Sub sections

Scapulocostal Syndrome (Levator Scapulae Syndrome)

By Bernard M. Abrams, M.D.

The Scapulocostal Syndrome is a common musculoskeletal, pain-producing syndrome that mainly affects the posterior shoulder area, but because of radiation characteristics, it can mimic numerous other conditions including cervical radicular pain, intrinsic shoulder joint disease, and even visceral pain. It can be diagnosed clinically with a careful history and physical examination. There are no related blood test abnormalities, neurophysiological, or imaging abnormalities in the syndrome, but these tests may be useful in eliminating other entities from diagnostic consideration.

History

This syndrome was first described by Michele and Davies in the New York Journal of Medicine, in 1950.[1] They pointed out that during the preceding 3 years, 30% of all middle-aged individuals presenting shoulder complaints had this syndrome and the protean manifestations and radiation of this syndrome. The pain might radiate to the occiput or spinous processes of the third 3rd and 4th cervical vertebra. Alternatively, it might appear to originate at the root of the neck and radiate into the shoulder joint, or radiate down the arm into the hand, usually located along the postero-medial aspect of the upper arm and along the ulnar distribution in the forearm and hand. They pointed out that the pain alternatively might radiate along the course of the 4th and 5th intercostal nerves, mimicking angina pectoris on the left, and cholecystitis on the right. Finally, the patient might present with any combination of the above symptoms and signs.

After some initial interest in this syndrome between 1956 and 1968, [2,3,4,5] interest languished until the 1980’s and early 1990’s, when attention was turned to the anatomy of this region.

The Clinical Syndrome – Signs, Symptoms, and Physical Findings

The hallmark of the Scapulocostal Syndrome is pain. The pain may be localized to the medial superior border of the scapula or it may radiate up into the neck, causing headache. It can also cause pain into the root the shoulder, simulating rotator cuff syndrome or other shoulder disorders. It can radiate around the chest wall or down the arm, usually in an ulnar distribution. The characteristic pattern is that of acute pain localized in the upper trunk. There may be complaints of radicular-type pain with or without sensory features. [4, 6] Although weakness of the arm and shoulder may be offered as complaints, these usually are a result of guarding, without atrophy or neurophysiological evidence of denervation on EMG. The pain has been described variously as aching, burning, or gnawing, and rarely as a sharp or radicular pain. The symptoms may be intermittent, but a nagging, constant quality is not uncommon. Insomnia is a frequent complaint, due to inability to find a comfortable sleeping position.

The original paper of Michele [1] cited an equal distribution between the sexes. Since then, most observers have noted a female predominance, and also a predominance in the dominant shoulder. Clerical occupation, rounded shoulders, the carrying of personal items, including handbags, and large pendulous breast are often implicated.

Russek [7] classified the syndrome into three types: 1) primary, probably postural in origin, 2) secondary, a complication of pre-existing neck or shoulder lesions and 3) static, occurring in severely disabled patients who are unable to control the scapulo-thoracic relationship.

There are usually no muscular, reflex, or sympathetic, or sensory findings in the examination. The classical finding is a trigger point elicited by digital pressure at the medial scapular border in a line extending from the scapular spine. This trigger point may be missed (both diagnostically and therapeutically), unless the arm is adducted, with the palm of the affected hand flat upon the opposite shoulder, crossing in front of the chest. Alternatively, extension and internal rotation of the arm will also elicit the pain. Secondary trigger points may be found in the trapezius and rhomboid. [1] Diffuse tenderness over the chest wall is usually mild.

No consistent biochemical, rheumatological, radiological, or neurophysiologic (EMG) findings have been reported. One study reported increased heat emission from the upper medial angle of the affected shoulder on thermography, in more than 60% of patients. [8] Reproduction of the pain by palpation (and relief by local anesthetic infiltration) are the sine-que-non of this syndrome.

Anatomical Basis

The constant location of the pain in the deep trigger point seems to indicate that the levator scapulae muscle is involved in this syndrome. Considerable controversy exists as to the constancy of a bursa in connection with the levator scapulae, which may be inserted in two layers enfolding the medial border of the scapula, and a second bursa found in the areolar tissue between the two layers. [8]  Williams et.al. [9] undertook a dissection of four fresh frozen human cadavers, and noted that the surgical anatomy of the scapulo-thoracic region has been described infrequently. They pointed out that there were three layers of the scapulo-thoracic articulation.[9] They pointed out the superficial layer is composed of the trapezius, latissimus dorsi, and an inconsistent bursa, which they found in 4 of 8 specimens, between the inferior angle of the scapula and the superior fibers of the latissimus dorsi.

