see also:

• orthopaedics in the ED
• acute thoracic back pain in the adult
• the painful shoulder
• the adult patient with chest pain in the ED

• pain between the shoulder blades is a relatively common problem and may be either referred pain or due to local causes

• many causes of anterior chest pain also radiate through to the scapular region
  • aortic dissection
  • acute coronary syndromes
  • pleuritic pain from posterior pleura
    • pneumothorax
    • pneumonia
    • PE with subpleural infarction
  • spontaneous pneumomediastinum
  • see the adult patient with chest pain in the ED
• abdominal causes tend to radiate lower but may be lower interscapular
  • biliary colic
  • pancreatitis
  • abdominal aortic aneurysm (AAA)

• midline thoracic spine pain
  • Scheuermann's Disease - usually commences in adolescence and results in kyphosis
    • usually defined by at least anterior wedging greater than or equal to 5 degrees in 3 or more adjacent vertebral bodies in the spine
  • osteoarthritis / spondyloarthritis
  • vertebral body fractures
    • osteoporosis
    • pathologic
    • traumatic
  • infective discitis / vertebral osteomyelitis - especially in the immunocompromised
  • metastatic malignancies
• radicular nerve pain (usually unilateral)
  • herpes zoster (shingles)
  • spinal conditions which put pressure on nerve roots
    • osteoarthritis / spondyloarthritis
    • vertebral body fractures
      • osteoporosis
      • pathologic
      • traumatic
    • severe scoliosis
    • infective discitis / vertebral osteomyelitis - especially in the immunocompromised
    • metastatic malignancies
• rib pathology
  • fracture
  • malignancy
  • osteomyelitis
• soft tissue causes
  • rhomboid muscle strain or injury
  • other scapular muscle strain or injury
  • symptomatic scapulothoracic crepitus
  • painful scapulothoracic bursitis “snapping scapula syndrome”
  • associated with winging of the scapular
    • this results in disturbed scapulohumeral rhythm, especially when walking and contributes to loss of power and limited flexion and abduction of the upper extremity and can be a source of considerable pain
    • it can affect the ability to lift, pull, and push heavy objects, brush hair and teeth and carry grocery bags
    • may be due to either:
      • neurologic causes due to damage to one of these nerves:
        • short scapular nerve (serratus anterior)
        • long thoracic nerve (eg. repeated stretching of the neck in later flexion as in tennis)
        • accessory nerve (eg. wearing heavy backpacks, iatrogenic)
      • musculoskeletal causes
        • muscular dystrophy, etc

• no direct bony attachment to thorax thus stability is provided by 3 major groups of muscles:
  • the scapulothoracic muscles
    • coordinate scapulothoracic motion
    • trapezius
      • originates from the skull and the spinous processes of C1-T12 vertebrae
      • primary insertion is along the spine of the scapula
      • superior portion elevates the scapula and rotates the lateral angle upwardly
      • the middle portion adducts and retracts the scapula
      • the inferior portion depresses the scapula and rotates the inferior angle laterally
      • paralysis of trapezius from Spinal Accessory Nerve damage results in lateral winging of the superior scapula
        • 50-70% of cases are iatrogenic
        • superficial course of the nerve makes it susceptible to:
          • closed traction lesions in assault cases, motor vehicle accidents, heavy lifting
          • direct trauma to the posterior cervical region - bites, penetrating wounds, iatrogenic (Cx LN biopsies, excision of mass lesions)
    • serratus anterior
      • separated from the thorax by the infraserratus bursa
      • separated from the blade of the scapula and subscapularis by the supraserratus bursa
      • paralysis of serratus anterior from Long Thoracic Nerve damage (C5-7) results in medial winging of the scapula
        • rare, but may occur in many sports and occupations
        • most cases resolve within 2 years as most arise from blunt trauma causing neuropraxia:
          • sudden depression of the shoulder girdle
          • unusual twisting of the neck and shoulder
          • repetitive movements such a hedge clipping, car washing, digging
          • prolonged stretch of the nerve - lying on bed with arms abducted and propping up the head to read
          • local pressure from enlarged and inflamed bursae - subcoracoid or subscapular bursae
          • iatrogenic - chiropractic manipulation, use of a single axillary crutch, surgery
          • electric shock
        • some cases arise from non-traumatic causes:
          • polio, influenza, other viruses, toxins
          • C7 radiculopathy
          • aortic coarctation
    • rhomboids
      • deep to the trapezius, the two rhomboid muscles work together to retract and elevate the scapula and rotate its lateral border downward
      • rhomboid minor:
        • origin in the ligamentum nuchae of the neck and the spinous processes of the C7 and T1 vertebrae
      • rhomboid major:
        • origin from the spinous processes of the T2-5 vertebrae
        • inserts on the medial border of the scapula below insertion of rhomboid minor
      • paralysis of this muscle from Dorsal Scapular Nerve (C4-6 but mainly C5) damage results in lateral winging of the inferior scapula
        • the nerve can become entrapped in the scalenus medius muscle and may be an atypical presentation of thoracic outlet syndrome
        • C5 radiculopathies
  • the rotator cuff muscles
    • regulate activities of the glenohumeral articulation
  • the scapulohumeral muscles
    • provide power to the humerus