Adam Rufa - 5/15/2006

Question
iam a medical student 23 years old
well thank you doctor for sharing with me my problem .
the problem is that i have chronic pain in the region between my right scapula and vertebral column, it have been with me for 4 years or even more , this pain is of stertching type or traction or like u feel that the muscle is so so fatigued , the pain come specially when i stand up for long time with semi-flexion of the neck (specially when iam exhausted) and this pain appears gradually when iam standing i.e. in first 20 minutes there is no pain but after 30 min i start to feal it and with time it become intensified,,
i can agrevate this pain by :stretching my 2 scapulae outwards (separate both scapulae away from the vertebral coloumn) and flexion my neck to the left side(the pain is in the right) ,, the pain is relieved by sleeping supine or trying to rest my back and neck staright on any board while setting .
please  sir you can't imagine how this problem is ditressing me iam really depressed specaially i went to alot of doctors and each time they gave me symptomatic treatment without telling me the pathology .
so please sir  , can you help me even by giving me difrential daignoses.? iam waiting you reply
in case it help : i tried (in the past 4 years) anti-inflamatory , analgesics even local anesthetic i tried also muscle relaxant but i didn't complete the course  

Answer
Osama

I see symptoms like this quite often. As you know I can not diagnosis your symptoms over the internet, however I can give you a differential diagnosis.

With a problem like this there are a few things to consider. (1)  what structure(s) is/are involved in the symptoms. This can be muscle, nerve or joint structures. (2) Then we have to decide which structures are the primary problem and which are secondary. (3) what is causing that structure to be dysfunctional.

Most people in your situation have involvement of muscle. However, this muscle involvement is almost always secondary. The muscles of the neck/thoracic spine get increased tone due to some other underlying problem. The pain you describe can be caused by several things. A few of them include:
             Trigger points in cervical /thoracic muscles
             "Cloward Sign" cervical disk referral
              Nerve dysfunction
              Rib subluxation/dysfunction
              Thoracic spine dysfunction

Often the above differential diagnosis is the easy part. The hard part is determining why one of the above structures is causing pain. Some of the common causes are

               Postural disorders
               Muscle imbalances
               Structural disorders (cervical rib ect)
               Movement dysfunction

Often when people complain of increasing pain with a certain position it is important to correct posture and muscle imbalances to remove stress from the painful structure. Often the above disorders result in increased pressure on a structure that results in deformation of the tissue which causes pain.

If you do not identify the underlying cause, you will simply be treating the symptoms and the best you will get is temporary relief.