Shoulder Blade (Scapula) Pain

What are the shoulder blades and where they are located?

Shoulder blades are two flat, triangular bones on each side of the top of your back. They are connected to the upper arm bones (humerus) and collar bones (clavicle) and to the muscles of the upper back, neck and arm.

What causes shoulder blade pain?

Pain in the shoulder blades can be caused by increased muscle tension, bad posture, psychological stress, shoulder overuse, injuries, pinched nerves and lung diseases.

The following conditions typically, but not always, cause pain in only right or only left shoulder blade or only between them:

• RIGHT shoulder blade pain: gallstones, liver cancer, pelvic inflammatory disease, rupture of an abdominal organ: stomach, appendix, spleen, ovary, ovarian tube (in ectopic pregnancy)
• LEFT shoulder blade pain: irritable bowel syndrome, disorders of the heart, pancreas and spleen
• Pain BETWEEN the shoulder blades: gastritis, peptic ulcer, broken vertebra (osteoporosis, bone cancer), scoliosis, esophageal cancer, Hodgkin lymphoma, aortic dissection

Picture 1. Shoulder blade pain location

Common Symptoms Associated with Shoulder Blade Pain

Tingling, numbness or burning speak for a nerve damage, either from a neurological disorder (shingles, brachial neuritis, transverse myelitis, multiple sclerosis) or nerve compression (herniated discs or broken vertebra in the neck spine, T4 syndrome); tingling can also result from increased muscle tension or migraine.

Pain in the shoulder blade when turning the head sideways can result from pinched nerves in the neck, wry neck or whiplash injury. Pain between shoulders when bending the neck forward usually results from tense upper back muscles. Pain between shoulder blades radiating to one shoulder or arm when bending the neck backwards can be from pinched nerves in the neck.

Crepitus–a grating sound when pressing upon the shoulder blade or moving the arms–can be from broken shoulder blade or ribs.

Causes of Shoulder Blade Pain by Organ

I. MUSCLES of the upper back
II. TENDONS in the shoulder area
III. BONES: scapula and spine
IV. NERVES
V. CHEST organs: heart, lungs, esophagus, aorta
VI. ABDOMINAL organs: gallbladder, pancreas, liver,
stomach, kidneys, spleen, ovary, appendix
VII. SHOULDER

I. MUSCLES

1. Poor Posture (Forward or Rounded Shoulders)

Rounded shoulders can result from tight chest and weak upper back muscles, for example, due to prolonged desk job, and can cause pain in one or both shoulder blades or between them [109].

Shoulder blade retraction exercises to strengthen your upper back muscles:

1. In a standing or sitting position with arms parallel to the body, pull your shoulders back and down and hold for 2-3 seconds (repeat 3 x 12) [70].
2. Place your arms in a hug position and squeeze the shoulder blades for 8 seconds (repeat 6 x) [71].
3. Plank. Lye on the ground (face-down) and raise your body to rest only on your toes and forearms, with elbows directly under the shoulders and hands made into fists. Hold as long as you can or until the onset of pain.
4. Seated rows. Put an elastic band around the solid object, sit down, hold the ends with both hands and pull 10 times [69].
5. More exercises to strengthen your upper back and neck muscles are shown and described here.

2. Emotional Stress

Chronic emotional stress, anxiety and depression can result in increased tension in your upper back muscles and discomfort or burning or stabbing pain between the shoulder blades; the pain can be triggered by touching the chest with the chin, deep breath or stretching the back muscles; you may also experience neck pain and headache [89,90].

3. Myofascial Pain Syndrome (Muscle Knots)

Myofascial pain syndrome is a chronic condition with palpable knots and taut bands in the muscles and their sheats (fascia) that act as trigger points. Snapping on the knots in the shoulder blade area triggers muscle twitches at the site of the snap and deep aches in the shoulder, back side of the arm, hand and little and ring finger (Picture 2) [18]. Trigger points can be also found on the back of the head, neck, in the lower back and hips [18]. The syndrome can be associated with headache, migraine, temporomandibular joint dysfunction or fibromyalgia [18].

