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Levator Scapulae Syndrome

Original Editor ­ Andeela Hafeez

Top Contributors - Andeela Hafeez, Rachael Lowe, Tony Lowe, Kim Jackson, Nehal Shah, Alexander De Bock, WikiSysop, Eugenie Lamprecht, 127.0.0.1, Kishan Muthukuda, Evan Thomas, Robin Meynendonckx and Shwe Shwe U Marma

Introduction

Levator Scapulae Syndrome (LSS) is a historical name for "pain over the upper medial angle of the scapula"[1] that is still used in clinical practice in certain settings round the world. This terminology (and use of the word syndrome) describes a set of signs and symptoms that often present together without identifying the cause of the pain and dysfunction, as is the case with other syndromes such as chronic fatigue syndrome and irritable bowel syndrome. Characteristics of LSS include pain and stiffness in the upper thoracic and cervical regions, restricted cervical range of motion, tenderness at the medial aspect of the superior angle of scapula, belly of Levator Scapulae muscle (LS) and teno-osseous attachment of the muscle and it may also result in enthesopathy due to sustained MTrP tension[2]

Clinically Relevant Anatomy

Origin and Insertion

LS has its origin from posterior tubercles of transverse processes of C1 to C4 vertebrae and it inserts on the posterior lip of the medial scapular border, typically between the superior angle and root of the spine of scapula. Sternocleidomastoid and Trapezius ,uscles lie above the superior and inferior aspects of LS respectively which together comprise the part of the floor of the posterior triangle of the neck[3]

Muscles of Upper back including Levator Scapulae
Nerve Supply

LS is gets its innervation from the Dorsal Scapular nerve which originates from C4 and C5 nerve roots. The nerve arises from the anterior rami of C5 nerve root from Upper Brachial plexus and it is the first nerve branch off the C5 root. The nerve also innervates Rhomboids muscle[4]

Muscle Action
  • Elevation of Scapula - LS works in conjunction with Trapezius and Rhomboids to elevate the scapula[4]
  • Inferior rotation of Scapula - LS along with Lower Trapezius, Latissimus dorsi, Rhomboid, Pectoralis major and minor and gravity inferiorly rotates scapula, thus depressing the glenoid cavity[5]
  • Neck Extension, Side flexion and Ipsilateral rotation - LS assist in all these three actions[6]

Description

This muscle often becomes tense and painful leading to reduced motion in the area. Evidence indicates an association between mechanical neck pain (MNP) and dysfunction of the muscles of the cervical spine[7]. The dominant shoulder is most commonly involved (82%) and pain radiates to the neck and shoulder, but rarely to the arm[1].Symptoms are exaggerated with movements that stretch LS muscle. It is hypothetised that due to anatomic variability and the confluence of a bursa between the insertion of LS, origin of Serratus Anterior and the Scapula, there are constant trigger points, crepitations and increased heat emission in that region[3]

Causes

  • Cervical spine dysfunction.
  • Altered shoulder biomechanics or poor posture.
  • Repetitive arm motions such as in swimming, throwing, or racquet sports.
  • Carrying bags with straps over the shoulder.
  • Stress/anxiety. Many individuals who experience the effects of these trigger points also complain of shortness of breath (similar to that associated with panic attacks).

Sign and Symptoms

  • Neck pain, which may extend to the head causing a headache.
  • Pain and restricted range of movement especially reduced cervical flexion and side flexion to the contralateral side.
  • Deep, achy pain and/or tightness on the upper back along the top of the shoulder blade or neck.
  • Increased muscle tone and trigger points. Active trigger points are more frequent in patients presenting with mechanical neck pain[8]
  • Headache - Myofascial trigger points in LS muscle can refer the pain to the head giving rise to chronic tension type headache[9]

Trigger points

The Levator Scapulae can present with two trigger points located in the lower half of the muscle. The lower trigger point lies just above the superior angle of the scapula and the upper trigger point lies 1-3 inches above the lower trigger point. Both trigger points lie deep to the upper trapezius muscle and both refer pain laterally to the shoulder and along the medial aspect of the shoulder blade.

Trigger points in the Levator Scapulae are also commonly misdiagnosed as cervical joint dysfunction so careful cervical assessment is required for individuals that present with these symptoms[10].

Examination

With this presentation of pain and trigger points in the region of the levator scapulae, it is important to complete a full assessment of the cervical spine as pain in this region is often referred from the cervical spine.

