On a Sunday afternoon on a surprisingly blue-skied Chicago day in January, I question which is more futile: the New York Jets offense or my efforts to extinguish this nagging knot in my upper back? This dang thing. Probably the size of a quarter. Sitting adjacent to my scapula. Or maybe on top of it? Under it? Who knows. It just hurts.
I’ve seen this before. This exact situation. In my patients and also in myself. And in my vapid rotation of massage devices, percussion guns, and a TENS unit, I wonder to myself what is causing a muscle knot right there.
Let me just say, first of all, that muscle knot etiology is not well-understood. Per my osteopathic training, we were taught that muscle knots have something to do with an exaggerated sympathetic nervous response to a wad of muscle fibers. Yes, the same fight-or-flight nervous system that makes your pupils pop when you’re stimulated and engages your pores to sweat when you find yourself speaking to a large crowd. That necessary-to-life nervous system needs you to pay rent apparently. Pay up.
What did my scapula do to deserve this? Or is it involved in the crime? Let me direct you to the image below. Besides triggering bad memories of the first year of medical school, this picture demonstrates the six main movements of the triangular bone in your back/shoulder called the scapula. Of note, there are many distinct muscles acting on the scapula.
One of the fascinating phenomena regarding muscles and the body in general is the togetherness of all its structures. Yes, each muscle has its own belly. It has its own tendons. It even has a twin on the other side of the body. There is, however, a layer of connective tissue that connects muscles to each other called fascia. Best seen in cadavers, this special connective tissue is rather thick but springy enough to absorb the wants, needs, desires, and cryptocurrency referrals from the muscles it connects. The rhomboid and trapezius are going to retract your scapula, and the fascia that connects them will be involved; more interestingly, that fascia will also whisper into the ears of the erector spinae muscles that longitudinally align your vertebral column. Cool stuff, right?
While muscle togetherness is interesting, it doesn’t necessarily explain the entire story behind painful knots found near the scapula. The individual muscles that make up your thigh are connected through fascia, yet muscle knots in your legs aren’t really a thing. The puzzling phenomenon of periscapular knots is advanced further into obscurity when you receive a massage. Ahh yes, there’s the spot. But a couple minutes later, the therapist has migrated to some random area on the other side of the back near the 8th rib. There’s apparently a knot there too, but the periscapular knot was the only one that was noticeable throughout your day.
Thus, there appears to be an element of neurological hypersensitivity of periscapular knots. We talked about the sympathetic nervous system. Is there a bias towards this area? Is the dysregulated loop of sympathetic signals supplying that bundle of muscle fibers accentuated by the rotational, linear, and torsional muscular and myofascial forces already acting in that area? Or do we just take a step back from nerding out on the neurological this-and-that and realize that the periscapular region is plush and roomy, allowing muscle knots to grow larger in size there than in other places, hence them being more painful?
I’m just going to say it. We are missing a joint. We are missing an anchor for the scapula to form a true connection with another bone in the back. Anatomists got really cute one day, and called the intersection of the scapula and the thorax the…scapulothoracic joint. It’s not a true joint. The movements of this joint are just the scapular movements shown in the picture above. The kinesiologists of the world would call me crazy for this because a true joint connecting the scapula to the back would impede our ability to move the shoulder as dynamically as we do. However, if there was a true joint there, that would likely stabilize the area well enough to provide taut connections for the periscapular muscles.
Physiotherapists and gym addicts of the world have theorized that scapular dyskinesis can be improved through mindful exercise. Through some research, I think there are definitely some techniques that may provide benefits in stabilizing the scapula and potentially decreasing periscapular muscle knots. “Activating exercises” like the ones seen in the link are a stark contrast to the static stretching we were all taught in school. The difference can be explained simply as strengthening a weak muscle versus lengthening a weak muscle.
For now, I’ll continue pressing on this knot and taking Tylenol.
This is not meant to be medical advice.
At the time of this publication, I am a Family Medicine resident physician.
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