Picture 2. Myofascial pain syndrome:
Pressure on a trigger pain can trigger pain over the shoulder blade
that radiates down the arm.

Myofascial pain syndrome can result from prolonged sitting (office job, computer work) or standing, carrying heavy loads in a hand or over a shoulder, pregnancy, breastfeeding or playing an instrument, such as violin, guitar, flute, piano or drums.

Trapezius Strain or Repetitive Strain Syndrome

Trapezius strain is characterized by discomfort, tightness and muscle knots between the shoulder blades. Pain and tingling can radiate to the shoulders, neck and head. Causes include poor posture, repetitive lifting, workout exercises, such as pull-ups, tilting the head sideways when using the phone, scoliosis and discrepancy in leg length [81].

Exercises (3 x 3 per day) [81]:

• Bend the neck and hold for 30 seconds.
• Place the arm on the affected side behind the back, hold the wrist with the other hand, bend the neck sideways to the opposite side and hold for 30 seconds.
• Clasp the hands in the front of the body and reach forward; hold for 30 seconds.

Serratus Anterior Muscle Pain Syndrome (SAMPS)

Serratus anterior muscles on both sides of your chest, below the armpits, help raise your upper arms forward and upward, for example, during sprint, workout exercises (push-ups, bench presses) and expand your chest during breathing in. Repeated sprints, prolonged running or prolonged hard coughing can cause pain between and below the shoulder blades and on the inner sides of the arms down to the pinky and ring finger (Picture 3); the pain can be aggravated by deep breathing [73].

Picture 3. Serratus anterior muscle pain distribution: 
on the side of the chest, below the shoulder blade
and down the inner side of the arm

Exercises [73,74]:

• Massage the tender points with a tennis ball.
• Place the right arm behind the back and hold the wrist with the left arm. Bend the neck sideways to the left while pulling the right arm and hold for 10-15 seconds. Repeat 3 x 3 during the day.

Diagnosis and Treatment of Myofascial Pain Syndrome

Diagnosis is made by physical examination.

Treatment [18,81]:

• Dry needling or injection of analgesics into the tender knots can provide immediate relief
• Spraying the affected area with a vapocoolant spray followed by slow muscle stretching until pain, or massage using “trigger point pressure release”
• Heat pads, hot showers or ice packs
• Therapeutic ultrasound.

Non-steroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, are less effective; muscle relaxants are not effective, because myofascial pain is not caused by muscle spasms [18]. Wearing a cervical collars may worsen the upper back rigidity [81].

4. Muscle Strain (Pulled Muscle) or Tear

Muscle strain refers to overstretched muscle and muscle tear refers to a rupture of a part and rarely of an entire muscle.

Strain or tear of the rhomboid muscle, which connects the shoulder blade with the spine, can cause mild to severe pain and swelling between the shoulder blades [85]. Strain can occur during carrying a heavy backpack, reaching for something heavy on a high shelf, push-ups, pull-ups, weightlifting exercises (deadlift, bench press, squat), or in sports, like basketball, bowling, boxing, cycling, gymnastics, golf, handball, martial arts, rowing, running, shooting, skiing and tennis.

Initial treatment includes rest of the shoulder and ice packs. When the pain diminishes, you can start with gentle exercises to the point of pain [85]:

• Interlace your fingers behind the back and push the hands backwards.
• Place the arm of the unaffected side horizontally over the chest, grab the wrist with the hand of the affected side and pull the arm sideways and backwards.

Rupture of the subscapularis muscle–the muscle under the shoulder blade–can cause severe pain under the shoulder blade, aggravated by lifting an arm [15]. Treatment includes physiotherapy.

5. Muscle Contusion (Bruise)

Muscle contusion is a muscle hematoma (a blood collection in the muscle) caused by a direct blow [4]. Symptoms include localized swelling, bruising (reddish-bluish discoloration), tenderness and mild to moderate pain;the range of shoulder motion should not be significantly reduced. Treatment can include shoulder rest and applying ice wrapped in a cloth for 20 minutes immediately after the injury. Massage can make bruise worse. A doctor can drain a large hematoma with a needle. A bruise may need more than two weeks to disappear.

