Shoulder Blade Pain: Symptoms, Causes, Types, Treatment, Exercise

Shoulder blade pain is also known as scapula pain. Scapula lies on right and left side over back of the chest wall. Shoulder blade or wing bone is a flat bone that is supported by ligaments and several muscle.¹ Four muscles that support shoulder blade forms rotator cuff. Rotator cuff supports shoulder joint. Shoulder joint pain also refers to shoulder blade. The upper end or head of humerus looks like a ball and known as epicondyle. The outer cup shape socket of shoulder blade is known as glenoid cavity. Shoulder joint is form by head of humerus covered by glenoid cavity or cup shape socket of scapula (shoulder blade). Referred shoulder joint pain to shoulder blade originates from cartilages of shoulder joint as well as ligaments and tendon that supports shoulder joint. Shoulder blade pain often originates in acromioclavicular joint. Acromioclavicular joint is form between acromion section of scapula and outer end of clavicle bone. Acromioclavicular joint pain is also referred to shoulder blade.

The shoulder blade moves inward and outward over the ribs on back of the chest wall.² Shoulder blade also rotates clockwise as well as anticlockwise when upper arm abducts and adducts. The shoulder joint movements are classified as abduction (away from body), adduction (towards the body), flexion (arm moves in front of body on side), extension (arm moves backward) and rotation. Shoulder blade moves during all shoulder joint movement. Shoulder blade pain is more often caused by diseases of rotator cuff. Rotator cuff prevents separation of ball shape head of humerus from cup shape socket or glenoid cavity. The rotator cuff is like a shackle that covers and protects shoulder joint. Rotator cuff is form by ligaments of four muscles. Shoulder joint pain that referred to shoulder blade is also caused by joint arthritis, inflammation of tendon as well as ligaments.

1. Prolong abnormal posture,
2. Repeated shoulder joint movement,
3. Diseases of spinal cord and spinal nerve,
4. Manual labor,
5. Contact sport and
6. Osteoporosis.

1. Posture- Lying on one side for prolong period of time occasionally causes ligament strain or tendon injury that results in pain. These ligament and tendons are attached to shoulder blade.
2. Repeated shoulder joint movement- Repeated shoulder joint movement as observed in golfer or tennis player causes shoulder joint and shoulder blade pain because of tendon injury to rotator cuff injury.
3. Diseases of spinal cord and spinal nerve- Irritation of cervical spinal nerve or cervical spinal cord causes pain in shoulder blade.
4. Manual labor- Manual labor involving repeated use of shoulder blade that often causes injury of muscles and tendons attached to shoulder joint. Manual labor also causes injury of shoulder joint cartilage and ligament that results in referred pain to shoulder blade.
5. Contact sport- Contact sport involves physical direct impact of shoulder blade by hard object or falling on hard ground. Such trauma can cause muscle and tendon attached to shoulder blade as well as shoulder bone injury.
6. Osteoporosis- Osteoporosis causes weak bone. The less calcium and weaker connective tissue within the skeletal of bone cause fracture of shoulder blade with fall or stretch.

Shoulder blade pain is either acute or chronic pain. Acute pain lasts for less than 6 months and chronic pain lass more than 6 months. Shoulder blade pain is caused by following diseases-

1. Diseases of Shoulder Blade

   1. Shoulder blade fracture
   2. Osteoporosis of shoulder blade
   3. Arthritis affects shoulder blade
   4. Muscle spasm of muscles that les over shoulder blade
   5. Myofascial pain of shoulder blade muscles
   6. Fibromyalgia pain
   7. Hematoma (blood clot) of shoulder blade¹

2. Intercostal Neuralgia-

   Nerve pain is felt along the intercostal nerve. Such pain is known as intercostal neuralgia. Intercostal neuralgia is caused by inflammation, irritation and pinch of spinal or intercostal nerve.

   Shingles- Post herpetic intercostal neuralgia is causes by chickenpox virus. Such inflammation of intercostal nerve is known as shingles.

