Shooting right scapular pain (Full Version)

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desertpalm -> Shooting right scapular pain (January 14, 2007 7:48:00 AM)

Hi everyone, I am new to the forums but thought I might post to see if I could get some speculation on my condition that has some of my providers a little stumped. I am a medical student myself, graduating this spring, and while I'm not going into physical medicine I'm very interested in the musculoskeletal system and am really striving to understand what is going on with me.

Basically, I go to the gym about every other day, and typically do mostly weights. Back in about April or May of 2006, I noticed that when I would use my *left* arm to lift a heavy free weight onto a rack (my arm was typically somewhat extended and I would lean to my right side) I would get a brief tingling sensation at the inferior tip of my *right* scapula. I thought it was strange but thought little of it until over a few weeks the sensation, when it happened, progressed to a needle like pain. Occasionally it would shoot laterally, like a lightning bolt.

Over the next few months, the frequency of the pain would increase, and it would happen with different exercises, particularly back exercises like rows. The pain was usually needle-like and shooting, but a few times the pain was so intense that it felt like I had literally just been struck by lightning. However, it was gone again in less than a second. Lately, the pain has actually progressed upward to just below my scapular spine. It has always happened on my right side, and as far as I can tell, never radiates down my arm. The severity waxes and wanes and I still go to the gym pretty much every other day, as I have learned what exercises seem to exacerbate it and which do not.

Nothing will produce the pain 100% of the time. I find that it tends to be associated with sudden movements. If I go running, it tends to happen after about 10 or 15 minutes. If I use my left arm to pull back against resistance, particularly if the arm is somewhat extended, it also tends to happen. More recently, it will occasionally happen when I don't really feel like I'm doing anything, which is somewhat distressing. It happens anywhere from never to several times a day.

I saw a neurologist initially, who ordered an EMG and MRI of the cervical and thoracic spine. On my MRI my disks are all in beautiful order, and it was read as "normal," though I do have some upper thoracic kyphosis. My EMG of my right supraspinatus, infraspinatus, and rhomboids, as well as an NCT of my right arm peripheral nerves, were all normal.

I was referred to one physical therapist who essentially had no idea what was going on. I was referred to another who I am seeing now and who specializes in myofascial pain. She found a few tender points along my thoracic spine (though lower than I would expect, around the T7/T8 area) as well as one on my right infraspinatus. These aren't really reproducing the shooting pain that bothers me, but they seem to be helping a little bit. She also said my scapulae were somewhat protracted and gave me a roller to stretch my pecs and hopefully bring those back.

If you made it this far, thank you so much for reading, and I would appreciate any other speculation you have. I had thought maybe one of my dorsal rami had gotten entrapped along my spine, but this seems to be relatively rare and I can find hardly any literature on the subject. Any help or speculation would be VERY much appreciated. Thank you!




dfjpt -> Re: Shooting right scapular pain (January 14, 2007 12:40:00 PM)

desertpalm, [QUOTE]maybe one of my dorsal rami had gotten entrapped along my spine, but this seems to be relatively rare and I can find hardly any literature on the subject.[/QUOTE]It could be that, notalgia paresthetica is what it's called, probably more common than one would think, underrated as a type of tunnel syndrome that can create a big pain, especially T-spine pain. The condition is documented quite well in a medical book called Tunnel Syndromes by Mark Pécina. They don't have much suggestion for treatment though, apart from injection. They talk a lot about PT in the book, but with only a vague idea about what kind. If you're already seeing a hands-on type of therapist, get into sidelying, cranky side up, and
1. ask her to treat the area of the posterior fold of the axilla with some skin stretching,
2. ask her to stretch the skin of your whole side with you in side lying and your elbow up in the air,
3. ask her to do a sustained push directly medially through your scapula, through the outer border of it, with you deep breathing, to lengthen out the serratus anterior,
4. in the same sidelying position, ask her to stretch some skin over the pec insertion in the front, along the direction of the fibres of the muscle.

I have lots of other ideas for unloading cutaneous nerves in the upper back by unloading shoulder girdles and helping contracted structures elongate, but that's a start. Others will likely recommend popping. Personally, I don't go there, as I think manipulation can become addictive.




joelkphysio -> Re: Shooting right scapular pain (January 15, 2007 8:20:00 PM)

I would check to see if there is a positive slump test with pain provocation in the area you are talking about. Sit on the edge of a bed, fully flex the head, and then slump. Straighten one leg followed by pulling the toes towards the head. If this reproduces pain (much like you would do for a lumbar spine slump test) extend the neck seeing if pain is relieved.
If this is the case, You can ask your therapist to do superior mobs to the area as you go into the slump position with knees bent (just goign into the pain provocation). Repeat and check slump. As you improve (assuming this is the case, try extending th eknees.
HOpe this helps.
Good luck.
(nice work getting all those tests done, you must be in the field!)
Joel




desertpalm -> Re: Shooting right scapular pain (January 16, 2007 2:35:00 AM)

Hi guys, thank you for the suggestions! Dfjpt, I will talk to her about possibly stretching some of those structures out. Joel, the slump test is negative, but thanks for the idea.