The presenting pain is likely to be reproduced on active and passive range of movement testing of the cervical spine especially flexion and side flexion to the contralateral side (placing the muscle in a lengthened position). The muscle is also likely to be tender on palpation and may present with increased tone, especially in the region and referral pattern of the trigger points.

One must also rule out the thoracic spine and shoulder pathology. The phenomenon of levator scapulae pain of cervical origin being reproduced on shoulder movement has long been clinically recognized[11].

Treatment

Levator scapula syndrome (LSS) is characterized by pain, stiffness, and discomfort in the levator scapula muscle, which is located in the neck and shoulder region. Physiotherapy management focuses on pain relief, muscle relaxation, posture correction and restoring functional movement

Electrotherapy and Manual therapy techniques play an important part in pain relief.

Role of Electrotherapy in pain relief

Role of electrophysical agents in LSS is pain relief and reduction in inflammation. Various electrophysical agents like TENS, IFT, Therapeutic US are mainly used for pain relief. TENS have shown to be an effective modality for pain relief[12]and in countries like US, people use TENS for years together for pain relief and improvement in functions. TENS provides pain relief by stimulating sensory nerves for pain modulation via Pain supression system[13]For acute pain, high TENS (80-120 Hz) and for chronic pain, low TENS (2-10 Hz) is used for 20-30 minutes with electrodes over the LS muscle and / or over the painful trigger point.

Therapeutic Ultrasound applied over the active trigger point provides pain relief by improving blood flow and promoting tissue healing thereby reducing stiffness via thermal and nonthermal effects. Mechanical effects of US like cavitation and acoustic microstreaming elicits stimulation of fibroblastic activity, collagen synthesis and enhanced tissue regeneration[14]

By producing low frequency currents in the deeper tissues, IFT can relieve deep pain and hence it has proven to be effective in patients with mechanical neck pain[15]IFT has proven to be effective an adjunct with therapeutic exercises in patients with chronic neck pain[16]IFT reduces muscle spasms and enhances pain modulation, especially in chronic conditions like myofascial pain

Shockwave therapy delivers acoustic waves and hence relieves pain and reduce tension on trigger points and hence are an useful electrotherapeutic adjuncts to relieve myofascial pain syndromes. Extracorporeal shockwave therapy provides significant pain relief and functional improvement in myofascial pain syndrome[17]

MANUAL THERAPY, EXERCISES AND POSTURE CORRECTION

Soft tissue manipulation techniques like trigger point release, myofascial release, other soft tissue mobilization techniques which primarily work on the culprit muscle to relieve pain and muscle spasm are employed[18]

It is also important that biomechanical problems that may be contributing to the condition, such as neck or shoulder muscle imbalances, postural problems, or thoracic mobility are identified and corrected as these are usually the cause increased demand on the levator scapulae.[19]  Treatment options include postural advice to ease the demand on the levator scapulae as well as stretching exercises to relieve tension. The levator scapulae can respond well to Active Release Techniques (ART).[20]

Stretching the Levator Scapulae and the surrounding muscles like the trapezius (upper and lower) are beneficial in reducing the pain, increasing range of motion and quality of life. [21]

Muscle strengthening exercises of the Levator Scapulae are also beneficial to correct and prevent any imbalance in the neck [22] (Upper crossed syndrome) which is correlated to bad posture and tension in the muscles.

Scapular orientations can be beneficial to improve the muscle balance ratio around the scapula and prevent (chronic) neck pain. It influences muscle imbalances, postural problems and thoracic mobility.[23] [24]Strengthening and stabilizing the scapular stabilizers (e.g., lower trapezius, serratus anterior) improves posture and reduces strain on the levator scapula[25]

Posture correction and safe ergonomics can reduce muscle fatigue and stress on the affected muscle[26]It is imperative to emphasize maintaining proper posture during daily activities and educate patients for safe ergonomics eg appropriate workstation setup, sleeping postures and correct lifting techniques and safe movements.

Dry Needling have proven to be effective in managing myofascial pain syndromes in terms of pain relief and functional improvement[27]

Immersive Virtual Reality (VR) distracts patient from pain and promotes relaxation. It has proven to be a promising adjunct for reducing pain perception. Additionally with gamification, posture correction, stretching and strengthening of muscles can be achieved using VR. Mechanism of action include distraction, sensory modulation [28]and postural improvement[29]

Blood Flow Restriction (BFR) Training has shown improvement in muscle performance and reduction in pain. Low load exercises with restricted blood flow improve muscle strength and endurance without overloading LS.


