Presentation
The patient presented with chronic upper back pain located between the shoulder blade and spine. The symptoms had begun more than a decade earlier during tennis and had remained persistent.
Previous treatment had included physical therapy, chiropractic care, and shoulder surgery. The surgery helped with other shoulder symptoms, but the pain around the shoulder blade persisted.
Lifting and carrying were particularly aggravating. Carrying groceries or other objects weighing more than a few pounds could reproduce significant pain.
The patient remained highly active with sports and resistance training, but the longstanding upper back and shoulder symptoms continued to interfere with exercise and daily activity. The primary goal was to reduce the pain and improve tolerance for lifting and carrying.
Examination
Examination showed altered positioning of the scapula. The shoulder blade rested in a more elevated and forward position, with the inferior angle rotated laterally.
The infraspinatus was notably prominent and tender, and the patient reported weakness with shoulder external rotation.
Significant muscular tension and sensitivity were found through the rhomboids and thoracic paraspinals along the medial border of the scapula.
As treatment progressed, additional findings were identified farther around the shoulder girdle, including the infraspinatus, teres major and minor, levator scapulae, and posterior cervical musculature.
Later examination also showed significant tension through the anterior shoulder and chest. The pectoralis minor, biceps, and coracobrachialis were notably tight.
The patient's symptoms were strongly influenced by loading. Carrying weight with the arm and certain pressing movements consistently reproduced the familiar pain around the shoulder blade.
Assessment
The clinical picture suggested that the longstanding pain involved altered scapular positioning and reduced tolerance to sustained loading rather than one isolated painful muscle.
Significant muscular tension was present throughout the muscles surrounding and influencing the shoulder blade. The altered scapular position, together with reported weakness in shoulder external rotation, suggested that the shoulder and surrounding musculature may have been functioning less efficiently during loaded activity.
The later findings around the anterior shoulder were also notable. The pectoralis minor, biceps, and coracobrachialis were all notably tight. This tension may have influenced the forward position and mechanics of the shoulder girdle.
The loading problem was especially apparent with activities that involved carrying. Sustained loading through the arm consistently reproduced the familiar pain around the medial scapular region, making carrying tolerance a useful functional marker for following progress.
Treatment
Treatment initially focused directly on the area of longstanding pain along the medial border of the scapula.
Acupuncture and dry needling were applied to the rhomboids, thoracic paraspinals, and other sensitive areas in the region. Electroacupuncture was incorporated in areas of significant muscular tension.
As symptoms changed and additional findings became apparent, treatment expanded outward to include the infraspinatus, teres major and minor, levator scapulae, and posterior cervical musculature.
Treatment later broadened to the anterior shoulder and chest after significant tension was identified through the pectoralis minor, biceps, and coracobrachialis.
Manual therapy was used around the scapula, upper back, and shoulder, with additional work to the pectoralis minor, biceps, and coracobrachialis. Cupping was incorporated during some visits.
Response
The initial response was significant.
After the first treatment, the patient reported that the days following their visit were the most pain-free they had experienced in several years, and day-to-day activities felt easier.
Carrying tolerance became one of the clearest markers of progress. Initially, carrying a relatively light load could bring on discomfort within less than a minute.
As treatment progressed, the patient was able to carry approximately 5–10 pounds for 5–10 minutes before discomfort developed. Later, they were able to do things like carry groceries for about 15 minutes before the discomfort became limiting.
During subsequent travel, the patient was able to carry a suitcase without reproducing the original upper back pain.
Exercise tolerance improved as well. Overhead pressing, which had previously aggravated the shoulder, became more comfortable, and the patient was able to return to increasingly demanding upper-body workouts.
Tennis tolerance also improved, with the patient able to play for longer periods without the shoulder symptoms that had previously developed with prolonged activity.
Overall, the most meaningful change was the patient’s increased tolerance for sustained loading. Carrying, exercise, and recreational activity became progressively easier without provoking the longstanding upper back pain.
Some clinical details have been generalized to protect patient privacy. Individual results vary.