Levator scap chronic muscle spasms

[salsaqueen99]

I have been suffering from chronic muscle spasms in the levator scap while I have been trying to rehabilitate a shoulder injury. About three years ago I tore the biceps tendon and prior to that I tore one of the rotator cuff muscles (I suspect it is infrasprinatus). When I had it diagnosed by a sports doctor, he noted that it had G-H instability, some mild shoulder dumping, and tightness in the thoracic region. About a year ago I had a cortisone injection into the long head of the biceps sheath and with rest and avoiding salsa dancing, I managed to keep it under control. My rehabilitation program at that time was very basic and involved using extremely light weights (1kg).

Over the last 12 months I have been working with a personal trainer and we hae managed to get my shoulder strength back and gained some of the shoulder stability I had lost after the injury. The dumping has lessened and the stability in the GH has improved. Scap retraction is much better too. But during this time, I have muscles spasms in the levator scap every 6-8 weeks. Dry needling has been helpful to treat the acute injury and I am working with my physio to take more of a prevention rather than treatment focus where he dry needles the levator scap, along with releasing the thoracic region. It seemed to be working well and I managed to avoid having a muscle spasm for about 2 and a half months.

Unfortunately, I had another muscle spasm today and I am really on my last threads. I've currently got it taped so that my shoulder sits in it's more natural position (my shoulders tend to role forward) and this seems to have helped along with NSAIDS and analgesics. It's been far too long since my original injury and I'm kind of fed up with this whole injury. I suspect the reason why I have experience recurring muscle spasms is part due to the intense nature of my rehab program and it seems that if I do too much work which elevates the scap, the muscle will normally spasms and the whole cycle begins again. So I'm wondering if any of the physio's can provide some advice on what options I could try and has anyone tried using kinetic chain rehabilitation on shoulder injuries? I've found a few articles and it seems like a possible option because the traditional rehabilitation methods seemed to have failed me.

Thoughts, options and any advice you can suggest is greatly appreciated.

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[physiobob]

Hi there. Perhaps you need to look at the cervical spine (neck) as a possible issue in this. Especially he upper neck and C5 as these give rise to the innervation of the levator scapulae.

Origin - Posterior tubercles of transverse processes of C1 - C4 vertebrae
Insertion - Superior part of medial border of scapula
Artery - dorsal scapular artery
Nerve - cervical nerve (C3, C4) and dorsal scapular nerve (C5)
Actions - Elevates scapula and tilts its glenoid cavity inferiorly by rotating scapula

Maybe it is also worth looking at the rhomboids and their relationship with the dorsal scapular nerve. It seems that taping techniques (which may be put an irritated neural structure at rest) are having an effect and that it is not the muscle but the nerve that is irritated.

[salsaqueen99]

Hi there,
Thanks for your response. When I first saw my sports doctor he identified tightness in the thoracic and first and second rib. He also normally treats the neck because I have tight scalenes and have had a few facet impingements on the left side (it's the right side of the levator scap which spasms). But your advice is very interesting and it's something we haven't considered.

My physio and I are also testing a new theory (previously thought my injury was due to a scap instability) to see if my problems (levator scap muscle spasms, biceps tendon pain etc) are stemming from an anterior g-h instability. In some ways it could be possible if the instability puts stress on the levator scap, RC and aggrevates biceps. Of course the problem is that every test which has been done, I've tested negative for g-h instability. Do you think this is possible? To me, it seems like we've gone two steps forwards and then three steps back because my scap stability has improved significantly and I am quite strong.

Also what are the treatment options for glenohumeral instability? I've been asked to go back to do external rotator cuff exercises (which I dislike) to try and get the g-h sitting better but my physio thinks that if there is no improvement in 4 months I should see a shoulder surgeon to consider the options of doing an arthroscopy to see if there is a tear in the joint which needs repairing. Also are there other less invasive options which can provide similar accuracy in diagnosing tears? Maybe it's time for another MRI to see if the pathology of my shoulder has changed since the original MRI I had 3 years ago?
Help is muchly appreciated

[physiobob]

The levator scap is only really under any load if the scapula is rotating outwards and upwards (to help rotate it back down/oppose the excessive movement). This is only really going to be an issue with 'loads' (rather than movements) above the horizontal which is perhaps not so common in your vocation.

I would keep looking to the nerve as a cause of the irritation to the muscle. Of course GH stability is or paramount importance but this might not be causing your issue. It adds weight to my initial thoughts that you have a history CT junction issues as tightness or restricted movements in the lower neck will cause excessive movements and protration of the neck higher up. In this case taping to inhibit the traps would help (perhaps try some Kinetic taping during Salsa training). Again that points to the neck and vertebral positions as possible suspects

Let us know how you get on. Look at the basic concepts and try not to over analyze the situation with the PT.

