Interfascial ultrasound-guided infiltration of the middle trapezius and rhomboids

What is ultrasound-guided interfascial injection between the middle trapezius and rhomboids?

Ultrasound-guided interfascial injection between the middle trapezius and rhomboids is an interventional procedure that uses ultrasound guidance to place an analgesic and anti-inflammatory medication between the fascia of the middle trapezius and rhomboid muscles. This injection can reduce inflammation and pain, improve muscle function, and indirectly improve scapular and shoulder mobility.

As we have seen in previous articles, the goal of ultrasound-guided injections at the interfascial level is to treat chronic myofascial pain in cases where rehabilitation treatment is ineffective, or in combination with physical therapy.
We recall the importance of the connective tissue that lines and separates the muscles (fascia), through which nerves and blood vessels circulate. Ultrasound imaging allows us to administer medication (usually local anesthetics and corticosteroids) with great precision, reducing the risk of injury to neurovascular structures. We see in Figures 1 and 2 that trigger points in the middle trapezius and rhomboids can be very similar, with referred pain in the same location between the thoracic spine and the inner border of the scapula. In the case of the middle trapezius, pain can also be referred to the posterior aspect of the shoulder and a tingling sensation in the arm.

What is the indication for ultrasound-guided interfascial injection of the middle trapezius and rhomboids?

• Myofascial pain syndrome: The main indication is the treatment of active trigger points in the middle trapezius and rhomboids. These points are hypersensitive areas that, when pressed, generate local pain and referred pain to other areas. In the case of the middle trapezius, pain may radiate to the posterior aspect of the shoulder, and in the rhomboids, it is primarily located on the medial border of the scapula and between the scapulae and the thoracic spine.
• Chronic pain and muscle tension: This is used in patients experiencing persistent pain in the neck, shoulders, and upper back that has not responded to conservative treatments such as physical therapy, stretching, or oral medication.
• Scapular dysfunction: Pain and stiffness caused by trigger points in these muscles can limit normal movement of the scapula, affecting shoulder and arm function. Injections aim to release this tension to restore movement.
• Diagnosis and treatment: Ultrasound-guided injections can also be used for diagnostic purposes. If the patient's pain is significantly relieved after the injection of a local anesthetic, it confirms that the source of the pain is indeed the myofascial trigger point.

What is the procedure for an ultrasound-guided interfascial injection of the middle trapezius and rhomboids?

The ultrasound-guided interfascial injection of the lower trapezius and erector spinae is usually performed in an outpatient setting and takes 10 to 15 minutes. Here is a summary of the procedure:

• Preparation: A prior ultrasound is performed, with recognition of anatomical structures and marking of the entry site on the skin.
• Local anesthesia: A small amount of local anesthesia may be applied to the skin to reduce pain during the injection.
• Asepsis: The skin is cleaned with antiseptic, and the equipment and the field are prepared under strict aseptic conditions.
• Ultrasound guidance: Ultrasound is used to guide the needle into the interfascial space of both muscles and ensure that the medication is administered in the correct location.
• Drug injection: The drug is administered through the needle, and we observe how it diffuses between both fascias.

Patients who fail to improve with various rehabilitation treatments are candidates for interfascial ultrasound-guided injections.

Figure 1 - Trigger points and referred pain of the middle trapezius muscle

Figure 2 - Trigger points and referred pain of the rhomboid muscle

Figure 3: Needle access to the interfascial space between the middle trapezius and rhomboid muscles (white line) or to the thickness of the rhomboid muscle (yellow line).

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