References

  1. ↑ 1.0 1.1 Menachem A1, Kaplan O, Dekel S. Levator scapulae syndrome: an anatomic-clinical study. Bull Hosp Jt Dis. 1993 Spring;53(1):21-4. Level of Evidence 3B
  2. ↑ Gagnon P, Dunning J, Bliton P, Charlebois C, Henry N, Gorby P, Mourad F. Dry needling in the management of chronic tension‐type headache associated with levator scapulae syndrome: A case report. Clinical Case Reports. 2024 May;12(5):e8858.
  3. ↑ 3.0 3.1 Henry JP, Munakomi S. Anatomy, head and neck, levator scapulae muscles. InStatPearls [Internet] 2023 Aug 28. StatPearls Publishing.
  4. ↑ 4.0 4.1 Cowan PT, Mudreac A, Varacallo M. Anatomy, Back, Scapula. 2023 Aug 8. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan–. PMID: 30285370.
  5. ↑ Frank RM, Ramirez J, Chalmers PN, McCormick FM, Romeo AA. Scapulothoracic anatomy and snapping scapula syndrome. Anatomy research international. 2013;2013(1):635628.
  6. ↑ Eliot DJ. Electromyography of levator scapulae: new findings allow tests of a head stabilization model. Journal of manipulative and physiological therapeutics. 1996 Jan 1;19(1):19-25.
  7. ↑ Shaun O'Leary, Deborah Falla, James M. Elliott, Gwendolen Jull. Muscle Dysfunction in Cervical Spine Pain: Implications for Assessment and Management. Journal of Orthopaedic & Sports Physical Therapy, 2009 39(5):324–333 Level of Evidence 5
  8. ↑ C. Fernández-de-las-Peñas, C. Alonso-Blanco, J.C. Miangolarra. Myofascial trigger points in subjects presenting with mechanical neck pain: A blinded, controlled study. Manual Therapy, 2007, 12(1):29–33 Level of Evidence 1B
  9. ↑ Fernández-de-Las-Peñas C, Ge HY, Alonso-Blanco C, González-Iglesias J, Arendt-Nielsen L. Referred pain areas of active myofascial trigger points in head, neck, and shoulder muscles, in chronic tension type headache. Journal of bodywork and movement therapies. 2010 Oct 1;14(4):391-6.
  10. ↑ Bosch L. The effectiveness of chiropractic adjustments with ischemic compression or ultrasound on active levator scapulae trigger points in physically active people (Doctoral dissertation, University of Johannesburg).
  11. ↑ Behrsin JF and Maguire K. Levator Scapulae Action during Shoulder Movement: A Possible Mechanism for Shoulder Pain of Cervical Origin. Australian Journal of Physiotherapy, 1986, 32(2):101–106 Level of Evidence 3A
  12. ↑ Johnson MI, Bjordal JM. Transcutaneous electrical nerve stimulation for the management of painful conditions: focus on neuropathic pain. Expert Review of Neurotherapeutics. 2011 May 1;11(5):735-53.
  13. ↑ Johnson MI. Transcutaneous electrical nerve stimulation (TENS): research to support clinical practice. Oxford University Press, USA; 2014.
  14. ↑ Waters M, Miljkovic B, Rascon J, Gomez M, Gurovich AN. Effects of 1 MHz therapeutic ultrasound on limb blood flow and microvascular reactivity: A randomized pilot trial. International Journal of Environmental Research and Public Health. 2021 Oct 30;18(21):11444.
  15. ↑ Sutariya N, Shukla Y. Effect of Interferential Therapy versus Shortwave Diathermy on Pain and Function in Mechanical Neck Pain-A Comparative Study. International Journal of Science and Healthcare Research (Www. Ijshr. Com). 2020 Mar;5:279.
  16. ↑ Albornoz Cabello M, Barrios-Quinta CJ, Espejo Antúnez L, Escobio Prieto I, Casuso-Holgado MJ, Heredia Rizo AM. Immediate clinical benefits of combining therapeutic exercise and interferential therapy in adults with chronic neck pain: a randomized controlled trial. European journal of physical and rehabilitation medicine, 57 (5), 767-774.. 2021.