6. Snapping Scapula Syndrome

Snapping scapula syndrome refers to snapping, grinding or popping sound during shrugging or lifting an arm sideways, when the shoulder blade rubs against the rib cage and, sometimes, tenderness and palpable crepitus over the medial side of the scapula, and pain between the shoulder blades when lifting the arm above the shoulder level [84].

Causes include sports with overhead arm movements, like swimming and throwing. Risk factors include weak upper back muscles, bone scars after a rib or scapula fracture or scapular dyskinesia [84]. Treatment includes physical therapy; rarely, surgical fixation of the scapula to the rib cage is necessary.

7. Sick Scapula Syndrome

SICK scapula syndrome (scapular malposition, inferior medial border prominence, coracoid pain and malposition, and dyskinesis of scapular movement) includes asymmetric shoulder blades, prominent inferior medial angle of the affected shoulder blade, pain in the shoulder blade area and upper outer part of the arm, aggravated by using the arm force against resistance, and tenderness along the medial shoulder blade border; the range of shoulder motion is usually not significantly reduced [6]. The syndrome can develop in overhead throwing athletes, such as baseball, tennis, volleyball and waterpolo players, javelin throwers, shot putters and swimmers. Treatment is with physiotherapy [7].

8. Migraine

According to some reports, migraine headache can start as pain or tingling in one shoulder blade that progresses to one side of the head. Migraine sufferers often have increased tenderness of the neck and shoulder muscles [91].

9. Dermatomyositis and Polymyositis

Dermatomyositis is an autoimmune inflammatory disease with bilateral muscle weakness, mild pain in the shoulders and hips, reddish rash on the face, upper back, chest and hands and painful nodules (knots) under the skin; the onset of symptoms is in childhood or adulthood [31]. Polymyositis is a similar condition without rash.

10. Polymyalgia Rheumatica

Polymyalgia rheumatica is an inflammatory muscle condition of an unknown cause in individuals over 50. Bilateral aches and stiffness in the shoulder and hip muscles that are worse in the morning and improve through the day may develop overnight or in few days [16]. A related condition called giant cell arteritis can also cause pain in the temples, disturbed vision and fever [16].

II. TENDONS

1. Whiplash – Neck Strain and Sprain

Whiplash is a strain or tear of the neck muscles, tendons or ligaments or even a damage of the spinal discs and nerves caused by a sudden neck movement backwards and forwards, most commonly in rear-end car accidents and motorbike falls. Symptoms include pain radiating from the neck downwards to the shoulder blades, neck stiffness, dizziness and headache [93,94]. Treatment may include icepacks, massage, analgesics and cervical collar; recovery may take weeks to months.

2. Fibromyalgia

Fibromyalgia is a chronic condition with widespread dull musculoskeletal aches, fatigue, sleep, memory and mood issues. Typically, more than 10 symmetrical tender points can be found on the bottom of the back of the head, above and between the shoulder blades, on the upper parts of the buttocks, bottom of the front side of the neck, on each side of the upper part of the breastbone, on the hips, on the outer sides of the elbows and on the lower medial sides of the knees (Picture 4) [13].

Picture 4. Fibromyalgia:
Tender points are above and below the waist line.

Fibromyalgia mostly affects women; it can develop after an accident, disease or stressful event or without an apparent reason. The mechanism is not known; it may be caused by the change in the way how the brain processes pain signals. There is no joint or muscle inflammation and no abnormalities in blood tests or X-ray images [14]. Treatment includes analgesics, stretching exercises and adopting a healthy life style [78].

III. BONES

1. Fractures

Shoulder blade fracture can occur during a fall on an extended arm or due to direct hit to the shoulder blade in motorbike falls or collisions, for example, in rugby or hockey. Symptoms can include sudden, extreme, sharp pain, and an audible click, pop or snap in the shoulder blade and can radiate into the neck or upper arm; it can be aggravated by moving an arm, pressing down on a shoulder or firmly pressing on a shoulder blade at the site of the fracture, by sleeping on the back, deep breathing or coughing [8]. A visible deformity and swelling are usually present. Diagnosis can be made by X-ray. Treatment includes wearing a sling, rest, physiotherapy and, sometimes, surgery; a fracture usually heals completely within 6-8 weeks, but rehabilitation may last for several months [9].