   Radicular Pain- Irritation or pinch of sensory branches of thoracic spinal nerve causes pain along the back of chest wall and scapula.² Such pain is known as radicular pain. Radicular pain is cause by following diseases.

   1. Disc bulge
   2. Disc herniation
   3. Foraminal stenosis

Radiculopathy– The pinch of entire spinal nerve causes degeneration of sensory and motor nerve fibers. The pinch or irritation of entire spinal nerve causes, pain, tingling, numbness and weakness of intercostal muscles.

1. Disc bulge
2. Disc herniation
3. Foraminal stenosis

1. Referred Pain from Shoulder Joint

   1. Glenoid Cavity Dislocation Or Fracture- – Also known as ball and socket joint. The pain originates when joint is dislocated or fracture.
   2. Inflammatory Disease Of Shoulder Joint- Pain originates in cartilage as in rheumatoid arthritis. Rheumatoid arthritis causes inflammation of cartilage that covers head of humerus and socket of scapula.
   3. Degenerative Disease Of Shoulder Joint- The degenerative inflammatory disease like osteoarthritis causes severe inflammation and damage of head of humerus and glenoid cavity that result in mild to severe pain.
   4. Rotator Cuff Tear And Inflammation- Rotator cuff dysfunction is caused by structural abnormalities of rotator cuff muscles that is attached to scapula.⁵ Scapular dyskinesia causes rotator cuff pain and dysfunction. Rotator cuff is formed by a tendon of Supraspinatus, Infraspinatus, Teres-Minor and Subscapularis muscles. Shoulder joint pain is observed when rotator cuff is torn or inflamed.
   5. Inflammation or Tear Of Shoulder Joint Ligament- There are several ligaments attached to head of humerus and glenoid cavity. Inflammation, micro-tear or tear of any one of the shoulder joint ligaments causes shoulder joint pain.

2. Diseases of Heart-

   1. Pericarditis
   2. Angina
   3. Aortic aneurysm

3. Diseases of Lungs

   1. Pleuritis
   2. Cancer
   3. Pneumonia
   4. Pneumothorax
   5. Pulmonary embolism

4. Abdominal Causes

   1. Pancreatitis
   2. Cancer of pancreas
   3. Gall stone

5. Cancer

   1. Esophageal cancer
   2. Breast cancer
   3. Lung cancer

Findings of Clinical Examination-

1. Pain-

   Pain is acute or chronic. Pain is felt over back of the chest over the shoulder blade. Pain intensity increase with movement of shoulder blade. Acute pain lasts for 6 month and pain lasting more than 6 months is known as chronic pain. Pain is mild to severe. The inflammation of muscle and tendon causes mild to moderate pain. Ligament and bone inflammation or injuries causes severe to very severe pain. Pain is initially dull, intermittent and pricking in character. Later pain become sharp and continuous. Pain is felt like stabbing or squeezing pain. Pain is felt over shoulder blade when pain originates from muscle, tendon, ligament and shoulder blade. Similarly, pain is also felt under shoulder blade when pain is caused by intercostal nerve, rib, diseases of lung, heart and abdominal organ.

2. Tingling and Numbness-

   Tingling and numbness over shoulder blade is felt when sensory nerve fibers of spinal or intercostal nerve is irritated or pinched. Tingling is irreversible if the cause is removed. Numbness indicates permanent sensory nerve damage or serious injury of sensory nerve and treatment must be initiated as soon as possible.

3. Weakness in Intercostal Muscle- Intercostal muscle helps to breath. The weakness in few segments of intercostal muscle often is not recognized since diaphragm and remaining intercostal muscle maintains normal breathing function. The weaknesses in intercostal muscle suggests possible severe injury of spinal and intercostal nerve resulting in motor nerve degeneration.

4. Shoulder Pain– Shoulder blade pain may be associated with shoulder joint pain. Look for shoulder joint diseases that may be causing shoulder blade pain.

5. Shoulder Blade Tenderness- Examination of shoulder blade like palpation causes severe pain. Pain often continues for several hours. Palpation or pressure over shoulder blade causes pain within inflamed tendon, muscle or ligament.

