What are the potential causes and management options for a patient with a history of chest pain and gastrointestinal symptoms who may be experiencing referred pain from the Rhomboidus muscle?

Rhomboid Muscle Referred Pain Pattern

The rhomboid muscles do not produce classic "referred pain" in the neurological sense; instead, they cause localized interscapular pain that may radiate along the medial scapular border, and critically, this musculoskeletal chest wall pain must be distinguished from life-threatening cardiac, aortic, and pulmonary causes before attributing symptoms to rhomboid pathology. 1

Pain Characteristics and Distribution

Rhomboid muscle pain presents as:

• Localized medial scapular pain between the spine and scapula, typically at the T2-T7 vertebral levels 2, 3
• Pain that worsens with shoulder elevation and scapular retraction movements 3, 4
• Tenderness reproducible with direct palpation over the medial scapular border 2, 4
• Possible scapular winging with lateral rotation of the inferior angle in cases of rhomboid weakness or paralysis 5, 3

The pain pattern is not true referred pain (visceral pain perceived at distant sites) but rather local musculoskeletal pain that may be perceived in the interscapular region and occasionally the posterior chest wall 1, 6.

Critical Differential Diagnosis: Life-Threatening Causes First

Before attributing chest pain to rhomboid pathology, you must systematically exclude:

Cardiac Causes

• Acute coronary syndrome: Look for pain with diaphoresis, nausea, radiation to arm/jaw, and obtain ECG within 10 minutes plus cardiac troponins 1, 7
• Critical finding: 7% of patients with reproducible chest wall tenderness on palpation still have acute coronary syndrome—reproducible pain does NOT exclude cardiac disease 7

Aortic Dissection

• Sudden onset "ripping" or "tearing" severe chest or back pain 1, 7
• Pulse differential >20 mmHg between limbs or pulse deficits 1
• High-risk features: Known thoracic aneurysm, Marfan syndrome, recent aortic manipulation 1

Pulmonary Embolism

• Sharp pleuritic pain worsening with inspiration plus tachycardia and dyspnea in >90% 7

Other Emergencies

• Pneumothorax: Sharp pleuritic pain with unilateral absent breath sounds and hyperresonant percussion 7
• Esophageal rupture: Severe pain after vomiting or instrumentation 8

Diagnostic Indicators Favoring Musculoskeletal Origin

Pain is more likely rhomboid-related when:

• Pain affected by palpation, breathing, turning, twisting, or bending 1
• Pain generated from multiple sites on the chest wall 1
• Pain varies with body position and food intake 1
• Well-localized tenderness on the medial scapular border 1, 2
• Absence of cardiac risk factors: No prior cardiovascular disease, younger age, atypical pain pattern 1

However, musculoskeletal pain accounts for 20-40% of chest pain presentations, making it the most common diagnosis after cardiac causes are excluded 1, 7.

Specific Rhomboid Pathology

Rhomboid Muscle Strain/Myofascial Pain

• Trigger points in rhomboid muscles causing localized interscapular pain 6, 4
• Associated with poor posture and repetitive overhead activities 2, 5
• Pain pressure sensitivity at trigger point locations 4

Rhomboid Muscle Tears

• Complete tears present with persistent medial scapular pain, visible dent on medial scapula, and scapular winging 3
• MRI findings: Muscle retraction at insertion on medial scapular border 3
• Mechanism: Typically after carrying heavy loads or sudden forceful movements 3

Dorsal Scapular Nerve Neuropathy

• Rhomboid paralysis causing scapular winging with lateral rotation of inferior angle 5
• Dynamic compression of dorsal scapular nerve by proximal medial scapular border when arm elevated >90° 5
• Confirmed by electroneuromyography showing rhomboid denervation 5

Management Algorithm

Step 1: Emergency Exclusion (First Priority)

• Obtain ECG within 10 minutes of presentation 7
• Measure cardiac troponin as soon as possible 7
• Chest radiography to evaluate for pneumothorax, pneumonia, widened mediastinum 7
• CT chest with contrast if pulmonary embolism or aortic dissection suspected 7

Step 2: Confirm Musculoskeletal Origin

• Detailed history: Pain with specific movements, posture-related, occupational factors (heavy physical work, overhead activities) 5, 4
• Physical examination: Palpate medial scapular border for tenderness, assess scapular position and winging, test shoulder range of motion 2, 3
• MRI of periscapular region if complete tear suspected (persistent pain, visible deformity, scapular winging) 3

Step 3: Conservative Treatment (First-Line)

• Physical therapy: Specific rehabilitation protocol targeting rhomboid strengthening and scapular stabilization 5, 4
• Thoracic spine manipulation: 2 sessions per week for 3 weeks significantly improves pain and pressure pain threshold 4
• Counterstrain technique: Addresses both scapular retraction and superior medial rotation without abduction 2
• Interfacial nerve block: Trapezius-rhomboid plane block with 10cc bupivacaine 0.25% plus methylprednisolone 40mg shows 70% pain reduction at 8 weeks 6

Step 4: Surgical Intervention (If Conservative Fails)

• Indications: Complete rhomboid tear with muscle retraction, persistent pain after 2 months of conservative treatment, functional disability 3
• Technique: Bone holes on medial scapular border with Krackow stitch repair of torn muscle to insertion 3
• For nerve compression: Multidisciplinary rehabilitation in specialized center; no established surgical solution for dorsal scapular nerve neuropathy 5

Critical Pitfalls to Avoid

• Never assume reproducible chest wall tenderness excludes cardiac disease—7% still have acute coronary syndrome 7
• Never attribute chest pain to musculoskeletal causes without ECG and cardiac biomarkers in patients with cardiac risk factors 1, 7
• Do not miss aortic dissection in patients with sudden severe "ripping" back pain, even with normal chest examination 1, 7
• Consider gastrointestinal causes (GERD, esophageal spasm) in patients with recurrent chest pain and normal cardiac workup 8, 7
• Recognize atypical presentations in women (back, neck, jaw pain) and elderly patients (≥75 years) 7

Special Considerations for Gastrointestinal Symptoms

If patient has concurrent gastrointestinal symptoms with chest pain:

• Severe constipation can cause chest pain in 10-20% of cases, but requires cardiac exclusion first 8
• GERD presents as squeezing or burning retrosternal pain, most common esophageal cause 7
• Evaluate bowel habits: Straining, incomplete evacuation, abdominal distention, fecal impaction 8
• Aggressive laxative therapy if constipation confirmed after cardiac causes excluded 8