Right shoulder blade pain
by Nathan Wei, MD, FACP, FACR
Nathan Wei is a nationally known board-certified rheumatologist and author of the Second Opinion Arthritis Treatment Kit. It's available exclusively at this website... not available in stores.
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Shoulder blade pain most often originates from areas other than the shoulder. As a result, shoulder blade pain must be distinguished from shoulder pain.
The shoulder is the most mobile joint in the body, but is dependent on the “rotator cuff” for stability. The rotator cuff consists of four muscles and their tendons that interconnect from the upper arm to the collarbone in front and to the shoulder blade behind, passing under the bony arch of the acromion. In addition, one of the tendons of the biceps muscle inserts nearby, and there is a bursa (a fluid-filled bag) that acts as a gliding mechanism between the rotator cuff and the acromion. Disorders of this rotator cuff and bursa are the cause of most cases of shoulder pain.
Rotator cuff tendonopathy is degeneration of the tendons that make up the rotator cuff; it is the most common shoulder disorder, accounting for 29% of cases. Subacromial bursitis is inflammation of the bursa. Both conditions occur when there is impingement of soft tissues by the bony arch of the acromion.
Rotator cuff syndrome is characterized by pain in the shoulder when lifting the arm out from the side of the body (abduction). There is a “painful arc of abduction” when lifting the arm between about 60º and 120º; once raised beyond this point, there is little pain in conditions related to the rotator cuff or subacromial bursa. As the condition gets worse, the pain becomes more persistent.
Rotator cuff tears occur after long-term wear causes degeneration in the soft tissues of the shoulder, and in association with untreated tendonopathy.
Most rotator cuff tears (90%) occur gradually, after a history of shoulder problems including a painful arc of abduction, night pain, and gradual weakness in the arm.
Calcific tendonitis is another condition of the rotator cuff that can cause pain and weakness in the shoulder. Calcium deposits in the tendons of the rotator cuff are seen in up to 20% of x-rays of adults with no symptoms. However, in some people (usually women, aged between 30-60 years, who have sedentary jobs) these deposits cause symptoms that can be severe. Initially there may some pain at rest or with abduction, “catching” on movement of the shoulder, and pain at night. Severe pain and marked restriction of the shoulder then develops as calcium crystals from the tendon move into the subacromial bursa. The shoulder is inflamed and the arm is usually held close to the chest. Eventually, the calcium is resorbed and the rotator cuff repairs and heals, although during this process there may be some residual pain and restriction of movement.
Treatment is ultrasound guided needle lavage of the calcium deposit.
Adhesive capsulitis or “frozen shoulder” is a disorder in which there is inflammation in the ball-and-socket joint of the upper arm bone and shoulder, resulting in adhesions (i.e. unnatural connections) within the joint and contraction of its “capsule”. Adhesive capsulitis may occur without any precipitating factors, or occur secondary to any condition that results in prolonged immobilization of the arm, including rotator cuff disorders, calcific tendonitis, mastectomy, or even fractures of the forearm.
Adhesive capsulitis results in limitation of both active and passive movement of the shoulder, causes pain at the extremes of motion, and interferes with normal daily activities. Night pain may be severe. It typically occurs in women aged between 40-60 years, and often in the non-dominant arm.
Pain localized just above the shoulder may occur because of problems in the acromioclavicular joint (i.e. between the shoulder blade and collar bone) or the neck.
Shoulder blade pain along the upper and medial border of the shoulder blade in the upper back is usually referred from the neck and signifies cervical nerve root irritation, generally at the C5 or C6 nerve root level. Patients will often wake up with a stiff neck. Pain may get worse as the day goes on. Headaches in the back of the head may occur.
Pain at the inferior tip of the shoulder blade may be referred from an abdominal problem such gall bladder disease, or from a lung condition such as pulmonary embolism, pneumonia, or pleurisy.
Patients with painful shoulders undergo a full examination of the shoulder and the neck to determine if there is any tenderness, the extent of any painful arc of abduction, and possible neck involvement.
Aggravation and reproduction of posterior shoulder blade pain with extension of the head and rotation to the side indicates a neck cause.
Imaging studies of the shoulder may be performed, including x-rays, ultrasonography or occasionally, MRI scans. Blood tests may also be performed.
The treatment of shoulder problems depends on their cause. Rotator cuff tendonitis and subacromial bursitis are initially treated with rest, non-steroidal anti-inflammatory drugs and modification of activities that cause pain. An injection of a corticosteroid-local anesthetic mixture into the joint may be beneficial in those in whom the pain persists. Those with night pain may be given physical therapy to maintain flexibility and a full range of movement. T
Acute rotator cuff tears require immobilization in a sling, and possible referral to an orthopedic specialist for surgical repair. Chronic rotator cuff tears are treated conservatively with non-steroidal anti-inflammatory drugs and shoulder rehabilitation. A corticosteroid injection into the joint may help relieve a painful arc of abduction. Ultrasound-guided needle tenotomy with platelet-rich plasma (PRP) is the preferred treatment of chronic tendinopathy.
Non-steroidal anti-inflammatory drugs and restriction of pain-inducing activities are used to treat patients with early symptoms of calcific tendonitis. In those with severe pain, ultrasound guided needle lavage with removal of calcium deposits is often curative.
Adhesive capsulitis is treated initially with non-steroidal anti-inflammatory drugs, and a gentle exercise program of stretching once the pain is controlled. A corticosteroid injection may be prescribed to control pain. Occasionally, the affected joint is manipulated with the patient under general anesthesia, in order to improve the range of movement.
Neck problems require anti-inflammatory medication, aggressive physical therapy, exercises, and gentle traction. Occasionally steroid injections into the tender trigger areas will help. More recently, patients with refractory pain have benefited from injections of botulinum toxin (Botox).
Shoulder blade pain may be referred from other areas such as the gall bladder, heart, aorta, fallopian tubes, abdominal organs, diaphragm, and lungs. A careful history, physical examination, and laboratory tests are needed. Imaging studies often are required.
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