Case

A 67-year-old female was referred for two weeks of left shoulder pain that kept her from sleeping and moving her arm and interfered with her job as a typist. The pain was located in the posterior shoulder just medial to the scapula, radiated down her left arm, and was positional. She had not noticed a decreased range of motion.

After failure of steroids and NSAIDs, she was referred to a chiropractor, who did not improve her shoulder pain. When she got up from the table, she noticed that she was having crushing chest pain bilaterally on each side of the sternum at the level of the first and second ribs. Since then, she had been on significant doses of opiates and oral steroids without pain resolution.

Physical Exam

A shoulder exam revealed bilateral normal range of motion with no crepitus. The patient’s head was slightly tilted, her back laterally rotated. There was a palpable tender mass over the medial aspect of her left scapula. Palpation of the rhomboid muscle caused intense acute pain that radiated down her arm and reproduced her symptoms (See sample photos 1 & 2).

Rhomboid Spasm

Etiology: A rhomboid muscle strain or spasm is usually caused by overuse of the shoulder and arm, especially during repetitive overhead activities like serving a tennis ball or reaching to put objects on a high shelf. It can also result from activities such as the prolonged use of a computer, the problem experienced by this patient.

Anatomy: The rhomboids originate on the last (seventh) cervical and first five thoracic vertebrae and insert on the medial border of the scapula. They work with the levator scapulae and the upper trapezius to elevate and retract the scapula. Spasms of the rhomboids refer pain to a local and limited area, as well as down the lateral aspect of the arm, and are often accompanied by trigger points in levator scapulae, trapezius, and pectoralis major and minor. (See photos 3a, 3b, and 4).

Treatment

Rhomboid spasm should be treated by local lidocaine injection and a depot corticosteroid into the rhomboid muscle. The lidocaine provides the direct effect of reducing the current spasm, and the anti-inflammatory effect of the steroid reduces recurrence.

Rhomboid Injection

To administer a rhomboid injection, first locate the rhomboid muscle just medial to the scapula on the posterior shoulder. A rhomboid muscle in spasm often presents as a painful, palpable mass. Next, identify an area of point tenderness. Inject lidocaine and a corticosteroid. The correct location will be confirmed by immediate pain relief; the steroid, however, may take up to a week to provide pain relief.

Three-Month Follow-Up

The patient returned three months after her rhomboid muscle was injected with lidocaine and a depo-steroid preparation. She has resumed her job as a typist and performs rhomboid spasm prevention exercises. She sleeps well and can move her arm without pain. She is active in her daily activities and enjoys shopping with her friends.

Prevention

Prevention can be achieved through the following rhomboid exercises:

Sit with your legs stretched in front of you. Bend your right knee and place your right foot on the left/outside of your left knee. With your right hand, grab and hold on to your right ankle. Holding on to your right ankle, lean back. (See 5A.)

The key: Press your right elbow into your right knee and point/push your right shoulder toward the floor in front of you. (See 5B.)

Stand with your arms at your sides. Stretch one arm across your body and pull it in toward your body with your other hand. (See 5C.)

Sit on a chair firmly planted on the floor. Lift your right leg and put the right ankle onto the knee of the left leg. Grab your right ankle with your right hand and rest your right elbow on your right knee. With your left hand, grasp the chair back behind you and rotate your torso to the left to look over your left hand. (See 5D.)

Dr. Ficalora is an associate professor of medicine at the Mayo Clinic College of Medicine, and Gerhart is a third-year medical student at the Mayo Clinic College of Medicine, Rochester, Minn.

Scapular Pain