What is the best initial approach to managing bilateral scapulothoracic junction pain in a patient with a negative magnetic resonance imaging (MRI) scan?

Management of Bilateral Scapulothoracic Junction Pain with Negative MRI

Conservative management with scapular strengthening exercises, postural correction, and NSAIDs should be the initial treatment approach for this 36-year-old female with bilateral scapulothoracic pain and negative MRI, as imaging abnormalities do not correlate with pain and conservative therapy is highly effective for soft-tissue causes. 1, 2

Understanding the Clinical Context

The negative MRI is actually reassuring and expected in scapulothoracic disorders. Scapulothoracic bursitis and crepitus remain primarily clinical diagnoses, and imaging studies often fail to reveal the underlying pathology. 2 The bilateral nature suggests this is likely related to:

• Scapulothoracic bursitis (inflammation of bursae between scapula and chest wall) 1, 2
• Scapulothoracic dyskinesis (disrupted scapular positioning and motion) 3
• Postural or biomechanical dysfunction affecting both shoulders 1, 2

The American College of Radiology guidelines emphasize that morphologic imaging changes do not correlate with thoracic pain, and thoracic disc abnormalities are common in asymptomatic individuals. 4

Initial Conservative Management Protocol

First-Line Interventions (4-6 weeks minimum)

• Scapular strengthening exercises targeting periscapular muscles (serratus anterior, rhomboids, trapezius) 1, 2
• Postural reeducation to optimize scapular positioning and mechanics 1, 2
• Core strengthening for endurance and stability 2
• NSAIDs for pain control and anti-inflammatory effect 2
• Activity modification to reduce aggravating movements 5
• Local modalities (heat, ice, ultrasound) as adjuncts 1, 2

Conservative treatment is highly effective when soft-tissue lesions are the cause of scapulothoracic symptoms. 1

When to Consider Additional Interventions

If symptoms persist after 4-6 weeks of appropriate conservative therapy:

• Local corticosteroid injection into the scapulothoracic bursa may provide diagnostic and therapeutic benefit 2
• Physical therapy intensification with supervised scapular stabilization program 3, 2
• Reassess for concomitant shoulder pathology (rotator cuff, labral tears) that may require separate treatment 3

Red Flags to Exclude

While the negative MRI is reassuring, ensure you have ruled out:

• Myelopathy symptoms (gait disturbance, upper motor neuron signs, bowel/bladder changes) 6, 5
• Cancer history or unexplained weight loss 6, 5
• Infection risk factors (fever, immunosuppression) 6, 5
• Progressive neurologic deficits 6, 5

The American College of Radiology emphasizes that these red flag conditions require urgent evaluation as they can cause significant morbidity and mortality. 6

Surgical Considerations (Only After Failed Conservative Management)

Surgery should only be considered after at least 6 months of failed conservative treatment and includes:

• Arthroscopic scapulothoracic bursectomy (increasingly preferred, less invasive) 1, 2, 7
• Open bursal resection 2
• Partial scapulectomy (for osseous lesions causing mechanical symptoms) 1, 2

Good to excellent outcomes have been demonstrated in a significantly high percentage of patients with surgical treatment, but this is reserved for refractory cases. 2

Common Pitfalls to Avoid

• Do not over-interpret imaging findings - thoracic disc abnormalities and facet arthropathy are common in asymptomatic individuals and do not correlate with pain 4, 6
• Do not pursue additional imaging unless new red flags emerge or symptoms suggest alternative diagnosis 4
• Do not rush to surgery - the bilateral nature and negative MRI strongly favor conservative management success 1, 2
• Do not neglect psychosocial factors - depression, anxiety, and catastrophizing predict poor outcomes and chronic disability 5

Follow-Up Timeline

• Reevaluate at 4-6 weeks to assess response to conservative management 5
• Consider injection if partial improvement but persistent symptoms at 6 weeks 2
• Refer to orthopedics only if symptoms remain debilitating after 6 months of appropriate conservative care 2