What is the management for musculoskeletal causes of unilateral back pain around the scapula area?

Management of Musculoskeletal Causes of Unilateral Scapular Pain

For musculoskeletal causes of unilateral back pain around the scapula, initiate conservative management with education, exercise therapy focused on scapular stabilization, and short-term NSAIDs, reserving imaging and interventional procedures only for cases with red flags or failure of 3 months of conservative treatment. 1

First-Line Conservative Management

Education and Self-Management

• Provide structured education about the benign nature of most musculoskeletal scapular pain and expected recovery timeline of 2-12 weeks 1
• Offer formal self-management programs that include activity modification strategies and pain coping mechanisms 1
• Reassure patients that imaging findings (degenerative changes) correlate poorly with symptoms and are common in asymptomatic individuals 2

Exercise Therapy (Primary Treatment)

• Prescribe scapular stabilization exercises as the cornerstone of treatment, which have demonstrated superior outcomes compared to stretching and strengthening alone 3, 4
• Scapular stabilization exercises improve muscle strength by addressing scapulothoracic dyskinesis, which is highly prevalent in patients with shoulder girdle pain 5, 3, 4
• Include stretching exercises for periscapular muscles, range of motion exercises, and progressive strengthening 3, 4
• Continue exercise program for minimum 6 weeks, 3 times weekly, as this duration shows statistically significant improvements in pain, muscle strength, and joint position sense 3, 4

Pharmacological Management

• Use short-term NSAIDs for pain relief, carefully considering risks and benefits 1
• Do not offer paracetamol (acetaminophen) as monotherapy, as guidelines recommend against this for musculoskeletal pain 1
• Avoid opioids for chronic musculoskeletal pain due to lack of additional benefit over NSAIDs and potential for harm 1
• Do not prescribe antidepressants (SSRIs, SNRIs, tricyclics) or anticonvulsants for isolated musculoskeletal back pain 1

When to Image

Red Flags Requiring Urgent MRI

• Fever combined with elevated inflammatory markers (ESR, CRP) suggesting vertebral osteomyelitis 2
• New neurologic symptoms or deficits 2
• History of malignancy or immunosuppression 2
• Constitutional symptoms (unexplained weight loss, night sweats) 2
• Recent bacteremia, particularly Staphylococcus aureus 2

Imaging for Non-Urgent Cases

• Do not order routine imaging for mechanical scapular pain without red flags, as degenerative findings are present in 53.9% of asymptomatic adults and increase with age 2
• If imaging is necessary after excluding red flags, begin with plain radiographs (AP internal/external rotation and axillary or scapula-Y views) 2, 6
• Reserve MRI for suspected soft tissue injuries around the scapula or when conservative management fails after 3 months 2, 6

Interventional Procedures (Limited Role)

Trigger Point Injections

• Consider trigger point injections only after failed conservative management, though evidence shows limited long-term benefit 1
• Anesthetic injections show short-term superiority over saline, but require correction of perpetuating mechanical factors for sustained relief 1

Procedures to Avoid

• Do not perform facet joint injections, medial branch blocks, intradiscal injections, or prolotherapy for non-radicular back pain 1
• Epidural steroid injections are strongly recommended against for non-radicular low back pain 1
• Radiofrequency procedures have conflicting evidence and should not be routinely offered without specific facet-mediated pain confirmed by diagnostic blocks 1

Surgical Consideration

• Offer surgical evaluation only after minimum 3 months of evidence-based non-surgical care has failed 1, 2
• Exception: unstable fractures or joint instability require immediate orthopedic referral 2
• For scapula fractures, isolated body fractures heal well without surgery; surgical intervention indicated only for glenoid neck involvement or significant displacement 6

Common Pitfalls to Avoid

• Do not assume degenerative changes on imaging explain symptoms, as these are ubiquitous in asymptomatic individuals and correlate poorly with pain 2
• Avoid attributing symptoms solely to obvious bony pathology while missing underlying scapulothoracic dyskinesis, which requires specific exercise intervention 5, 4
• Do not delay appropriate conservative treatment by pursuing extensive imaging workup in absence of red flags 1, 2
• Recognize that 40% of patients may not achieve significant pain relief by 3 months with conservative treatment alone, at which point reassessment is warranted 1

Multidisciplinary Approach When Needed

• Coordinate care with physical therapy for supervised scapular stabilization exercise programs 3, 4
• Consider rheumatology referral if systemic inflammatory conditions suspected (polymyalgia rheumatica, fibromyalgia) 1, 7
• Address psychosocial factors through assessment, as these predict outcomes in musculoskeletal pain, though specific psychological interventions have limited guideline support 1