Fracture of one or more ribs can cause sudden, severe, sharp pain near the shoulder blade; the pain is usually aggravated by breathing, coughing, moving, bending or pressing upon the broken rib. An audible cracking sound during moving can be present. The chest wall can be deformed [10].

Fracture of the vertebra in the cervical or thoracic spine can cause mild and dull or sudden and severe pain and tenderness between the shoulder blades [12]. Vertebral fractures are most common in older people with osteoporosis or spinal cancer (metastases, multiple myeloma) in whom they can be caused by minor accidents, like falls, or even by coughing hard [11].

2. Scoliosis

Scoliosis–a sideways curvature of the spine–causes uneven shoulders and, rarely, pain between the shoulder blades [27].

3. Paget’s Disease

Paget’s disease is a chronic viral infection of the bones, usually in adults after 40. Symptoms include fatigue, neurological symptoms (hearing loss, blindness, muscle weakness, tingling), asymmetric pain in the pelvis or other bones, possibly including one or both shoulder blades [39].

4. Scapular Cancer

Bone cancer or spread of lung or other cancer into the shoulder blade can cause shoulder blade tenderness and pain, especially when sleeping on the back. Other common cancer symptoms are fatigue, nausea, loss of appetite and weight. Injecting a bone cement into the affected bone (scapuloplasty) can relieve the pain [3].

IV. NERVES

1. Pinched Spinal Nerves

Pinched nerves arising from the neck spinal cord can cause burning and shooting pain and tingling:

• C4, C5 and C6 nerve roots: above the shoulder blade [2,92]
• C7 and C8 nerve roots: between the shoulder blades [2]
• C8 nerve roots: in the right or left shoulder blade area [2]

The pain can get worse by bending the neck backwards or lying down and can spread to the back of the neck and head or down the arm to the fingers [21]. Common causes include bulging or herniated discs due to spinal wear and tear (spinal osteoarthritis or spondylosis) [21], cervical spinal stenosis [24], inflammatory arthritis of the spine (ankylosing spondylitis) or broken vertebra caused by injury, osteoporosis or cancer.

A cervical rib (abnormal rib above the first rib) can press on a bunch of nerves that supply the upper arm (the brachial complex)–at their exit from the thorax to an arm and cause pain, numbness, pins and needles in the shoulder blade, arm or even fingers, arm coldness and weakness and headache (thoracic outlet syndrome); symptoms are aggravated by raising the arm above the shoulder level, for example, during combing the hair [20].

Pectoralis minor syndrome (pectoralis minor muscle runs from the scapula to the ribs below the armpit) can cause pain and tenderness below the collar bone, in the armpit and in or between the  shoulder blades; pain can radiate down the arm to the 4th and 5th finger [22,28]. Causes include injuries, prolonged use of crutches, carrying a heavy bag over the shoulder, head-forward posture during computer work and hyperventilation due to anxiety [29].

2. T4 Syndrome or Upper Thoracic Syndrome

T4 syndrome refers to the symptoms caused by irritation of the spinal joints and sympathetic nerves at the Th4 level (or from Th2 to Th7 level) and can include one-sided pain and stiffness between the shoulder blades, in the neck and head, chest tightness and abnormal sensations (a sense of swelling, extreme perception of cold and heat, numbness and tingling) in a hand, all 5 fingers and forearm (Picture 5); symptoms are not aggravated by active movements of the spine [79,87]. Causes include repetitive forward, backward and sideways bending or twisting of the torso (dentists, surgeons, electricians, assembly-line workers) and carrying heavy backpacks [87]. Pain can be relieved by laying flat (without a pillow) on the back [87].