6. Grating Sound- The movement of arm like abduction and adduction rotates the shoulder blade. Such movement causes grating sound. The presence of grating sound suggests possible inflammation or fracture of shoulder blade.

7. Short of Breath- The symptoms like short of breath or dyspnea is observed when pain is caused by diseases of lungs.

8. Fatigue and Weakness- Cancer, cardiac diseases and diseases of abdomen as well as liver causes feeling of fatigue and weakness.

1. Blood Examination-

1. White Blood Cell Count (WBC)- WBC count is increased if pain is caused by pneumonia, pleuritic or gall bladder infection.
2. Hemoglobin- Low hemoglobin is observed when pain is caused by cancer. Cancer causes low hemoglobin and anemia.
3. ESR- Erythrocyte sedimentation rate (ESR) is increased when pain is caused by pneumonia.
4. Calcium Blood Test- Abnormal calcium blood test suggests presence of osteoporosis.
5. Liver Function Test- Abnormal liver function test suggest gall bladder and liver disease.
6. Cardiac Enzymes- Abnormal cardiac enzyme suggests possible cause of shoulder blade pain is myocardial infarction and angina.
7. C-reactive Protein and Rheumatoid Factor- Abnormal level of C reactive protein and rheumatoid factor suggests pain may be originating in shoulder joint and cause is rheumatoid arthritis.
8. Antinuclear Antibody- Abnormal anti-nuclear antibody suggests pain may be originating from shoulder joint and caused by osteoarthritis of shoulder joint.

2. Radiological Examination- These tests are done in order to obtain a clear image of the shoulder blade to evaluate the cause of pain.

1. X-ray: X-ray shows the clear two dimensional images of shoulder blade. Fracture and osteoporosis of shoulder blade is diagnosed with X-Ray.
2. MRI and CT Scan– Magnetic Resonance Imaging (MRI) and computerized tomography (CT) scan images show 3-dimensional view of shoulder blade and shoulder joint. MRI and ST scan shows fracture of shoulder blade as well as shoulder joint. MRI and CT scan also shows soft tissue injuries of tendon, muscle and ligament, as well as shoulder joint dislocation. Images also shows intervertebral disc abnormalities and rib diseases that may cause shoulder blade pain.

3. EKG and Stress Test- Shoulder blade pain in few caused by angina or myocardial infarction (heart attack). Abnormal EKG and stress test indicates possible cause of shoulder blade pain.

4. Ultrasound– This technique utilizes the high-frequency sound waves that are reflected by the shoulder region and are translated into the images. Ultrasound shows muscle and tendon injury as well collection of pus or blood clot over shoulder blade. The infection of subcutaneous tissue may result in cellulitis or abscess formation that can cause severe pain over shoulder blade. Similarly, injury results in bleeding and blood clot collection over shoulder blade that can cause shoulder joint pain.

5. Orthopedic Tests: These tests are designed specially to identify the cause and severity of shoulder pain. The tests are conducted for the assessment of the stability, power, and the extent of movement of the shoulders.

These Tests Include:

1. Painful Arc Test: It aims at identifying the painful arc or the position of maximum pain between 70 to 120 degrees of abduction in shoulder blade.
2. Drop Arm Test: It identifies damage in the rotator cuffs by making the patient to lower the abducted arm to the waist slowly.
3. External Rotation Test: This test checks for the out ward rotation of the arm when the elbow is withheld to the side.
4. Gross Arm Test: This test focuses on the pain in the acromioclavicular in which the ailed arm is required to be raised to 90 degrees, followed by holding the other arm across the chest.

1. Electromyogram (EMG): This test is used to evaluate the presence of any nerve injury or damage in the shoulder region that may amount to pain in the shoulder blade.

