What is the treatment for right scapular pain?

Treatment of Right Scapula Pain

Treatment of right scapular pain should follow a stepwise approach, beginning with conservative measures including NSAIDs, physical therapy with scapular strengthening exercises, and activity modification, progressing to more invasive interventions only if conservative management fails. 1

Initial Assessment and Diagnosis

When evaluating right scapular pain, consider these common causes:

• Calcific supraspinatus tendinopathy
• Scapulothoracic bursitis
• Scapular dyskinesis (altered positioning and motion)
• Levator scapulae syndrome
• Rhomboid strain or injury
• Dorsal scapular nerve lesion
• Snapping scapula syndrome

Imaging may be necessary to determine the exact cause. For suspected scapular fractures, CT is the best imaging modality as it can identify and characterize fracture patterns that may be missed on conventional radiography 2.

Treatment Algorithm

Step 1: Conservative Management (First 4-6 weeks)

1. Medications:

   • NSAIDs (first-line): Ibuprofen 400-800 mg three to four times daily with meals to reduce pain and inflammation 3
   • Acetaminophen: Up to 4g/day if NSAIDs are contraindicated or insufficient 1
   • Muscle relaxants: For acute muscle spasms (short-term use, 7 days) 1

2. Physical Therapy:

   • Scapular strengthening exercises focusing on the rhomboids, trapezius, and serratus anterior
   • Postural correction exercises
   • Deep transverse friction massage to reduce pain 1
   • Eccentric strengthening exercises for the rotator cuff if involved 1

3. Activity Modification:

   • Relative rest
   • Avoid overhead movements and activities that exacerbate pain 1
   • Ergonomic adjustments at work/home

Step 2: If No Improvement After 4-6 Weeks

1. Local Interventions:

   • Corticosteroid injection directed to the site of inflammation (limited to 2-3 injections with 4-6 weeks between injections) 1
   • Consider ultrasound-guided injection for better precision

2. Advanced Physical Therapy:

   • Manual therapy techniques
   • Neuromuscular re-education
   • Taping techniques to improve scapular positioning

3. Consider Extracorporeal Shock Wave Therapy (ESWT):

   • Particularly effective for calcific tendinopathy and chronic cases 1

Step 3: For Persistent Symptoms (3-6 months of failed conservative treatment)

1. Surgical Options:
   • For scapulothoracic bursitis: Open or arthroscopic scapulothoracic bursectomy 4
   • For snapping scapula syndrome: Partial scapulectomy in selected patients 4
   • For calcific deposits: Arthroscopic removal of calcification 1

Special Considerations

1. For Scapular Dyskinesis:

   • Focus on scapular stabilization exercises and motor control training 5
   • Evaluate for and treat any associated conditions (rotator cuff disease, labral injury, etc.)

2. For Levator Scapulae Syndrome:

   • Targeted physical therapy for the levator scapulae muscle
   • Analgesic injection at the muscle insertion point 6

3. For Dorsal Scapular Nerve Lesion:

   • Nerve-gliding exercises
   • Gabapentin may be considered for neuropathic pain 7

4. For Snapping Scapula Syndrome:

   • Evaluate for possible association with thoracic outlet syndrome 8
   • Consider surgical intervention if conservative measures fail

Monitoring and Follow-up

• Reassess pain and function every 4-6 weeks
• Adjust treatment plan if no improvement is seen after 8-12 weeks of consistent therapy 1
• For most conditions, expect a recovery period of 3-6 months with appropriate management 1

Pitfalls and Caveats

1. Avoid overuse of corticosteroid injections - limit to 2-3 injections with 4-6 weeks between injections to prevent tendon weakening 1

2. Don't overlook scapular dyskinesis when treating shoulder conditions, as it is found in association with most shoulder injuries 5

3. Consider rare causes such as dorsal scapular nerve lesion in cases of winging scapula with rhomboid weakness 7

4. Be aware that diabetic patients may respond less favorably to conservative measures and may require a modified approach 1

5. Don't miss associated conditions - scapular pain may be part of a broader issue like thoracic outlet syndrome 8