Picture 5. T4 or upper thoracic syndrome pain distribution: 
between the shoulder blades, in the neck, hand and forearm

3. Shingles (Herpes zoster)

A reactivation of an old chicken pox infection in one of the nerves that arise from the lower neck or upper chest part of the spinal cord can cause burning pain, which is usually, but not always, followed by red, itchy, blisters that hurt to touch and extend in the form of a stripe horizontally from the spinal line over the shoulder blade toward the front of the chest, usually only on one side [23]. The pain and rash can persist for several weeks or months.

4. Brachial Neuritis

Brachial neuritis, idiopathic brachial plexopathy, neuralgic amyotrophy or Parsonage-Turner syndrome (PTS) is a rare condition with sudden, severe, burning pain above the shoulder blade and in the upper arm. The pain lasts from 1 day to several weeks and is followed by abnormal protrusion of the shoulder blade (scapular winging) and weakness, paralysis, tingling or numbness in an arm or hand. Recovery may last from few months to years; the cause is unknown but may include infection, vaccination (flu, tetanus, hepatitis B), surgery or trauma [60,75].

5. Transverse Myelitis

Transverse myelitis is an inflammation of the spinal cord, which may be caused by a viral infection, Lyme disease, multiple sclerosis or systemic lupus erythematosus. When it affects the upper parts of the spinal cord, it can cause shooting pains triggered by light touch or clothes (allodynia), or abnormal sensations, like tingling and numbness (paresthesia) in the neck and upper back, and weakness in the arms [86].

6. Long Thoracic Nerve Injury

The long thoracic nerves travel from the armpits vertically down the sides of the chest and supply the serratus anterior muscles. They can be damaged by a direct blow to the side of the ribs, sustained bearing of heavy loads over the shoulder, repetitive forward arm movements (sprint, boxing), deep massage or during removal of a breast and lymph nodes in the armpit (radical mastectomy). Symptoms include trouble lifting the arm on the affected side forward and above the shoulder level, winging scapula (a shoulder blade that sticks out) and mild burning pain on the side of the chest and in the scapular area; full recovery may lost for up to 2 years [82,83].

V. CHEST ORGANS

1. Gastric Reflux

Gastro-esophageal reflux disease (GERD) symptoms can include heartburn, that is burning sensation behind the breastbone, and pain between the shoulder blades that tend to be worse after eating, and metallic taste in mouth [46].

2. Bacterial Pneumonia

Bacterial infection of the lungs (pneumonia) usually presents with a sudden onset of high fever, rapid breathing, coughing up mucus, pain, usually on one side of the chest, in a shoulder blade or armpit [40].

3. Pleurisy

Pleurisy is an inflammation of the lung membrane (pleura) caused by a viral infection, such as flu, or bacterial infection, such as pneumonia or tuberculosis [43]. Symptoms may last from few days to 2 weeks and can include fever, rapid and shallow breathing and stabbing chest pain on one side of the chest or upper back that is worse during breathing in, coughing and sneezing [43].

4. Pneumothorax

Pneumothorax–a rupture of a lung membrane that results in the collapse of the lung, usually on one side–can cause sudden knife-like pain on one side of the chest, followed by vague pains around the chest and shoulder blades, worsened by breathing, coughing and moving the arms and torso [44].

5. Lung Cancer

Symptoms can include constant pain on one side of the chest or back, coughing up blood, loss of appetite, nausea and weight loss [41].

A malignant tumor that grows on the top of the lung can invade the nerves and cause severe constant pain in the shoulder blade that can radiate down the arm to the pinky and ring finger on the side of the tumor; other symptoms can include eyelid drop and absence of sweating on the affected side of the face and arm (Pancoast syndrome) [38].

6. Pulmonary Embolism

Pulmonary embolism is a clot in the pulmonary artery; it usually occurs in individuals with deep vein thrombosis. Symptoms include sudden, stabbing pain on one side of the chest or in the shoulder blade area (the pain is worse during inhaling), coughing up bloody sputum and mild fever [42].

