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 must be distinguished from shoulder pain.

The shoulder is the most mobile joint in the body, but is dependent on surrounding soft tissues for its stability. These soft tissues are known as the “rotator cuff” and are made up 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 a bony arch as they do so. 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 adjacent bone. Disorders of this rotator cuff and bursa are the cause of most cases of shoulder pain.

Rotator cuff tendonitis is inflammation 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 these soft tissues by the adjacent bony arch with everyday wear-and-tear, and both produce similar symptoms.

They are characterized by pain in the shoulder when lifting the arm out from the side of the body (abduction), 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, 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 the soft tissues of the shoulder, and in association with untreated tendonitis. Tears usually occur in the dominant arm In about 10% of cases, the rotator cuff ruptures after a specific traumatic event (without a preceding history of shoulder problems) - usually breaking a fall by stretching out the hand, lifting a heavy object, or falling directly onto the shoulder. This is known as an acute tear and causes severe pain in the shoulder, radiating into the arm, and associated with limitation of movement and muscle spasm. Although the patient cannot move the arm out himself, the arm can be lifted passively, although will drop back to the side with the slightest pressure on the wrist.

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. These chronic tears can eventually cause limitation of all directions of movement of the shoulder, and may result in wasting of some of its muscles.

Calcific tendonitis is another condition of the rotator cuff that can cause pain and weakness in the shoulder. Calcium deposits laid down 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 moves into the subacromial bursa. The shoulder is red, warm and tender to touch, and the arm is usually held close to the chest. These severe symptoms generally last about two weeks, and may be associated with generalized illness and fever. 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.

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 fore-arm.

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. There may be a sense of restriction of the joint when it is passively moved. It typically occurs in women aged between 40-60 years, and often in the non-dominant arm.

Pain localized to above the shoulder or the shoulder blade may occur because of problems in the acromioclavicular joint (i.e. between the shoulder blade and collar bone) 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 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.

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 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. Those with generalized symptoms (e.g. in calcific tendonitis) may have blood tests taken.

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. There is still much debate as to which treatment is best, although many trials have compared different non-steroidal anti-inflammatory drugs, physiotherapy, and corticosteroid injections. One recent study noted that patients treated with corticosteroid injections appeared to get faster relief of symptoms than those who received physical therapy, although other investigators have found no difference between these treatments in their long-term effects.

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. An orthopedic specialist should be consulted if pain and weakness persists, because surgical repair may also be necessary in these cases.

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 local anesthetic into the joint. Application of an ice pack may help ease the pain. A recent study found that the frequent use of ultrasound (the use of high-frequency, inaudible sound waves) 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.

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 or a short course of oral corticosteroids may be prescribed to control pain, although joint movement will not be restored by these drugs. Occasionally, the affected joint is manipulated with the patient anesthetised, in order to improve the range of movement. Adhesive capsulitis is a condition that is best prevented: in any shoulder disorder, prolonged immobilization should be avoided and early return to movement should be encouraged.

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.

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