[salsaqueen99]

Hey there,
Thanks for your advice. I think that it is possible that the levator scap gets loaded when I dance because the scap is rotated upwards when I am being turned and outwards when I dance.

I'll get my physio to look into the nerve issue and it is worthwhile investigating. We haven't gone down this path before. Will keep you posted and see what happens. I'm seeing my sports doc at the end of the month and I'm hoping he'll have some more ideas to try.

Cheers

[salsaqueen99]

Hi physiobob,
So I am starting to think that you are a bit of a genius because a few days ago I started getting referred pain down my right hand (fourth finger and pinky). My physio thinks that I have irritated the ulnar nerve and the infraspin ... he mentioned sth along the lines that infraspin can cause pain which mimics nerve pain but instead I have done both. He cpouldn't explain why it happened which is fine, I have a complex injury which no one can diagnose only how it happens. Can you point me in the direction of some literature which I can look at? and also how long does it take to settle? i've had this for almost a wk and i can't take anti inflams anymore.

I have also now concluded after piecing it altogether that I think it is a nerve issue which is causing the muscle spasms (levator scap, supraspin) and would appreciate your advice in terms of what I need to look ( you mentioned to look at the dorsal scap nerve and rhomboids which I've asked my physio to look at) and what to ask as I am seeing my sports dr next wk. It seems to me I need a strategy for when it flares and to continue strengthening my scap muscles and RCs.

Advice greatly appreciated.

[physiobob]

My next step would be to treat the lower levels of the cervical spine (neck) as the irritation is probably coming from there. It is of course most likely biomechanical in origin so perhaps ask your PT if they might tape you prior to a dance rehearsal to see if that assists you. Some active taping like K-taping concepts should be really useful as you will need to learn to move slightly differently to address the likely causes of this issue.

Best of luck

[salsaqueen99]

Hi physiobob,
Hoping you can help. It's like my body is putting me through the works as I have now compressed the ulnar nerve. Over the last three weeks I have been suffering from a very irritated ulnar nerve where the pain radiates down my arm on the inside of the arm (anterior side I think).

Recently I had a muscle spasm in supraspin and have had levator scap muscle spasms of the last year. With the recent muscle spasm of supraspin I experienced some tingling down my arm on the fourth and little finger which my physio believes was referred pain.

Then about two weeks later I had to take minutes for a meeting and my shoulder went. It almost felt like it was about to spasm but it settled after I stopped writing. After training three days later, I was unable to write. I haven't been able to type for long periods of time for almost three weeks where I was unable to type at all during the first week. My physio believes that I have compressed/inflammed the ulnar nerve.

I guess I'm looking for advice in relation to how to manage this, how long it will take to heal (this is the longest time it has taken for something to heal) and if I should be training at all. My physio is currently doing dry needling work and I get acupuncture every wk to treat the rotator cuff bc it too is irritated and I know that it can cause referred pain down the arm. I guess the million dollar question is how long will it take to heal and if I should be training at all? Training makes me feel better and it doesn't seem to aggravate my shoulder because it gets it warm (normally cold at the moment even though it's 35C in Oz). Is this the right thing to do be doing or should I just rest for a week and see how it goes. I've already taken it really easy for 4 days and I didn't really see much improvement. I actually drove myself insane not being able to do anything.

My thoracic is also very tight and I know I need to work on freeing this up. I'm using a foam roller to do this at night but I'm thinking I'll need to do more if I'm at a desk all day long. Is that right?

Any advice you can offer is greatly appreciated. If you could also refer me to some literature on treatment of compressed nerves that would be awesome.

Thanks in advance

[maldo1]

Salsaqueen - hello im also an Australian physio and have just caught onto your thread.

This may seem like a stupid question/suggestion but seeing as i can't see you i need to ask. Are you 100% sure the pain you felt was in your levator scap? The posterior scalene is anatomically very close the levator scap (but more anterior). The posterior scalene would potentially cause some of the problems you have had - particularly the ulnar nerve irritation.

Just a thought.

[salsaqueen99]

Hi Maldo,

Thanks for your advice. No question is silly because we are trying most things. The levator scap muscle spasms are a bit different to the current pain I'm experiencing. When I get muscle spasms in the levator scap we're pretty sure that it is the culprit because when we dry needle it, it pretty much hits the sport.

