inflammatory tablets and Physio therapeutic measures without any success.

This condition is common in people who does computer work and also in people driving vehicles with the shoulders elevated to reach to the work object. They will constantly try to press  onto the pain with the other hand to try to relieve the symptoms.

 

Clinical diagnosis

The clinical diagnosis is relatively easy to make. The patient has pain behind the shoulder blade and there is a specific area of tenderness when palpitating onto the ribbs at the back of the shoulder.

 

It is very important to make the patients sit with the arms hanging down to open up the ribbs of the back to be palpated. When the patient stands the shoulder blades will close up at the back and will cover the area with the pain. It is only when the shoulder blade move forward that the ribs are exposed and one can palpate onto that in the area over the ribes.

 

This position is also critically important when the physiotherapist wants to do local therapy on to the area. If the shoulder blades are not taken out of the way by hanging forward the muscle cannot be reached and therefore the palpation of the specific area is not possible.

 

Management

The first step in the management is to diagnose the condition correctly. One can then start with anti-inflammatory tablets, painkillers and physio therapeutic measures to reduce the pain. This includes deep friction therapy specifically with the shoulder blades being taken out of the way to allow for direct pressure to the affected area.

The next step would be to inject cortisone into the muscle using ultrasound guiding to ensures that the cortizone is placed exactly on the rib.

 

Using the ultrasound is critically important as the rib is really close to the lung. Missing the rib can cause the needle to puncture the lung and cause a pneumothorax with collapse of the lung. It is extremely dangerous to inject this area without ultrasound guidance.

In a small percentage of cases even the cortisone injections will not be successful and a surgical release can be performed. At this operation this Serratus  Posterior Superior is divided. As this is an unimportant muscle there are no long-term consequences of the release.

 

The pain relief is almost instantaneously and complete.

 

Summary

 

Although this is a relatively undiagnosed condition the results can be excellent with complete pain relieve if the condition is recognised and treated correctly. 

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