A 35-year-old man with what his sports physician described as "left periscapular pain of unknown origin." The sports doctor was hoping that a physiotherapy test and subsequent treatment would settle the symptoms. Chiropractic injury specialist Dr. Alexander Jimenez investigates...
This gentleman had a 15-year history of work from the sheeting department of a local hardware store. His job took him to lift and load on to trucks around 200 plasterboard sheets daily. The store man was also an energetic outrigger canoeist, currently in heavy training for an upcoming long-distance event.
In outrigger canoeing six paddlers sit at a 14m canoe built of Kevlar, graphite and S glass (a magnesiaalumina- silicate glass with high tensile strength). The kayak design comprises an elongated arm (the outrigger), which helps to balance the canoe in open water. The canoeists use 4--5ft paddles, and possess a specific paddling sequence where they change sides every 15--20 strokes.
Upon questioning he stated he thought the pain had been mildly gift for the best part of ten years. Employer records confirmed that he had complained of a similar pain seven decades before but had chosen not to seek treatment, having thought that the symptoms in the time to be too gentle for any intervention. However, the symptoms had lately become far more acute -- to the point where he could no longer physically carry the plasterboard sheets at work.
A few days prior to visiting me, the store guy's symptoms had significantly slowed following a lengthy paddling session (20km). The final straw came in the close of the session when group members had to carry the 145kg canoe about 50m to load it on into the back of a trailer. He had been carrying the kayak with his left hand and the pain radiating from his mid spine area had become excruciating. He decided to take illness leave out of work and cease all of his coaching.
Upon examination, I could see that he had a very long and gloomy left scapula, with hypertonicity (overdevelopment) in the left posterior shoulder muscles and right-sided paraspinals. The costo-transverse joints of the third to seventh ribs on the left side were especially hypomobile.
All active motions of the shoulder and cervical spine were normal selection and all of the muscle tests round the shoulder and cervical spine seemed to offer normal results. The customer described no history of significant left knee or cervical spine injury or injury.
He demonstrated that the lift and carry technique he was using with all the plasterboard sheets. He also carried the sheets on his left side with his left arm fully externally rotated and elbow in extension so he could hold the base of the sheet. This activity seemed to force his scapula to a depressed and protracted position. He would then elevate the right arm above his head to hold the top of the sheet. In this manner he can "hang the sheet off his left arm, together with his right hand to balance it.
On palpating the offending area, I found he had two spots of exquisite tenderness. The first was just under the medial edge of the scapula; the second on the rib angle of the fourth or fifth rib. Due to the severity of his symptoms, the night pain and point tenderness about the rib angle, I called him to get further investigation (x ray and bone scan) to rule out any stress fractures of the rib.
The x-rays came back negative, so I guided my therapy at mobilization, muscle energy techniques to address the rib hypo-mobility, and soft-tissue therapy and acupuncture for the rhomboids, back shoulder and upper trapezius. Following two weeks my canoeist showed no improvement in symptoms and his night pain continued. I referred him for a CT scan to rule out degenerative changes in the thoracic spine, costo-transverse or costo-vertebral joints.
So two weeks farther on, without a clear diagnosis and no actual improvement in symptoms, I routed the store guy for an MRI scan to rule out any additional soft-tissue harm to rhomboids or middle trapezius, and to investigate the cervical spine to exclude virtually any radiculopathies in that area that might mimic soft-tissue injury in the periscapular area.
After consulting with the referring doctor, we all agreed that the store man could vanish for a while off on a much needed holiday. I sent him off with directions to self-manage the injury, using a tennis ball to the rhomboids, a thoracic roller to mobilize his thoracic spine and some scapular-setting/ stabilization exercises.
He returned three weeks later (seven months after his initial trip to the clinic) at exactly the exact same state as when he'd left. Client and physiotherapist both being exasperated with the lack of progress, we decided to take the plunge and see whether the sports physician could diagnostically block the pain, with a regional anesthetic infiltration.
The sports physician palpated the painful place thoroughly and determined that the most tender stage was the spot under the lateral border of the scapula, which he believed corresponded to tendon material of their rhomboid. Miraculously, the pain at the periscapular area fully disappeared with the local anesthetic -- despite there was no evidence of degenerative or inflammatory modification on the MRI. The physician followed this up with a corticosteroid injection in the same spot.
Fourteen days after the patient was ongoing to become symptom free so we began a progressive rehabilitation program to re-strengthen that the rhomboids and proceeded to handle the thoracic spine and rib joint hypomobility. Following six weeks (16 months from initial presentation), he returned to perform and paddling, and although perhaps not 100% symptom-free, was able to resume sheet- carrying at work and was back into paddling long distances without any ill effects.
An Unusual Tendinopathy?
Even the rhomboid muscles (minor and major) are described as strong retractors and downhill rotators of the scapula. There is very little from the literature on pathologies affecting the rhomboids, which makes it apparent that these deep bending shoulder muscles are not often injured in either sporting or occupational environments. This case shows that the rhomboid muscle and its bony scapular attachment can be just as vulnerable to pathological tensile and compressive loading as other more common culprits (like Achilles tendon), provided the right mixture of repetitive and traumatic stress.For me this was an extreme blend of occupational and sporting stress that had led to an isolated instance of "rhomboid tendinopathy , although the exact origin of the pain still remains a mystery, as nothing ever showed up on the MRI. Perhaps the magnetic strength of the MRI (1.5 Tesslar) was not powerful enough to pick up high signal density at the rhomboid tendon, or perhaps that the MRI results returned as a false negative, a case occasionally seen in chronic patellar/ Achilles tendinopathies.
It seems that the recurrent protraction and melancholy of the scapula brought on by carrying and holding heavy plasterboard sheets over many years -- and exacerbated by the repeated action of the paddling -- had contributed to an inflammatory or degenerative process in the thoracic and attachments of the rhomboid muscle on to the scapula. Upon release the individual still exhibited a somewhat protracted and gloomy scapula. It is likely that this imbalance may never be completely solved with the scapular retraining exercises; the protracted period of time that his scapula was subjected to the unbalancing forces could have led to permanent length-tension changes from the rhomboids and upper trapezius.
