Dorsal Scapular Nerve Entrapment: What You Need to Know

Upper to mid-back or shoulder blade pain is a common presentation to sports doctors or physiotherapists. Common causes include dorsal muscle strain, rib pain and cervical or thoracic spine disc degeneration. A less common but frequently missed cause is dorsal scapular nerve entrapment. How do we diagnose dorsal scapular nerve entrapment, and what can we do about it? 

What is the dorsal scapular nerve? 

The dorsal scapular nerve originates from the nerves in the neck and axilla called the brachial plexus. It passes through a neck muscle called the middle scalene and down between the trapezius and levator scapulae muscles. It then courses deep to the rhomboid muscles along the inside of the shoulder blade. Finally, the nerve ends at the tip of the shoulder blade. 

The dorsal scapular nerve supplies the muscles inside the scapula: levator scapula, rhomboid minor and rhomboid major muscles. It also supplies the skin next to the mid-back T5 and T6 vertebrae. 

What causes dorsal scapular nerve entrapment? 

We have identified several causes of dorsal scapular nerve entrapment, including:

• Repetitive heavy lifting, such as weight training, can increase tension on the dorsal scapular nerve.

• Wearing a brace to treat scoliosis can also lead to nerve traction.

• Repeated shoulder dislocation

• Acute whiplash injuries. 

Dorsal scapular nerve entrapment symptoms 

Ususally, symptoms range from mild discomfort on the inside of the shoulder blade to severe shoulder blade pain. 

Generally, patients experience pain and stiffness on the inside of the shoulder blade. The onset of symptoms can be gradual or sudden. Pain can be sharp stabbing or a dull ache. These symptoms can move to the base of the neck. Sometimes, there is muscle wasting of the muscles on the inside of the shoulder blade, leading to winging of the scapula. Rarely, numbness and pins and needles can occur inside the shoulder blade. 

When your doctor examines you, they may find stiffness and tenderness on palpation of the lower cervical and upper thoracic spine. Tenderness may extend into the scalene muscles. Movement of the neck can aggravate symptoms. Sometimes, weakness of the muscles is so profound that we can see abnormal scapular movement, such as scapular winging. Touch sensation on the inside of the shoulder blade can be reduced. 

It is essential to exclude other musculoskeletal conditions which can mimic nerve entrapment. These conditions include spinal disc or joint pathology, thoracic outlet syndrome, a muscle strain or shoulder joint or tendon pathology. Your doctor should perform MRI scans and nerve studies to confirm the diagnosis. 

How to fix dorsal scapular nerve entrapment 

In general, you should start with simple, non-invasive treatments such as soft tissue therapy to the inner border of the scapular, joint mobilisation of stiff and painful joints in the neck and mid-back and simple adjuncts such as acupuncture. Dorsal scapular nerve entrapment stretching exercises focus on releasing tension in the levator scapulae and rhomboid muscles. Scapular stabilising strengthening exercises will also correct muscle atrophy and abnormal winging of the shoulder. 

Medications are generally less effective. However, neuropathic medications such as amitriptyline or duloxetine might be considered if the pain is nerve-like, i.e. sharp, burning and stabbing or if numbness or pins and needles are present. 

Dorsal scapular nerve block

In suspected dorsal scapular nerve entrapment cases that fail non-invasive treatments, cortisone infiltration around the nerve may be helpful. Ususally, the infiltration site is at the neck near the middle scalene muscle or deep to the rhomboid muscles on the inside of the shoulder blade. A positive result with an injection will also confirm the diagnosis. 

Injections should be performed with ultrasound guidance to improve accuracy and avoid hitting essential structures such as vessels or lung tissue. In general, you should see a doctor experienced in performing nerve injections. 

Final word from Sportdoctorlondon about dorsal scapular nerve entrapment

Dorsal scapular nerve entrapment is a less common cause of neck or shoulder blade pain. You should see a doctor experienced in diagnosing and managing these conditions. 

Related conditions:

• Shoulder blade pain 
• Chest and rib pain