7. Coronary Heart Disease and Heart Attack

The risk of coronary heart disease increases in men after 45 and in women after 55 [33]. Typical symptoms are a sudden, heavy, burning pain behind the breastbone (angina) and shortness of breath aggravated by exercise, stress or cold and relieved by rest or an analgesic nitroglycerin and usually lasting for less than 5 minutes; the pain can radiate to the neck, jaw, into the left, both or between the shoulder blades or down the upper left arm to the fingers [32].

Pain from a heart attack is similar to angina but much stronger and longer (>15 minutes); in men, the pain can radiate to the neck, chin, left shoulder and down the left arm; in women, it can radiate to the neck, chin, both shoulder blades or arms [34].

8. Inflammation of the Heart Sac (Pericarditis)

Symptoms of pericarditis include sharp, central or left chest pain, which can radiate to the throat, jaw and left or both shoulder blades or arms, nausea, shortness of breath and, sometimes, low-grade fever [35]. The pain can be aggravated by deep breathing, eating, coughing and lying down, and relieved by sitting and leaning forward [36]. Causes include viral infections, tuberculosis, heart attack, trauma, systemic lupus erythematosus, rheumatoid arthritis, kidney failure or cancer.

9. Esophageal Cancer

Esophageal cancer can cause pain behind the breastbone or between the shoulder blades, especially during swallowing [45].

10. Enlarged Chest Lymph Nodes

Enlarged lymph nodes in the chest, for example, in Hodgkin lymphoma, leukemia, tuberculosis, histoplasmosis, cystic fibrosis and sarcoidosiscan cause persistent cough, wheezing or difficulty swallowing [19] and, according to anecdotal online reports, pain behind the breastbone and between the shoulder blades.

11. Aortic Dissection

Aortic dissection (tear) can cause sudden, severe, tearing pain in the middle of the chest and between the shoulder blades [37].

VI. REFERRED PAIN FROM THE ABDOMINAL ORGANS

Disorders of abdominal organs that irritate the diaphragm–the flat muscle between the chest and abdominal cavity–can cause pain in the left or right shoulder, because the phrenic nerve, which conducts sensory stimuli from the diaphragm, and the nerves that conduct sensory stimuli from the shoulders enter the spinal cord via the same nerve roots, so the brain can wrongly interpret the pain origin [88]. Sometimes, only shoulder pain without abdominal pain is present [5]. Referred shoulder pain is not aggravated by shoulder movements.

1. Trapped Gas in the Intestine

In individuals with irritable bowel syndrome or constipation, trapped gas in the part of the colon near the spleen can cause moderate pain on the left side of the upper abdomen, chest, shoulder, inner part of the arm and little and ring finger (splenic flexure syndrome); the pain can last for few hours [30,80].

Trapped Gas After Laparoscopy, Hysteroscopy or Colonoscopy

After endoscopic investigations, such as laparoscopy (an investigation of the abdominal cavity) or hysteroscopy (investigation of the uterus), some gas instilled during the procedures can get trapped under the diaphragm and cause pain in the right shoulder blade for some days; laying flat can help relieve pain [52,53]. After colonoscopy, a pain in the left shoulder blade is common [54].

2. Stomach Disorders

Gastritis, most commonly caused by Helicobacter pylori bacteria, can cause burning pain in the upper middle abdomen and, according to anecdotal online reports, between shoulder blades.

Peptic ulcer (stomach or duodenal ulcer) can cause burning or gnawing pain in the upper middle stomach or in the middle of the back between the shoulder blades; pain can be relieved by antacids; eating can bring relief to duodenal but less likely stomach ulcer [62].

3. Gallbladder Disease

Acute or chronic gallbladder inflammation (cholecystitis) with or without gallstones can cause a “gallbladder attack” or “biliary colic” with sudden, severe, crampy pain and tenderness below the rib cage on the right side; pain can persist from few minutes to several hours, it may be worse during breathing and after eating and can radiate to the right flank or beneath or below the right shoulder blade or between the blades; other possible symptoms include nausea, vomiting and fever [47,48,49].

Stones in the common bile duct can present with additional symptoms: jaundice, pale and smelly stools and dark urine [50].

Biliary dyskinesia–a movement disorder of the gallbladder–can cause similar pain than gallbladder inflammation; the pain can persist after a gallbladder removal [51].

