Shoulder blade pain in women
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 in women must be distinguished from primary shoulder pain.
The shoulder is the most mobile joint in the body, but is dependent on the “rotator cuff” muscles and tendons for stability.
Rotator cuff tendonitis is inflammation or degeneration of the tendons that make up the rotator cuff. Subacromial bursitis is inflammation of the bursae, fluid filled sacks that cushion joints. Both conditions occur when there is impingement of these soft tissues by the bony arch formed by the acromion, clavicle, and coracoid processes of the shoulder.
Symptoms are characterized by pain in the shoulder when lifting the arm out from the side of the body, causing restriction of movement. 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, pain becomes worse and particularly severe at night. Eventually, if the tendonitis/bursitis continues without treatment, a rotator cuff tear may develop.
Rotator cuff tears occur after long-term wear leads to degeneration in the soft tissues of the shoulder, and also in association with untreated tendonitis. In about 10% of cases, the rotator cuff ruptures after a specific traumatic event, usually lifting a heavy object, or falling directly onto the shoulder. This is an acute tear and causes severe pain in the shoulder and is associated with limitation of movement and muscle spasm.
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. Treatment with ultrasound-guided needle lavage is often curative.
Adhesive capsulitis or “frozen shoulder” is a disorder where there is inflammation in the ball-and-socket joint of the upper arm bone and shoulder, resulting in adhesions in 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, and mastectomy.
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 at the top of the shoulder or in the shoulder blade may occur because of problems in the acromioclavicular joint or the neck.
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 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 foes 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.
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. An injection of a corticosteroid into the joint may help. Physical therapy can be initiated to maintain flexibility and 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 may help relieve pain. Ultrasound-guided needle tenotomy with platelet-rich plasma (PRP) may allow healing of the tear without the need for surgery (www.arthritistreatmentcenter.com).
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, the arm should be put in a sling, and medications prescribed: non-steroidal anti-inflammatory drugs and perhaps an injection of glucorticoid into the joint. A recent study found that the frequent use of therapeutic ultrasound relieved symptoms and promoted healing in patients with calcific tendonitis. Once pain is controlled, exercises should be performed to maintain the function and mobility of the shoulder, and strengthen the rotator cuff. Ultrasound-guided needle lavage with removal of crystals can be curative.
Adhesive capsulitis is treated initially with non-steroidal anti-inflammatory drugs, and a gentle exercise program of stretching. A corticosteroid injection may be prescribed. Occasionally, the affected joint is manipulated with the patient under general anesthesia. Adhesive capsulitis is a condition that is best prevented: in any shoulder disorder, prolonged immobilization should be avoided.
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).
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