I have a client who experiences pain in the upper medial border of her right scapula when exercising. The pain seems to be close to or at the insertion point of the rhomboid minor or levator scapula on her right scapula. Basically, she is pain free until she starts exercising, although she has noted that she also feels the same pain when she takes off her sports bra. Any exercise will trigger the pain: bicep curls, arm scaptions, tricep kickbacks, lunges holding dumbbells, etc. She can lessen the pain a little by tucking in her chin while exercising, but the pain does not go away until she stops the exercise. During her initial assessment, I noted that her left shoulder was slightly raised and forward. Her head and shoulders were to the right of her lower body. Her heels rose and her arms fell forward during overhead squats. She has slightly protracted shoulders and one hip slightly swung forward when walking. As a result of these findings, we do work on calves and lats. We work on chest flexibility and strengthening her tibialis, middle and lower traps and rhomboids. I would love some guidance on what I can do to help her minimize the pain she is feeling in her scapula. Thanks so much!
There may be a few things going on here. The information you provided helps a lot to reduce the possibilities and approach this scientifically. Here are your possible scenarios:
Some of the mis-alignments of the body that were mentioned can be a sign of a subluxation of the atlas or cervical spine. For various reasons, particularly the atlas, a subluxation can occur and alter the entire alignment of the entire body. The amount of information received, the rotational movement that occurs that enhances the information received and processed, make the head and all of its vital components vital to survival. In order to maintain balance of the head and neck, everything underneath will alter. This could present with various compensations such as a hiked shoulder, a lordotic lumbar region, torsion in the pelvis, etc. The combination can be as unique as the individual. A subluxation will present with instability, and certain musculature will spasm or increase the tone of contraction to hold it together. The levator scapulae and rhomboids are innervated by C3, C4, C5 and C6. I would take a look in these areas. It’s quite possible that the problem may be higher up originating from the atlas. If you haven’t been trained to identify atlas subluxations, refer your client out to an upper cervical chiropractor. There are a few organizations that do this highly specialized work and can confirm and treat if in case there is a subluxation. The pain felt by your client can be due to the fact that these muscles may already be in a heightened state of contraction from a subluxation, and any additional stimulus presents with pain. As a side note, the entire spinal column reflexively mirrors itself above and below when there is compensation. For instance, an out of line atlas will usually reflex with some type of torsion in the pelvis. This is a clue to consider since you mentioned that one of your client’s hip swings forward during gait.
Scapular Contraction and Lifestyle Habits
It is very common in the fitness industry, particularly in group fitness classes, to combine most pulling movements with an equal amount of scapular contraction through the whole range of motion. “Squeeze the shoulder blades together” and “Imagine trying to crack a walnut with your shoulder blades” are common phrases heard in the gym. This can present problems. Scapular contraction should be turned on at the end of the range of motion; however, most people turn it on at the beginning, which can lead to overdevelopment of the underlying musculature of the scapula. In turn, this can encroach upon a nerve root or become facilitated from chronic exposure and become painful. Be sure to have the scapula set and contraction minimized during exercises like the seated or bent over row. I would avoid reverse flyes and be careful of single arm dumbbell rows as the range of motion may have to be limited. If your client carries a bag, it may be either too heavy or not switched off enough with the other arm. This can change the resting tone of the muscles on the side where the client carries the load. Also it’s important to consider whether your client holds stress in this particular area. Many people hold stress in their neck and upper shoulders. For that, massage, yoga and stress management techniques may be of some use.
Continue to work on posture, particularly addressing the protracted shoulders, which will help to relieve some of the pressure. You will have to be careful doing this because when addressing posture, retraction of the shoulders to combat the protraction is the very position that can cause pain. Test and assess the tension of the pectoralis major and minor, supraspinatus and infraspinatus. If they are tight, stretch them. You may be able to get some mileage out of that, but if they are not tight, there’s no point stretching them. You’ll have to work within the pain principle by performing as many reps as you can without pain. When the pain presents itself is when you stop as that will be the maximum tolerance of load on the painful tissues. You will also have to consider the natural swelling of the tissue that will occur during training and how it might accelerate pain.
The final thing I would recommend would be deep tissue work or massage on the client. See if massage on the specific area before the workout improves performance and decreases pain. Also, while the client is working out and performing the movements that aggravate it, as a test, massage the area briefly and have the client perform a few repetitions immediately and note any differences. Good luck!