  17. ↑ Paoletta M, Moretti A, Liguori S, Toro G, Gimigliano F, Iolascon G. Efficacy and effectiveness of extracorporeal shockwave therapy in patients with myofascial pain or fibromyalgia: a scoping review. Medicina. 2022 Jul 28;58(8):1014.
  18. ↑ de las Penas CF, Cleland J, Dommerholt J, editors. Manual therapy for musculoskeletal pain syndromes: An evidence-and clinical-informed approach. Elsevier Health Sciences; 2015 Apr 28.
  19. ↑ Castelein B1, Cools A2, Parlevliet T3, Cagnie B2, Are chronic neck pain, scapular dyskinesis and altered scapulothoracic muscle activity interrelated?: A case-control study with surface and fine-wire EMG, J Electromyogr Kinesiol. 2016 Dec;31:136-143. doi: 10.1016/j.jelekin.2016.10.008. Epub 2016 Oct 19.( LOE 3b )
  20. ↑ Kim JH1, Lee HS1, Park SW1, Effects of the active release technique on pain and range of motion of patients with chronic neck pain, J Phys Ther Sci. 2015 Aug;27(8):2461-4. doi: 10.1589/jpts.27.2461. Epub 2015 Aug 21. ( LOE 3b )
  21. ↑ Cunha, Ana Cláudia Violino et al. “Effect of Global Posture Reeducation and of Static Stretching on Pain, Range of Motion, and Quality of Life in Women with Chronic Neck Pain: A Randomized Clinical Trial.” Clinics (Sao Paulo, Brazil)63.6 (2008): 763–770. PMC. Web. 25 May 2018. Level of Evidence 2A
  22. ↑ Bae, Won-Sik et al. “The Effect of Middle and Lower Trapezius Strength Exercises and Levator Scapulae and Upper Trapezius Stretching Exercises in Upper Crossed Syndrome.” Journal of Physical Therapy Science 28.5 (2016): 1636–1639. PMC. Web. 25 May 2018. Level of Evidence 2B
  23. ↑ Huang TS1, Du WY1, Wang TG2, Tsai YS3, Yang JL4, Huang CY1, Lin JJ5, Progressive conscious control of scapular orientation with video feedback has improvement in muscle balance ratio in patients with scapular dyskinesis: a randomized controlled trial, J Shoulder Elbow Surg. 2018 Aug;27(8):1407-1414. doi: 10.1016/j.jse.2018.04.006. Epub 2018 Jun 6.( LOE 1a )
  24. ↑ Ou HL1, Huang TS1, Chen YT1, Chen WY2, Chang YL3, Lu TW4, Chen TH4, Lin JJ5, Alterations of scapular kinematics and associated muscle activation specific to symptomatic dyskinesis type after conscious control, Man Ther. 2016 Dec;26:97-103. doi: 10.1016/j.math.2016.07.013. Epub 2016 Aug 4. ( LOE 2b )
  25. ↑ Yuksel E, Yesilyaprak SS. Scapular stabilization exercise training improves treatment effectiveness on shoulder pain, scapular dyskinesis, muscle strength, and function in patients with subacromial pain syndrome: A randomized controlled trial. Journal of Bodywork and Movement Therapies. 2024 Jan 1;37:101-8.
  26. ↑ Van Der Beek AJ, Dennerlein JT, Huysmans MA, Mathiassen SE, Burdorf A, Van Mechelen W, Van Dieën JH, Frings-Dresen MH, Holtermann A, Janwantanakul P, Van Der Molen HF. A research framework for the development and implementation of interventions preventing work-related musculoskeletal disorders. Scandinavian journal of work, environment & health. 2017 Nov 1:526-39.
  27. ↑ Dach F, Ferreira KS. Treating myofascial pain with dry needling: a systematic review for the best evidence-based practices in low back pain. Arquivos de Neuro-psiquiatria. 2023 Dec;81(12):1169-78.
  28. ↑ Viderman D, Tapinova K, Dossov M, Seitenov S, Abdildin YG. Virtual reality for pain management: an umbrella review. Frontiers in medicine. 2023 Jul 14;10:1203670.
  29. ↑ Kumar V, Vatkar AJ, Kataria M, Dhatt SS, Baburaj V. Virtual reality is effective in the management of chronic low back ache in adults: a systematic review and meta-analysis of randomized controlled trials. European Spine Journal. 2024 Feb;33(2):474-80.
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