They further identified that the intermediate layer contains the rhomboid minor, rhomboid major, and levator scapulae muscles, along with the spinal accessory nerve, and a consistent bursa found in 8 of 8 specimens, between the superior medial scapula and the overlying trapezius. The deep layer consisted of the serratus anterior and subscapularis muscle in addition to two bursae. One of the two bursae was consistently located between the serratus anterior the thoracic cage, whereas the other was inconsistently located between the serratus anterior and subscapularis. These relationships probably account for the clinical finding that turning the head opposite to the affected limb will reproduce the pain.

Differential Diagnosis

The differential diagnosis of pain in and about the scapula is extensive. Shoulder problems including rotator cuff disease, adhesive capsulitis, instability or arthritis of the glenohumeral joint, and vascular or neurogenic thoracic outlet syndrome, may be at play. [10] The pain in these individuals is generally exacerbated by scapulo-thoracic movement, and also by movements at the glenohumeral joint. Restriction of range of motion is frequent. Imaging of the shoulder with plain x-ray will generally show degenerative changes. MRI or CT arthrogram may be definitive.

An entity known as the “snapping scapula” has been used to describe the clinical scenario of tenderness at the superomedial angle of the scapula, painful scapulo-thoracic motion, and scapulo-thoracic crepitus. [10] Etiology of “snapping scapula” include scapular exostosis, malunion of scapula or rib fracture, and Sprengel’s Deformity. [11, 12]

Cervical radiculopathy can produce an aching pain into the scapula (protopathic pain), especially with C7 radiculopathy associated with sharp (epicritic) pain down into the appropriate segment of the upper limb. In the case of the C7 radiculopathy, usually down the posterior aspect of the upper arm (triceps muscle) into the middle finger associated with weakness of the triceps and wrist extensors, diminution of the triceps reflex, and hypesthesia in the C7 dermatome. Suprascapular nerve entrapment [13] may produce deep, poorly circumscribed pain. As the suprascapular nerve is a motor nerve, the pain resulting from its irritation is deep and poorly circumscribed. It is roughly localized to the posterior and lateral aspects of the shoulder. When there is an appreciable traction stress element on the upper trunk, there will also be pain down the radial nerve axis. If the neuropathy has been present for a sufficient time, there will be visual and palpable atrophy of the supraspinatus and infraspinatus muscles. Their weakness is reflected in difficult in initiating abduction and rotation at the glenohumeral joint.

In most cases of suprascapular neuropathy, there is a prior motion impediment at this joint. Deep pressure toward the region of the suprascpular notch will be painful. Motion of the scapular will cause pain. The cross body adduction test, performed by adducting the extended arm passively across the midline, will be extremely painful, since it levers the scapular away from the thoracic and so tenses the suprascapular nerve. A suprascapular nerve block may be necessary for diagnosis. The region involved is somewhat lateral to the medial superior scapula border (at least 3-4 fingerbreadths in a normal sized individual) so the tender area is clearly differentiated from the medial angle of the scapula where the levator scapulae muscle inserts in the scapulocostal syndrome.

Treatment

Non-operative treatment of patients sometimes is successful and is comprised of activity modification, physical therapy, systemic anti-inflammatory medications, and injection into the region of the medial superior scapular border. Mixtures of 2 to 8 cc of plain 1% lidocaine HCl, plus 1 cc of betamethasone, followed by physical therapy exercises, have been advocated. [14] Ormandy [14] treated 190 patients: 43% with one block, 40% with 2 blocks, and 17% with 3 blocks.

Upon completion of treatment, approximately 98% of patients were relieved of pain, and returned to their original occupation. Fourie [15] invoked the serratus posterior superior muscle, a member of the third muscle layer of the back. He used 1 mL of steroid, and 1.8 mL of local anesthetic. He claimed that of 201 cases, conservative treatment was successful in 95.9%. The author has been struck by the failure of writers on this subject to mention that the arm needs to be cross-adducted or internally rotated and extended, in order to throw the scapula out of the way so as to expose the insertion of the levator scapulae muscle at its insertion into the medial border of the scapula. If this is done, success is much more likely. It is also the practice of this author to use a 25-gauge needle, bent at a 90-degree angle, to get underneath the scapula, and to place it in the most lateral excursion of the scapula, and then infiltrate while withdrawing the needle toward the medial superior scapular border. Surgical treatment for patients who have had no response to non-operative management include scapulothoracic bursectomy, excision of the superior-medial angle of the scapula, and combined bursectomy and superior angle resection. [9, 16, 17] A recent report [18] concerned the operative treatment of scapulothoracic bursitis in professional pitchers, four of whom were operated on, and all returned to their pitching careers. Recently there has been treatment using endoscopic surgery in the scapulothoracic region. [19, 20, 21] Results of surgery have been reported infrequently and inconsistently. [9]

