What structure in the left upper back near the scapula could be torn from fatigue after prolonged raking?

Muscle Strain of the Rhomboid or Trapezius from Repetitive Raking

The most likely structure torn in the left upper back near the scapula from prolonged raking is the rhomboid muscle (major or minor) or the lower/middle trapezius muscle, both of which attach along the medial border of the scapula and are vulnerable to fatigue-related strain from repetitive pulling motions. 1

Anatomical Structures at Risk

The periscapular region contains several muscles that stabilize the scapula during repetitive arm movements:

• Rhomboid major and minor muscles originate from the thoracic spine (T2-T5) and insert along the entire medial border of the scapula, functioning to retract and stabilize the scapula during pulling activities 2
• Middle and lower trapezius fibers also attach to the medial scapular border and spine of the scapula, providing scapular retraction and depression during repetitive overhead or pulling movements 2, 3
• Latissimus dorsi attaches more inferiorly and laterally but can be injured during forceful pulling motions, though this typically occurs in throwing athletes rather than from raking 4, 5

Why Rhomboid/Trapezius Injury is Most Likely

Raking involves repetitive scapular retraction and depression with the arm in front of the body, placing sustained eccentric load on the rhomboid and trapezius muscles. 1 This mechanism differs from the acute traction or throwing injuries that typically cause latissimus dorsi tears 4, 5.

• Fatigue-related muscle tears occur when repetitive eccentric contractions exceed the muscle's capacity to recover, leading to microscopic fiber disruption that can progress to partial or complete tears 1
• The rhomboids and trapezius are particularly vulnerable because they must continuously stabilize the scapula against the chest wall during the pulling motion of raking 2, 3

Clinical Presentation to Expect

• Pain localized to the medial scapular border that worsens with scapular retraction movements (pulling the shoulder blade toward the spine) 1, 2
• Visible or palpable asymmetry of the scapular position at rest, with the affected scapula sitting more laterally (winging pattern) if significant muscle detachment occurred 2
• Weakness with resisted scapular retraction and difficulty maintaining scapular stability during arm movements 2, 3
• Possible ecchymosis or swelling along the medial scapular border in acute complete tears 2

Diagnostic Approach

Plain radiographs are not indicated for isolated soft tissue injuries without trauma history, but MRI without contrast is the gold standard for evaluating suspected muscle tears in the periscapular region. 6, 1

• MRI will demonstrate muscle edema, fiber disruption, retraction, and the extent of any tendinous avulsion from the scapular border 6, 2
• Ultrasound can visualize superficial muscle tears but has limited utility for deep periscapular muscles like the rhomboids 6, 1

Management Strategy

Most rhomboid and trapezius muscle strains are managed nonoperatively with rest, anti-inflammatories, and progressive rehabilitation focusing on scapular stabilization. 2, 4

Initial Phase (0-4 weeks):

• Complete rest from aggravating activities including any pulling or lifting motions 1, 2
• NSAIDs for pain control during the acute inflammatory phase 1
• Gentle range of motion exercises to prevent adhesive capsulitis, avoiding scapular retraction movements 1, 7

Intermediate Phase (4-12 weeks):

• Progressive scapular stabilization exercises once pain-free motion is achieved, focusing on controlled retraction and depression 1, 2
• Avoid overhead activities and heavy lifting until adequate strength is restored 1, 2

Advanced Phase (12+ weeks):

• Gradual return to functional activities with emphasis on proper body mechanics during repetitive tasks 2, 8
• Full recovery typically requires 3-6 months for partial tears and up to 12 months for complete muscle detachments requiring surgical repair 2

Surgical Considerations

Surgical reattachment is reserved for complete muscle avulsions from the scapular border that fail conservative management, particularly in younger active individuals. 2, 3

• Surgery involves reattachment of the muscle to the medial scapular border using suture anchors or transosseous sutures 2, 3
• Post-operative rehabilitation requires 16 weeks of protected motion followed by gradual strengthening over 12 months 2
• Functional overhead strength may not fully return until one year post-operatively 2

Critical Pitfall to Avoid

Do not confuse periscapular muscle injury with rotator cuff pathology—rhomboid/trapezius tears cause pain with scapular retraction and demonstrate scapular winging, while rotator cuff tears cause pain with shoulder abduction/rotation and demonstrate focal weakness with preserved scapular position. 1, 2 The location "left of spine near shoulder blade" specifically indicates the medial scapular border where rhomboids and trapezius attach, not the lateral shoulder where rotator cuff pathology manifests. 1, 2