Scapular Pain Coming From the Neck

Will Freres, PT, FAAOMPT, CSCS, CMTPT

As a sports physical therapist and dry needling instructor for Myopain Seminars, I often encounter patients with stubborn scapular pain. Many of these individuals turn to common remedies like stretching, foam rolling, or using massage guns on their upper backs and scapular regions. While these interventions might provide temporary relief, the lingering pain often returns within hours. This raises the question: If the pain persists despite local treatment, could the source be elsewhere?

One area often overlooked in cases of scapular pain is the lower cervical spine, specifically the multifidi muscles. Research findings and clinical observations support the importance of considering the cervical spine’s contribution to scapular pain.

Research demonstrates that cervical discs, facets, nerves, and muscles can all cause pain in the scapular region. If cervical nociception is present, patients may report pain along the medial border of the scapula, an area frequently mistaken as solely related to issues in the rhomboids or other medial scapular muscles.^1-6 Active trigger points in the cervical multifidi and deep paraspinal muscles have been observed in individuals with cervical dysfunction.⁷ Trigger points and cervical dysfunction often have a perpetuating relationship, where the dysfunction contributes to the development of trigger points in the surrounding muscles, further complicating the pain presentation.⁷

The cervical multifidi are deep stabilizing muscles that span two to four vertebral levels and play a significant role in spinal stability and movement. They share connections with the facet joint capsule⁸ and dysfunction in the multifidi, often found at the same level/side as the most painful spinal segment.⁹ Dr. Janet Travell noted that these muscles can even refer pain to the vertebral border of the scapula.¹⁰ Essentially, multifidi dysfunction can manifest as scapular pain, making it an important area to examine.

In my clinical experience, if I cannot rule out the neck as a contributor to a patient’s scapular pain during the physical exam, I prioritize treating the cervical spine before addressing the local musculature of the scapular region. Patients often report short-lived relief after self-treating their rhomboids and medial periscapular area with stretching, foam rolling, or percussion tools. If these strategies fail to provide lasting results, it’s a strong indicator that the pain source may be elsewhere.

A careful assessment of the cervical spine can provide valuable clues. In a prone position, you can often determine the most painful spinal segment by performing central posterior-anterior (PA) pressures on the spine.11 Dysfunction in the multifidi at that level frequently recreates the patient’s characteristic scapular pain.

One of the most rewarding aspects of using dry needling in clinical practice is witnessing the “ah-hah” moment when a patient feels their familiar pain reproduced—often in a surprising way. Patients are frequently amazed when a precisely placed needle in their cervical multifidi generates the scapular pain they’ve been struggling with for months. This reinforces the idea that their upper back isn’t the sole culprit. A well-targeted intervention directed at the cervical multifidi can alleviate the dysfunction at its source, leading to longer-lasting relief compared to treating only the scapular musculature.

A few relevant references

1. Grubb SA, Kelly CK. Cervical discography: clinical implications from 12 years of experience. Spine (Phila Pa 1976). 2000;25(11):1382-1389.
2. Bogduk N.Innervation and pain patterns of the cervical spine. In: Grant R, ed. Physical Therapy of the Cervical and Thoracic Spine. 3rd ed. Edinburgh: Churchill Livingstone; 2002:399-412.
3. Bogduk N. The anatomy and pathophysiology of neck pain. Phys Med Rehabil Clin N Am. 2003;14(3):455-v.
4. Bogduk N, McGuirk B. Management of Acute and Chronic Neck Pain: An Evidence-Based Approach.Edinburgh: Elsevier; 2006.
5. Cooper G, Bogduk N.Cervical zygapophyseal joint pain maps (Poster 97). Arch Phys Med Rehabil. 2005;86(9):e22-e23.
6. Wolff MW, Levine LA. Cervical radiculopathies: conservative approaches to management. Phys Med Rehabil Clin N Am. 2002;13(3):589-vii.
7. Sari H, Akarirmak U, Uludag M. Active myofascial trigger points might be more frequent in patients with cervical radiculopathy. Eur J Phys Rehabil Med. 2012;48(2):237-244.
8. Macintosh JE, Bogduk N. The biomechanics of the lumbar multifidus. Clin Biomech (Bristol). 1986 Nov;1(4):205-13.
9. Hides JA, Stokes MJ, Saide M, Jull GA, Cooper DH. Evidence of lumbar multifidus muscle wasting ipsilateral to symptoms in patients with acute/subacute low back pain. Spine (Phila Pa 1976). 1994;19(2):165-172.
10. Donnelly JM, de las Peñas CF, Finnegan M, et al. Travell, Simons & Simons’ Myofascial Pain and Dysfunction: The Trigger Point Manual, 3e. Lippincott Williams & Wilkins, a Wolters Kluwer business; 2019.
11. Schneider GM, Jull G, Thomas K, et al. Derivation of a clinical decision guide in the diagnosis of cervical facet joint pain. Arch Phys Med Rehabil. 2014;95(9):1695-1701.