Shoulder blade pain causes

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.

Click here: Second Opinion Arthritis Treatment Kit

There are many different causes of shoulder blade pain- many of which do not originate from the shoulder. Shoulder blade pain must be distinguished from primary shoulder pain.

The shoulder is the most mobile joint in the body, but is dependent on the “rotator cuff” for stability.

In addition to the rotator cuff muscles and tendons, one of the tendons of the biceps muscle inserts nearby, and there are bursae that act as a gliding and cushioning mechanism between the rotator cuff and adjacent bone. Disorders of the rotator cuff and bursae are the cause of most cases of shoulder pain.

Rotator cuff tendonitis is inflammation/degeneration of the tendons that make up the rotator cuff; it is the most common shoulder disorder. Subacromial bursitis is inflammation of the bursa. Both conditions occur when there is impingement of soft tissues by the adjacent bony arch with everyday wear-and-tear.

Symptoms are 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 worsens, the pain becomes more persistent, and particularly severe at night. Eventually, if the tendonitis/bursitis continues without treatment, a rotator cuff tear may occur.

Rotator cuff tears occur after long-term wear causes degeneration. In about 10% of cases, the rotator cuff ruptures after a specific trauma. This is known as an acute tear.

Most rotator cuff tears (90%) are chronic and occur gradually, after a history of shoulder problems including painful abduction, night pain, and gradual weakness in the arm. Ultrasound-guided needle tenotomy with platelet-rich plasma can heal the tear, if it is a partial tear, and avoid the need for surgery. (

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 pain at rest or with abduction, “catching” on movement of the shoulder, and pain at night.

Severe pain can develop. The shoulder is red, warm and tender to touch. This problem can be debilitating. Ultrasound-guided needle lavage can help flush out crystals and relieve symptoms.

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 inside 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.

Adhesive capsulitis results in limitation of both active and passive movement of the shoulder, causes pain with motion, and interferes with normal daily activities. Night pain may be severe. There may is limitation of range of motion with both active and passive maneuvers. It typically occurs in women aged between 40-60 years, and often in the non-dominant arm.

Pain localized at the top of the shoulder or the shoulder blade may occur because of problems in the acromioclavicular joint or the neck.

In particular, shoulder blade pain along the upper and medial border of the shoulder blade in the upper back is almost always referred from the neck and indicates 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 tip of the shoulder may be referred from an abdominal problem such gall bladder disease, or from a lung condition such as pulmonary embolism.

Patients with painful shoulders should be asked to give a full history of their pain, and of any possible overuse or trauma that may have occurred. A full examination of the shoulder and the neck need to be performed, to determine if there is any tenderness, the presence of a 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.

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 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.

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 pain. Ultrasound-guided percutaneous needle tenotomy with platelet-rich plasma (PRP) may heal the tear and prevent the need for surgery.

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, injection of a glucocorticoid may help. Application of an ice pack may also help ease the pain. A recent study found that the frequent use of therapeutic ultrasound relieved symptoms and promoted healing in patients with calcific tendonitis. Ultrasound-guided needle lavage has been found in a number of studies to be curative. Once pain is controlled, exercises should be performed to maintain the function and mobility of the shoulder, and strengthen the rotator cuff.

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 used to control pain, although joint movement will not be restored. Occasionally, the affected joint may be manipulated under general anesthesia in order to improve the range of movement. Adhesive capsulitis is a condition that is best prevented.

Neck problems require anti-inflammatory medication, aggressive physical therapy, exercises, and gentle traction. Occasionally local anesthetic 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 procedures are also helpful. The most important thing to bear in mind is that shoulder blade pain may have its origins far from the shoulder itself.

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