The pain near my right scapula seems curiously related to the manipulation of my left shoulder - it's one of the things that most often reproduces it - particularly resisted extension and abduction. When I told my therapist she said when she sees crossed signs like that she thinks of a facet syndrome, and I agree it could be - does it sound like anything else?

Thanks again for your help!




keldada -> Re: Shooting right scapular pain (January 16, 2007 8:33:00 AM)

Parascapular pain can be complicated because it often proves difficult to troubleshoot. Many parts of the body will radiate/refer to that area. Though it sounds like nerve pain from what you are describing (quality, pattern etc).

Facet pain will NOT cross the body. Crossover is usually due to intervertebral disc pathology. A negative MRI does not rule out disc derangement. It won't rule out scleretogenous referral either.

What your therapist needs to do is rule out c spine involvement first (end range loading of c spine and joint and soft tissue palpation/mobiliazation). This should also be done for the thoracic spine. Trigger points in the thoracic spine are very common but almost never a primary pain generator. Trigger points in the infraspinatus are also very common and can often be primary,but in your case, probably unrelated. Good luck and keep us posted.




drbuddy -> Re: Shooting right scapular pain (January 16, 2007 12:46:00 PM)

If I saw this, I would perform a trial of manual therapy to any abnormally tight/shortened or tender muscles of the involved shoulder girdle coupled with scapular stabilization exercises. I'd give it two weeks, if no change discontinue and look elsewhere.

Make sure they pre and post test after working each muscle to see if you can pinpoint the problem area.




desertpalm -> Re: Shooting right scapular pain (January 22, 2007 2:22:00 PM)

Thanks everyone for your input. During my first session my therapist twisted and turned my C-spine until I thought my head would pop off and there was nothing. The pain is essentially never associated with any neck motion whatsoever. She has also given me a lot of scapular and trap exercises to help strengthen those areas which are admittedly somewhat weak as I have largely ignored those muscle groups in the gym.

The pain has lessened in frequency and severity over the past couple weeks, thankfully, though it can still happen. It mostly gets in the way of my cardio, particularly running and ellipitical, which is what is most annoying to me because I feel like I'm not in as good a shape as I want to be.

I agree that the pain is almost assuredly neuropathic, as at various times I have felt shooting, burning, itching, and paresthesias at various points in that area, but as long as I'm improving I won't argue with my therapist!

Thanks everyone for your help, I'll keep you posted if something else comes up.




FLAOrthoPT -> Re: Shooting right scapular pain (January 23, 2007 1:33:00 PM)

i concur with most, but what about a pure thoracic instability, like a T1/2 instability that occasionally turns into joint type pain? I'd have gone C-spine or peripheral nerve causes as first guessed, but if not, I'll go T spine for 400 alex




ginger -> Re: Shooting right scapular pain (March 24, 2007 5:44:00 PM)

Sounds like you have protective responses occurring involving the upper thoracic and lower cervical spine. these lead to altered behaviours and sensations, typically with exercise or posturaly induced fatigues of paravertebral musculature. You could either get your upper spinal facet joints thoroughly mobilised ( manipulations won't do it ) , or just attach a lightning rod to your head and step outside in a storm. If you decide on b. I want pictures.




Randy Dixon -> Re: Shooting right scapular pain (May 28, 2007 12:59:00 AM)

desert,

I had something very similar to this happen to me, it was definitely neurological and the symptoms were much like yours. I could never reproduce it intentionally. The problem I believe was my sleeping position. I had a new baby girl and I was sleeping with my arm extended and over my head. I quit doing that and the pain stopped. Impingement or something, nothing ever showed up on examinations.

Another time I had hip pain that was interfering with my daily life, it so happened I went to the Philippines at the time and my wife made me transfer my wallet to my front pocket from my rear one to prevent pickpockets. My hip pain disappeared. I tested putting my wallet in my back pocket again and the pain immediately returned. So this technically complex post's moral is, things don't usually happen for no reason, find the reason, it may not be obvious except in hindsight.




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