Pain Between the Shoulder Blades: Interfascial Hydrodissection for Medial Scapular Myofascial Pain

A Problem We See Constantly

Nagging pain along the inner edge of the shoulder blade — the medial scapular border — is one of the most common complaints we see. It shows up in athletes who load their arms overhead (golfers, throwers, swimmers), and just as often in people at a desk or on a phone all day. It’s frequently brushed off as “just a muscle knot,” treated for months without lasting relief, and left to interfere with sport, work, and sleep.

Often the real culprit is a fascial adhesion — the sheet of connective tissue between the trapezius and rhomboid muscles sticking down where it should glide. On ultrasound we can see it, confirm it’s the source of your pain, and release it with a precise hydrodissection. The case series below — published by our team — shows how well this works in athletes. The same approach helps the desk-bound patient, too.

Abstract

01 · Introduction

Neck and upper back pain are common chief complaints for athletes, with estimated lifetime prevalence of neck pain ranging from 3 to 22% and upper back pain from 6 to 17%.¹ Myofascial pain syndrome (MPS) can be a cause of neck and upper back pain in athletes, including with trauma or overuse.² Myofascial trigger points were originally described by Travell and Simons as localized areas of palpable taut bands within muscle, with a predictable, discrete zone of pain that worsens with palpation.³

The trapezius is a large superficial muscle of the upper and mid back, extending from the external occipital protuberance, medially over the spinous processes down to T12, laterally over the scapular spine, and anteriorly to the lateral third of the clavicle.⁴ It superficially covers the medial scapular border; deep to the trapezius and the scapula lie the rhomboid major and minor. When muscle is injured, it moves through phases of healing — degeneration, inflammation, regeneration, and fibrosis.⁵ Fibrosis entails excessive accumulation of extracellular matrix (ECM), from excessive production, altered degradation, or both.⁶ Within fascial cells, injury triggers fibroblast recruitment and upregulation of N-cadherin, a protein that promotes cell-to-cell adhesion.^7,8 The negative space between the rhomboids and trapezius may allow fascia to undergo fibrosis and adhere, causing limited movement and pain.

Management options include noninvasive techniques — spray and stretch, physical therapy, TENS, ultrasound, massage, and ischemic compression.⁹ Trigger point injections are well-researched and improve pain compared with placebo.^9,10 Interfascial hydrodissection involves injecting within fascial planes to separate fascia from surrounding structures (muscle, nerve, vasculature, or other fascia). We previously reported its efficacy for chronic hamstring injuries,¹¹ and a case report describes hydrodissection of a compressed dorsal scapular and spinal accessory nerve to relieve upper-back numbness and pain.¹² Anesthesiologists have used interfascial hydrodissection for regional anesthesia,^13,14 and Domingo et al. showed interfascial injection diffuses into the interfascial space in cadavers and improves trapezius myofascial pain clinically.¹⁵

Ultrasound should guide both evaluation and intervention: it is relatively inexpensive, well-tolerated, allows dynamic real-time evaluation of muscle and fascia, and permits serial follow-up of healing.¹⁶ It identifies the fascial abnormality, gives real-time feedback as the patient confirms the pain location, and visualizes the needle during hydrodissection. In this series, we describe interfascial hydrodissection of the medial scapula between the trapezius and rhomboid muscles for MPS.

02 · Case Series

Figure 1. Ultrasound of a trapezius–rhomboid major fascial adhesion.

Figure 2. Ultrasound during a fascial hydrodissection.

03 · Discussion

These three cases highlight dorsal scapular nerve block and interfascial hydrodissection as an effective treatment for medial scapular myofascial pain, with both immediate improvement and longer-term resolution. Myofascial neck and upper back pain may be more likely in these athletes because they heavily use their upper extremities. Fascial thickening and adhesions at the point of tenderness — with immediate relief after releasing them — suggest the adhesions contribute to the pain. Domingo et al. identified peripheral nerves in the interfascial space on histology,¹⁵ and interfascial nerve blocks have managed post-operative pain,^13,14 so relief likely reflects both mechanical release of adhesions and anesthesia of nerves within the interfascial space. Metin Ökmen et al. found deeper rhomboid injections more effective than superficial trapezius injections for MPS in a double-blind RCT.¹⁷

Ultrasound is a necessary tool here. At bedside the clinician identifies and palpates the fascial abnormality; when sonopalpation reproduces the patient’s pain, there is real-time feedback to direct treatment. Its dynamic nature, lack of radiation, and low cost make it more useful than MRI for myofascial pain, and guidance improves accuracy while reducing risk to neural and vascular structures. The physician must be experienced in ultrasound: the spinal accessory nerve courses deep to the trapezius and superficial to the rhomboid, and any anomalous vessels must be identified and avoided. Possible complications include infection, pneumothorax, organ injury, bleeding/hematoma, local-anesthetic toxicity, fat atrophy, skin discoloration, and post-injection flare.¹¹

Two athletes had decreased but continued pain during their season — from untreated adhesions or an acute strain of already-fibrotic tissue. The golfer needed treatment of additional adhesions; the baseball player strained a prior adhesion. The lesson: if fascial pain continues, re-evaluate and treat other acute or chronic fascial abnormalities. For competitive athletes, return-to-play should be coordinated with the athletic trainer or physical therapist — as with our hamstring protocol, a graduated reintroduction leads to full return around four days after hydrodissection.¹¹ Off-season treatment may reduce the need for repeat procedures, but real-world timing must balance rehabilitation with the pressure to compete.

04 · Conclusion

USG interfascial hydrodissection is a quick, well-tolerated, and effective treatment for myofascial pain at the medial scapular border. Ultrasound improves technical accuracy and lets the patient give feedback during evaluation, raising the likelihood of success. We postulate the benefit is a combination of separating fascial adhesions and peripheral-nerve anesthesia in the targeted region. Research on interfascial hydrodissection is growing, but larger randomized trials — comparing USG hydrodissection to blind trigger-point injection, and measuring time to return to play in competitive athletes — are needed.

Works Cited

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Struggling with upper back or posture-related pain between visits? We’re fans of AlignMed posture wear as a between-treatment support.

Disclosure: The AlignMed link is an affiliate link; The Fascia Institute may receive a small commission at no extra cost to you. This case series is provided for education and professional reference; it is not medical advice and does not create a physician–patient relationship. Hydrodissection should be performed by a clinician experienced in ultrasound. Individual results vary. The Fascia Institute and Treatment Center® · 2520 Harvard Ave, Ste 2B, Metairie, LA 70001 · (504) 704-1254.