4. Kidney Disease

Kidney disease can cause dull flank pain below the right or left shoulder blade that can be triggered by tapping over the kidney but not likely by the body movements. Kidney stones can cause sudden, sharp, spasm-like pain in the right or left flank, which can radiate to the right or left abdomen or groin.

5. Acute Pancreatitis and Pancreatic Cancer

Acute pancreatitis (inflammation of the pancreas) can cause severe, persistent pain in the upper middle abdomen that can be worse after meals and can radiate to the middle of the back or left shoulder blade;other symptoms can include fever, nausea, bloating and diarrhea [55].

Pancreatic cancer can cause pain in the upper middle abdomen that can radiate to the left or right shoulder or between shoulder blades; other symptoms can include a lump in the upper middle abdomen, loss of appetite, nausea, weight loss and jaundice [56,57].

6. Enlarged Spleen

Enlarged spleen (in infectious mononucleosis, malaria, leukemia, lymphoma or liver cirrhosis) can present with a lump and dull, persistent pain in the upper left abdomen, which can be worse with deep breathing and may radiate to the top of the shoulder blade (Kehr’s sign) [76].

Other splenic disorders with possible left shoulder pain include ruptured spleen, splenic infarct and abscess [30,65].

7. Liver Cancer

Liver infection (hepatitis C) [61] or liver cancer [58] can cause a lumpand pain below the right rib cage and near the right shoulder blade. Other symptoms can include loss of appetite, unexplained weight loss and jaundice [77].

After liver biopsy, some individuals can feel pain in the right shoulder blade area for few days [59].

8. Other Causes of Visceral Pain Due To Irritation of the Diaphragm

Any process in the abdomen or chest that irritates the diaphragm–a flat muscle between the abdomen and thorax–can cause pain on the top of the right shoulder blade [64]:

• Perforated stomach or duodenal ulcer. Symptoms: severe pain in the upper central abdomen or middle back [63].
• Ruptured appendix. Symptoms: lower central or right abdominal pain, nausea, vomiting, fever [67].
• Peritonitis–inflammation of the abdominal membrane–resulting in a subphrenic abscess–a collection of pus beneath the diaphragm. Symptoms: severe abdominal pain and tenderness and fever [67].
• Ruptured ectopic pregnancy with abdominal bleeding. Symptoms: a sudden, sharp pain in the lower left or right abdomen [64].
• Ruptured ovarian cyst. Symptoms: lower right or left abdominal pain [68].
• Spread of the pelvic inflammatory disease–a sexually transmitted disease–to the diaphragm. Symptoms: pain in the lower middle and upper right abdomen [66].
• Endometriosis. Symptoms: abdominal pain that is worse during ovulation and period [17,110].

Winging (Winged) Scapula

A shoulder blade that is out of place and sticks out–winging scapula–may result from holding the shoulder in a certain way to avoid pain or from damaged nerves, ligaments, tendons, muscles, bones or joints [72].

VII. SHOULDER PAIN

Conditions that can cause pain in the front or tip of the shoulder and in the upper arm rather than in the shoulder blade:

1. Rotator Cuff Tendonitis and Tear

Rotator cuff is a collective term for the muscles that move the shoulder. Inflammation of the rotator cuff tendons or impingement syndrome is common in sports with overhead arm movements, like tennis, golf, throwing (“thrower’s shoulder”), swimming (“swimmer’s shoulder”), lifting, and in jobs, like painting. A sharp pain in the front of the shoulder and dull ache in the outer side of the upper arm radiating to the hand, and spasm of the shoulder muscles usually develops over the months; initially it can be relieved by warming up but often worsens after the exercise (at night and in the morning) [96,102]. Trigger points in the muscles around the shoulder are common [106]. Pain is aggravated by lifting an arm over the levels of the shoulder or reaching forward [102]. Rotator cuff tear results in similar symptoms; chronic tear can cause a popping sound during moving a shoulder [96,97].

