Rhomboid Pain and Recovery

author : AMSSM
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Member Question 


"About 3-4 months ago I somehow injured my right rhomboid (not sure if major or minor) pretty severely. There's a lot of pain when I lie down and a large percentage of my back will spasm if I lift my arm above my head. I also experience a small amount of pain after 30-45 minutes of running, but the real pain comes at night when I lie down the night after a run. I can't swim freestyle without my whole back spasming, but I can swim breaststroke with no issues whatsoever. I've been to a couple of physios and they haven't been able to help. My wife seems to think it might be related to my posture and I'm somewhat inclined to agree. I've been icing and heating and massaging, but I just can't kick this injury. Triathlons are just not happening in my near future without running and only being able to swim breast stroke. If anyone has had this problem and recovered, what did you do? If it healed with primarily the passage of time, how long did it take? "

Answer by Caitlyn Mooney, MD
Member AMSSM


Sounds like you have had a frustrating problem. Pain around shoulder blade and rhomboids are common complaints in sports medicine clinics both in athletes and non-athletes. The rhomboid major and minor are skeletal muscles of the upper back that connects the scapula or shoulder blade to the vertebral column. The rhomboids help move and stabilize the shoulder blade. The shoulder blade is a large triangular bone held mostly in place by muscles including the rhomboid as it only has one bony attachment to the rest of the bony skeleton of the body. One edge of the scapula creates the socket for the ball of the shoulder to attach to the rest of the skeleton. For this reason, normal movement of the scapula is required for normal shoulder motion. As one of the muscles that attaches the shoulder blade to the spine, several things can predispose one to pain in the rhomboids and peri-scapular area including repetitive arm motion such as in swimming or postural or ergonomic issues which can occur with desk jobs or with being in a cycling position for a prolonged period.

Cyclists and swimmers also are prone to upper back and shoulder overuse injuries which can cause pain in this area. It is important to consider that pain in this area can be referred from an injury outside of the rhomboid including the cervical spine or shoulder thus an evaluation by a physician with knowledge in musculoskeletal injuries is recommended to determine the cause of your pain. Shoulder bursitis, rotator cuff tears, and shoulder impingement syndromes can all cause pain to be worse at night which may also result in pain that could be referred to the area surrounding the scapula. Commonly an evaluation will include taking a history, a physical exam, potentially neck and shoulder x-rays, and potentially further imaging such as ultrasound or MRI.

Upper back pain including pain in the rhomboids can be common in cyclists and triathletes. While on a road bike or a triathlon bike the upper back is curved and the neck is often hyperextended. This rounded shoulder posture can cause all sorts of shoulder and upper back problems. Over long rides this can cause fatigue of the surrounding muscles. Prolonged fatigue can result in overuse and muscle injury. Trigger points and spasm are common. If there is a possibility that this is a cycling related overuse injury consider cutting back on cycling mileage, getting a professional (medical oriented rather than performance oriented) bike fit,   working on upper back and neck exercises.   Cyclists likely would benefit from stretching exercises to combat the muscle tightness that can occur due to the prolonged posture on the bike. Some common stretching exercises that will help cyclists include tilting head to the side with ear on shoulder, rotating head to the side, and bending head forwards (chin to chest). Chest and upper back stretches are also important including such stretches as cross body arm stretches (arm across the front of the chest), child’s pose stretches, door-frame stretches and others. Stretches can be held for between 30 seconds and repeated about 3-5 times.     Strengthening the back is also critical to lessen fatigue in these muscles that support your head and posture while on the bike. Working on scapular stabilization exercises and scapular retraction exercises with proper form are very important to start with.   Planking, rotator cuff exercises, upper back, and chest exercises will also likely be helpful.  

Another common cause of pain in the area where you have been experiencing pain includes something called SICK scapula syndrome or scapula dyskinesis. SICK scapula is mnemonic for scapula malposition, inferior medial scapula winging, coracoid tenderness, and scapula dyskinesis (inappropriate movement of the scapula). The scapula and the humerus (upper arm bone) account for the motion in the shoulder. The muscles surrounding the scapula are critical in its motion as it has no (true) bony attachment to the rest of the bone structure of the upper extremity. Thus when the scapula does not move correctly it affects the range of motion of the shoulder which can result in pain around the shoulder including in the posterior shoulder and upper back. The treatment for SICK scapula and scapular dyskinesis is working on range of motion in the shoulder, working on scapular control and strength, and progressing to work on rotator cuff strength. Often time patients will also benefit from working on core strength as well.

If your pain has persisted I recommend getting evaluated by a physician. They will likely get some imaging such as ultrasound, x-rays, or MRI depending on the exam.   Most likely you will be prescribed physical therapy. To get maximum benefit from therapy you should work with the therapist for several weeks to perfect your form with the exercises. You should also be doing a home exercise program and the exercises should be done at least 5-6 days a week. Given the length of your symptoms it can take several months of exercises to note improvement and even longer to fully recover. Stick with it and hang in there. 


Caitlyn Mooney, MD

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date: September 29, 2017

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The American Medical Society for Sports Medicine (AMSSM) was formed in 1991 to fill a void that has existed in sports medicine from its earliest beginnings. The founders most recognized and expert sports medicine specialists realized that while there are several physician organizations which support sports medicine, there has not been a forum specific for primary care non-surgical sports medicine physicians.

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