Scapulocostal syndrome is a clinical syndrome characterized by pain and paresthesias over the medial border of the scapula that radiate into the neck, upper triceps, chest wall, and distal upper extremity.
The pain is burning and aching. The intensity level of pain associated with scapulocostal syndrome is moderate.
Also known as traveling salesman shoulder, the scapulocostal syndrome is thought to be an overuse syndrome resulting from repetitive use of the shoulder stabilizing muscles, including the serratus anterior, levator scapulae, pectoralis minor, and rhomboid, when carrying out activities such as reaching backward over a car seat for samples and prolonged use of the telephone cradled between the shoulder and neck.
Racquet sports also have been implicated in the evolution of scapulocostal syndrome.
What are the Symptoms of Scapulocostal Syndrome
Physical examination reveals myofascial trigger points in the rhomboid, infraspinatus, and subscapularis muscles. These trigger points are best shown by having the patient reach across the chest and place his or her hand on the uninvolved shoulder.
Palpation of trigger points along the medial border of the scapula produces a positive jump sign and causes pain to radiate into the ipsilateral upper extremity.
The neurological examination of the upper extremity is normal in scapulocostal syndrome. Untreated, patients with scapulocostal syndrome develop decreased range of motion of the shoulder and scapula, resulting in functional disability and pain.
How is Scapulocostal Syndrome diagnosed?
Plain radiographs are indicated in all patients with scapulocostal syndrome.
Based on the clinical presentation, additional tests, including complete blood cell count, erythrocyte sedimentation rate, and antinuclear antibody level, may be indicated.
Magnetic resonance imaging (MRI) of the shoulder is indicated if rotator cuff tear is suspected. Radionuclide bone scanning is indicated if metastatic disease or primary tumor involving the shoulder is being considered.
Chest radiographs with apical lordotic views should be obtained if superior sulcus tumor of the lung is a possibility. Electromyography and nerve conduction velocity testing help rule out radiculopathy, brachial plexopathy, and entrapment neuropathy.
Scapulocostal syndrome is most commonly misdiagnosed as cervical radiculopathy. In contrast to cervical radiculopathy, however, which is associated with numbness and weakness in the affected dermatomes, the upper extremity neurological examination in scapulocostal syndrome is normal.
Osteoarthritis, rheumatoid arthritis, posttraumatic arthritis, and rotator cuff tear arthropathy also are common causes of shoulder pain secondary to arthritis that may be confused with scapulocostal syndrome.
Less common causes of arthritis-induced shoulder pain include the collagen-vascular diseases, infection, villonodular synovitis, and Lyme disease.
Acute infectious arthritis usually is accompanied by significant systemic symptoms, including fever and malaise, and should be easily recognized by an astute clinician and treated appropriately with culture and antibiotics, rather than injection therapy.
The collagen-vascular diseases generally manifest as a polyarthropathy rather than a monarthropathy limited to the shoulder joint, and the pain does not radiate into the upper extremity.
Pancoast tumor and brachial plexopathy also may mimic the clinical presentation of scapulocostal syndrome.
Initial treatment of the pain and functional disability associated with scapulocostal syndrome should include a combination of nonsteroidal antiinflammatory drugs (NSAIDs) or cyclooxygenase-2 (COX-2) inhibitors and physical therapy.
The local application of heat and cold as well as the use of massage and scapular stabilization exercises also may be beneficial. Repetitive movements that incite the syndrome should be avoided.
For patients who do not respond to these treatment modalities, injection of myofascial trigger points with local anesthetic and steroid may be a reasonable next step.
The major complication in the care of a patient thought to have scapulocostal syndrome is misdiagnosis.
Tumors of the superior sulcus of the lung or primary or metastatic tumors of the shoulder and scapula must be included in the differential diagnosis.
Scapulocostal syndrome is a less common cause of shoulder and upper extremity pain encountered in clinical practice, with cervical radiculopathy occurring much more commonly. This painful condition must be separated from other causes of shoulder pain, including rotator cuff tears.
Coexistent bursitis and tendinitis also may contribute to shoulder pain and may require additional treatment with more localized injection of local anesthetic and depot steroid.
Trigger point injections are a safe procedure if careful attention is paid to the clinically relevant anatomy in the areas to be injected. Care must be taken to use sterile technique to avoid infection and universal precautions to avoid risk to the operator.
The incidence of ecchymosis and hematoma formation can be decreased if pressure is placed on the injection site immediately after injection.
The use of physical modalities, including local heat and gentle range-of-motion exercises, should be introduced several days after the patient undergoes trigger point injections for scapulocostal syndrome. Avoidance of activities responsible for the evolution of the disease must be considered or the syndrome will recur.
Vigorous exercises should be avoided because they would exacerbate symptoms. Simple analgesics and NSAIDs or a COX-2 inhibitor may be used concurrently with an injection technique.