Re the nerve irritation, that's a little murkier because the whole issue is confounded by a tight thoracic. My physio is currently dry needling c5 and c6 which helps and certainly gets the trigger points along with infrasprinatus (as I am getting pain in the last two fingers. I have had the scalenes worked on but not as much. I tend to breath like a fish so it would surprise me that it could play a part in the irritation. I have found a few trigger points in the scalenes (anterior aspect) when I am getting referred pain in my wrist and by releasing them it seems to help it. So your suggestion is very much on the spot and it's kind of ironic that I just discovered over the last few days that the scalenes are having a role in this because I was feeling like it was getting very tight. But as mentioned before I'm open to ideas and I'll run it by my physio.

Do you have any thoughts on why I get more pain when I am sitting in front of a computer and typing rather than writing? Do you think it's because I'm in a static position? I am however getting up every 15 minutes (rather than 30 minutes) to at least break the cycle and to stretch every 30 minutes.

Many thanks for your advice

[maldo1]

The scalene was just a thought as a potential source of the 'lev scap' pain. If the lev scap pain is located directly on the superomedial scapular border where the fibrous tendon is located then you are most likely on the right track with that being your original source of pain. If the pain was more focused in the belly and particularly anteriorly, then it might be easy to confuse the lev scap with the post scalene.

It sounds like what you have now developed - ulnar distribution pain etc.. would then point the finger at the lower cervical levels C6-T1 and rib dysfunctions.

Out of interest do you have any tricep or pec pain/weakness? This would then signify a C7/T1 disc type issue.

Back to the original lev scap problem. Chronic fibrosis in the tendon insertion with subsequent 'trigger points' in the muscle belly is reasonably common. Whether it is developmental due to posture (constant neck flexion, contralateral side flexion type posture), due to overuse (i get a problem with mine if i deadlift too heavy - the traction on my scapular must place a lot of strain on the lev scap and i feel a transient burning pain) or due to cervical spine pathology which drives the tone through the muscle.

The question about the head down posture is intersting as i am currently treating a guy at the moment who is a professional MMA (UFC ) fighter. He trains twice per day for a least 2 hours (much of it grappling and in head locks) but he does not feel it then. He feels it the most when he sits at the computer for too long or if he drives long distances. We get great relief by really hammering the insertion of the tendon on the border of the scapular, however the relief only lasts 3-4 days. He is now about to see a musculoskeletal physician who specialises in trigger point injections into chronically fibrosed muscle. What he does is very invasive and extraordinarily painful whereby he needs to sedate patients to do this. He also inject a whole cocktail of natural bits and pieces such as traumeel and vit C into it when he is done. This would be step on from simple dry needling.

I will let you know how this goes when he is done.

Other than that i feel for you and your physio, as these little suckers can be recalcitrant.

[alophysio]

Hi salsaqueen,

Not sure if you remember but i think we corresponded a few years ago...

the above info from physiobob and Maldo1 seems to be good to me so far...

Lev scap in my honest opinion tends to be present in people who hold their shoulders down and back.

Now it sounds like your physio is aware of scap position and dynamics so you shouldn't be "dumping" your shoulder right?

For lev scap overactivity, we train lots of upper traps and serratus anterior to support the scapula in some upward rotation. We stretch the lev scap if it is truly short and we tend to have to stretch pec minor and pec major. We also focus on assessing, mobilising and/or stabilising any dysfunctional neck or thoracic (vert or ribs) segments.

Lev scap and rhomboids as pointed out by physiobob are innervated by dorsal scap and the cervical nerve roots higher. C/S assessment and Rx should be mandatory for any shoulder problem in my opinion. As should T/S assessment since lower traps go to T12, serratus anterior goes to rib 8 and external obliques also interdigitate with serr ant. And of course, lats goes to the pelvis.

How is your dissociation of your shoulder from thorax, thorax from L/S, L/S from pelvis and pelvis form hip - as a salsa dancer, these should be good but perhaps this is something you are struggling with in your dancing...

Maldo1, your MMA fighter's treatment sounds interesting...trigger points if chronic need to be treated but i would have defaulted to treating the reason why it gets like that in the first place.

As an aside, i show my patients this video on how far my neck exercises can take you but they can't do it for about 2-3 years i reckon!! No more neck problems...because he doesn't have a neck!!

YouTube - Neck Bridge Workout - Neck Exercise

Cheers

[Barton]

I'm a lowly LMT, but I use KT regularly in my practice and have found that levator scap spasm can usually be relieved by activation (taping origin to insertion) of the muscle. My take is that the dominant arm seems to be to upwardly rotated and stretches the levator. What you said about arm position during salsa dancing would make sense in this context.

Try having your practitioner tape from the transverse processes (or as close as possible due to hair and sensitivity) past the superior angle of the of the scapula with the muscle in a stretched position. If you are experiencing pain before the taping, you should know pretty much right away if this works. Manual therapy of the serratus anterior, which I suspect is dysfunctional from the arm hovering in space when dancing, can also help.

Hope this helps.

Barton