Shoulder overuse can also result in tenosynovitis–inflammation of the tendon sheets–or bursitis–inflammation of the subacromial bursa (a fluid filled sac on the top of the shoulder blade) with swollen red skin over the tip of the shoulder that is sore and warm to the touch [98,99]. Other causes of rotator cuff tendonitis or bursitis: systemic lupus erythematosus (SLE) [101], rheumatoid arthritis, gout and diabetes [99].

2. Calcific Tendonitis

Calcific tendinitis, a chronic inflammation of rotator cuff tendons of an unknown cause, can cause mild or severe and sharp pain in the shoulder and upper arm that comes and goes; other symptoms can include stiffness, catching or snapping in the shoulder [96,100].

3. Adhesive Capsulitis (Frozen Shoulder)

Adhesive capsulitis is an inflammation and thickening of a shoulder capsule, which wraps the shoulder joint. Causes can include shoulder immobilization, diabetes, hypothyroidism and hyperthyroidism. It can gradually develop in adults over 40 and cause deep ache in the front or the back of one shoulder and upper arm and severe stiffness with greatly limited range of motion of the shoulder [107]. The condition usually spontaneously resolve within 1-2 years.

4. Arthritis of the Shoulder Joint

Common types of the shoulder arthritis–inflammation of the shoulder joint–are rheumatoid arthritis, osteoarthritis, post-traumatic arthritis [95]. Symptoms can include severe pain in the shoulder and entire arm and, sometimes, swelling, warmth and redness of the shoulder and a popping sound when moving the shoulder; pain can become worse by weather change [96,97].

5. Shoulder Sprain and Subluxation

Shoulder sprain means overstretching or rupture of the shoulder joint capsula, which can be caused by falling on an outstretched arm, direct blow to the shoulder or overuse of the shoulder in sports, such as swimming, waterpolo, baseball, rugby, skiing, or heavy lifting [103]. Symptoms may include dull or sharp pain in the shoulder and upper arm, tenderness, shoulder joint instability, swelling, redness, warmth or bruising around the shoulder [103].

Shoulder joint subluxation means partial dislocation of the head of the upper arm bone from the shoulder joint caused by an injury of the shoulder joint capsula or cartilage (labrum) [104,105]. A tear of shoulder joint cartilage can result in painful clicking, popping or locking when moving the shoulder [96,97].

6. Avascular Necrosis

Avascular necrosis of the head of the upper arm bone (humerus) means bone death due to impaired blood supply. The cause is not always known but can include shoulder trauma, using corticosteroids, alcoholism, sickle cell anemia or AIDS. Symptoms include deep, throbbing, poorly localized pain around the shoulder that can radiate down to the elbow [111].

How to treat shoulder blade pain?

Rest

In an early, painful phase of a shoulder or shoulder blade injury, shoulder rest prevents further damage.

Ice Packs

To reduce pain, swelling or bruising, put ice in a plastic bag, wrap it into a cloth and hold over the painful area for up to 20 minutes, several times a day.

Heat Pads

Heat pads can help relieve pain in myofascial pain syndrome due to increased tension of the upper back muscles.

A Sling or a Shoulder Brace

A sling prevents the motion of the shoulder blade and shoulder and encourages their healing after a fracture, dislocation, rotator cuff injury or surgery. A doctor can prescribe a shoulder brace in shoulder joint instability and impingement syndrome [108]. When you stop wearing a sling, you need to start with shoulder exercises as instructed by your doctor, to prevent shoulder stiffness.

Scapular Stretching (Retraction) Exercises

Shoulder blade exercises are intended to relieve pain due to tension of the upper back muscles or to prevent stiffness of the shoulder joint after injury. Do not exercise immediately after an injury or until you experience severe pain.

Drugs

• Non-steroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, can be used to relieve mild to moderate pain.
• Steroids can be used to treat inflammation in disorders, such as rheumatoid arthritis, polymyalgia rheumatica [16], polymyositis [31] and brachial neuritis [60].

Surgery

Surgical treatment may be needed in pinched nerves, broken shoulder blade, calcific tendonitis, adhesive capsulitis and snapping scapula syndrome.

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• References +