What is the treatment for levator scapulae syndrome?

Treatment of Levator Scapulae Syndrome

Levator scapulae syndrome should be treated with a combination of physical therapy including targeted stretching exercises in the sitting position, and trigger point therapy using either dry needling or ischemic compression, with dry needling showing superior short-term outcomes for pain relief and muscle function. 1, 2, 3

Diagnostic Confirmation

Before initiating treatment, confirm the diagnosis by positioning the patient so the scapula is elevated, which makes the levator scapulae muscle insertion protrude and allows direct palpation of the tender insertion point at the superior medial angle of the scapula 1. Look for:

• Localized tenderness at the superior medial scapular border that reproduces the patient's symptoms 1
• Associated cervical range of motion limitations, particularly in rotation and lateral flexion away from the affected side 4
• Myofascial trigger points within the muscle belly that refer pain to the neck, shoulder, or posterior scapular region 2, 3

First-Line Treatment: Stretching Exercises

The sitting position is the most effective stretching position for lengthening the levator scapulae and improving cervical range of motion 4. This position demonstrated:

• Greater improvement in levator scapulae length index compared to quadruped (p < 0.01) or prone positions (p = 0.01) 4
• Significant increases in cervical ROM compared to baseline (p < 0.01) and quadruped position (p < 0.01) 4

Comprehensive Stretching Protocol

Include the following muscles in the stretching program 5:

• Upper trapezius and levator scapulae (primary targets)
• Suboccipital muscles
• Scalene muscles
• Sternocleidomastoid
• Pectoral muscles

Trigger Point Therapy

Dry Needling (Preferred Method)

Dry needling targeting myofascial trigger points in the levator scapulae muscle and its distal periosteal enthesis provides superior outcomes compared to ischemic compression 2, 3. Evidence shows:

• Immediate effects: Pressure pain threshold initially decreases immediately post-treatment but then increases significantly at 48 hours and one week 3
• Pain reduction: Greater improvement in pain intensity at 48 hours and one week compared to ischemic compression 3
• Tissue quality: Superior improvement in mechanical heterogeneity index (elastography measure) compared to ischemic compression 3
• Symptom resolution: Full resolution of chronic tension-type headaches associated with levator scapulae syndrome achieved with three sessions over 2 months 2

Ischemic Compression (Alternative)

If dry needling is unavailable or contraindicated, ischemic compression can be used 3. However, recognize that:

• Pressure pain threshold increases immediately but to a lesser degree than dry needling at follow-up 3
• Mechanical heterogeneity improvements are less pronounced than with dry needling 3

Strengthening and Postural Correction

Scapular Stabilization

Strengthen lower scapular stabilizers beginning in gravity-assisted positions to restore normal cervico-scapular movement patterns 5. This addresses the underlying biomechanical dysfunction that perpetuates the syndrome.

Postural Education

Provide specific instruction for 5:

• Sitting posture: Maintain neutral cervical spine, avoid forward head posture
• Standing posture: Scapular retraction and depression
• Sleeping positions: Avoid positions that place the levator scapulae on stretch for prolonged periods

Multimodal Treatment Plan

A typical treatment course should include 2:

1. Initial phase (Weeks 1-2):

   • Dry needling sessions (2-3 treatments) targeting trigger points and distal enthesis 2
   • Daily stretching exercises in sitting position 4
   • Postural education 5

2. Progressive phase (Weeks 3-8):

   • Continue stretching program 4
   • Add strengthening exercises for scapular stabilizers 5
   • Behavioral modification at work and home 5

3. Maintenance phase (Beyond 8 weeks):

   • Continue home exercise program 5
   • Monitor for recurrence 1

Important Clinical Considerations

Recurrence Risk

Like other forms of tendinitis, levator scapulae syndrome has a high likelihood of recurrence 1. This necessitates:

• Patient education about ergonomic modifications 5
• Compliance with long-term stretching and strengthening programs 5
• Behavioral modification to address perpetuating factors 5

Treatment Duration

Expect a treatment course of 5 visits over 2 months for resolution of symptoms when using dry needling combined with exercise 2. Follow-up at 6 months confirms sustained benefit 2.

Injection Therapy

While analgesic injection at the muscle insertion was mentioned as effective treatment 1, more recent evidence supports dry needling as the preferred interventional approach due to its superior outcomes on validated measures 3 and its ability to address both trigger points and enthesopathy 2.