The treatment of shoulder blade pain mainly includes the following measures to prevent further increase in pain. Medications can also be taken in case the shoulder blade pain doesn’t subside. The various types of treatments available are:

1. Conservative Treatment for Shoulder Blade Pain- The measures ensure that the condition of the patient suffering from shoulder blade pain does not get worse and results in gradual relief. Some of the preventive measures include:

1. Rest: Rest helps in healing which in turns aids in combating the shoulder blade pain.
2. Reducing Physical Activity: It is required to reduce the strain on the shoulder by preventing the occurrence of pain in it due to repetitive motion.
3. Heat and Cold Applications to Treat Shoulder Blade Pain: The application of ice packs for compression followed by heat application in alternating manner can soothe the pain. This should be done at least three times a day.
4. Proper Posture to Prevent Shoulder Blade Pain: Following proper posture especially while sleeping can prevent severe aches and pains around shoulder blade.

2. Physiotherapy for Shoulder Blade Pain:

1. Massage Therapy- Massage therapy is recommended when pain is caused by diseases of muscles that lies over shoulder blade and also shoulder joint.
2. Ultrasound Therapy- High frequency ultrasound waves penetrate through skin and passes into muscles. The soundwave helps to reduce the pain.
3. Infrared or Heat Therapy- Heat therapy is used to treat muscle pain. Cold therapy is used to reduce the tissue swelling and also relieve pain.
4. Pressure Point Therapy- The paravertebral and scapular muscles causes pain and muscle spasm. The muscle knots that causes pain is treated with pressure point therapy.
5. Exercise: Regular exercise can ensure proper healing of shoulder blade pain as it helps in improving strength, flexibility, and mobility of the shoulder joint thereby decreasing the pain around the shoulder blade gradually.

3. Medications:

1. Muscle Relaxants- Shoulder blade pain caused by muscle spasm, myofascial pain and fibromyalgia is treated with muscle relaxants. Muscle relaxants prescribed are Soma, Robaxin, Flexeril and Baclofen.
2. Anti-Inflammatory Drugs (NSAIDs)- Shoulder blade pain caused by inflammation of muscle, tendon and ligament is treated with NSAIDs. Shoulder blade pain caused by inflammatory disease of shoulder joint like osteoarthritis and rheumatoid arthritis are also treated by NSAIDs.
3. Tylenol- Shoulder blade pain not caused by inflammatory diseases is treated with tylenol pills.

4. Interventional Treatment for Shoulder Blade Pain-

1. Trigger Point Injection- Shoulder blade pain caused by diseases of muscles that lies over shoulder blade is treated with trigger point injection. Cortisone solution injected using thin needle on to most painful tendon and muscles.
2. Intercostal Nerve Block- Post herpetic neuralgic pain or neuropathic radicular pain caused by spinal nerve pinch is treated with intercostal steroid injection.
3. Epidural Steroid Injection- Irritation and pinch of spinal nerve in epidural space causes radicular pain along the intercostal nerve. The pinch is caused by disc bulge, herniation or foraminal stenosis. Such pain is treated with epidural steroid injection.

5. Surgery-

   Snapping of scapula is treated with arthroscopic surgery.

There are exercises which can help in reducing shoulder blade pain and strengthen the shoulder. These exercises help in controlling and supporting the shoulder blade by targeting the scapula muscle and making it stronger by allowing a wide range of motion of the shoulder joint. Some of such exercises for shoulder blade pain are:

• Shoulder Blade Pain Exercise #1- Wall Pushups: The patient stands in front of the wall with feet apart as per the shoulder width and palms placed against the wall in front. Then the patient should push the upper body away from the wall.
• Shoulder Blade Pain Exercise #2- Sitting Shoulder Pushups: In this exercise, the patient sits on the chair with hands on the arm rest and feet flat. Then he or she has to lift the body from the chair with the help of the arms.
• Shoulder Blade Pain Exercise #3- Shoulder Flexion: It involves clapping of hands stretched in front with elbows straight, followed by lifting of arms above the head and subsequently down the head.

One must follow the exercises to prevent any injury to the shoulder and to avoid subsequent pain. However, if the shoulder blade pain has already set in, follow the preventive measures to stop it from aggravating. The preventive measures help in reducing the pain around shoulder blade to a great extent. If it still persists, one must seek immediate help as a shoulder blade pain could also indicate certain serious health problems.

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