Complications and Pitfalls

The major pitfall is a failure to diagnose this common and easily overlooked syndrome. Thorough history taking plus a few simple physical diagnostic maneuvers involving the crossed adduction of the affected arm with palpation should serve to make the diagnosis. The treatment can be unsuccessful if a similar posture for injection is not maintained, as one would be attempting to inject through the scapula itself, to reach the levator scapulae insertion or the putative bursa in this area. Once one attempts to inject in this area, the possibility of a pneumothorax should be borne in mind at all times, and the patient warned of this possibility and its potential consequences, including traction pneumothorax. They should be instructed to go the E.R. with any pain on inspiration of the chest.

Operative techniques obviously hold their own mortality and morbidity. However, inconclusive results up to this point have clouded the issue.

Conclusion

Scapulocostal syndrome is a common occurrence, especially in posturally compromised, middle aged individuals, usually woman, especially with desk jobs or those vocations that force them to extend their arms in front of them for prolonged periods. There are no definitive biological markers for this syndrome. The differential diagnosis rests largely in ruling out cervical radiculopathy, intrinsic shoulder disease, osseus disease of the bony skeleton, and other afflictions of the scapula including the “snapping scapula syndrome,” and Sprengel’s Deformity. It is easily diagnosed and may be treated with a relative degree of success by injection therapy, which should be combined with physical therapy and alteration of lifestyle. Surgical treatment may be considered in refractory cases, but its success remains largely controversial.

 
References

1. Michele, AA, Davies,JJ, Krueger, FJ, and Lichtor, JM: Scapulocostal syndrome(Fatigue-postural paradox) New York J Med 50: 1353, 1950

2. McGovney, RB Scapulocostal syndrome Clin Orthoped 2:191-6, 1956

3. Rose, DL and Novak, EJ The painful shoulder. The scapulocostal syndrome in shoulder pain. J Kans Med Soc 67: 112-4, 1966

4. Shull, JR Scapulocostal syndrome: clinical aspects South Med J 62: 956-9,1969

5. Michele, AA and Eisenberg, J Scapulocostal syndrome Arch Phys Med Rehabil 49:383-7, 1968

6. Cohen, CA Scapulocostal syndrome: diagnosis and treatment South Med J 73:433-7, 1980

7. Russek,AS Diagnosis and treatment of scapulocostal syndrome JAMA 150:25, 1952

8. Menachem, A, Kaplan, O, and Dekel,S levator scapulae syndrome: an anatomico-clinical study Bull Hosp Jt dis 53:21-4, 1993

9. Williams,GR, Shakil,M, Klimkiewicz, J, and Iannoti,J Anatomy of the scapulothoracic articulation Clin Orthop and Rel Research 1:237-246

10. Butters,KP and Matsen, FA(eds) The scapula335-8 In The shoulder ed 1 WB Saunders company Philadelphia, 1990

11. Milch,H Snapping scapula Clin Orthop 20:139-150, 1961

12. Parsons,TA The snapping scapula and subscapular exostoses J Bone Joint Surg 55B:345-9, 1973

13. Kopell, HP & Thompson, WAL Suprascapular entrapment neuropathy Surg Gynec & Obst 109: 92-96, 1959

14. Ormandy, L Scapulocostal syndrome Va Med Q 121:105-8, 1994

15. Fourie,LJ the scapulocostal syndrome S Afr Med J 79:721-4,1991

16. Milch,H Patial Scapulectomy for snapping in the scapula J Bone Joint Surg 32A 561-66

17. Morse,BJ, Ebraheim,NA, & Jackson,WT Partial scapulectomy for snapping scapula syndrome Orthop Rev 22:1141-4,1993

18. Sisto, DJ & Jobe,FW The operative treatment of scapulothoracic bursitis in professional pitchers. Am J Sports Med 14:192-4, 1986

19. Ciullo,JV Management of pain at the superiomedial angle of the scapula J Shoulder Elbow Surg 5 (suppl) :589, 1996

20. Ciullo, JV& Jones, E Subscapular bbursitis:conservative and endoscopic treatment of “ snapping scapula” or “washboard syndrome” Orthop Trans 16:740, 1992

21. Roland, LJ 3 Scapulothoracic anatomy for the arthroscopist. Arthroscopy 11:52-6, 1995