What are Causes of Pain Between the Shoulder Blades?

Possible Reasons for Interscapular Pain

photo of man lying on stomach with shoulder blades protruding
What are the causes of pain between the shoulder blades?. istockphoto.com

Pain between the shoulder blades, otherwise known as interscapular pain, can have many causes. While this symptom is commonly caused by something as minor as a muscle strain, it's important to be aware that it may also be a sign of something more serious such as a heart attack or even lung cancer.  What are some conditions that can cause this pain, and what questions may your doctor ask you?

Anatomy of the Shoulder Blades

The muscles present in the region between the shoulder blades include the rhomboids and middle and lower trapezius muscles.

 These muscles play a key role in keeping the shoulder blades back and down. Beneath these muscles lie the thoracic spine, the thoracic aorta, part of the esophagus, part of the heart, and a portion of the lungs.

Possible Causes of Pain Between the Shoulder Blades

Pain may be felt in the shoulder blades from conditions located in this region, or can instead be referred pain – pain that is felt between the shoulder blades but arises from another area. Some possible causes of pain between the shoulder blades (not in order of frequency) include:

Muscle strain - The most common cause of pain between the shoulder blades is​ a muscle strain. This can result from poor posture (especially leaning forward with prolonged sitting or standing,) excess lifting, activities that involve twisting such as golf or tennis or even sleeping on a poor mattress.

Trauma - Conditions which may result in pain bewteen the shoulder blades following trauma commonly include acromioclavicular joint separation, and rotator cuff tears.

A shoulder separation is different from a shoulder dislocation which is felt more commonly in the shoulder joint.

Herniated or bulging discs Degenerative disc disease in the cervical spine and thoracic spine can cause referred pain to this region. It's not uncommon for people with disc disease in their neck to feel pain only in other regions, and this can result in a delay in diagnosis.

Other symptoms may include numbness of tingling or pain in one or both arms. Sometimes pain due to disc disease in the neck is positional, for example, it may improve or get worse with flexing or extending your neck.

Arthritis - Arthritis in the neck or even the ribs may cause interscapular pain. As with disc disease, arthritis in the neck may cause pain between the shoulder blades or other regions even in the absence of any neck pain.

Heart attack – Heart attacks, especially heart attacks in women, don't always begin with chest pain. In one study pain looking at people with heart attacks, 3 percent had pain confined to the area between the shoulder blades.This pain tends to be nagging and may be accompanied by chest pain, shortness of breath, or lightheadedness. This article discusses how the symptoms of heart attacks in women differ from those in men.

Cancer - Lung cancer, especially Pancoast tumors, may cause referred pain between the shoulder pain by pushing on nerves near the top of the lungs.

Other cancers which may cause pain in this region include esophageal cancer, mesothelioma, lymphomas, and liver cancer. Cancers which spread to the bones in the neck such as breast cancer, may also cause pain between the shoulder blades, sometimes without any other symptoms. 

Gallbladder disease - Referred pain from gallbladder disease often occurs as a stabbing pain between the shoulder blades, and may be associated with pain in the right upper quadrant of the abdomen and nausea. It commonly occurs after eating a fatty meal.

Nerve entrapment - Nerve entrapment such as in myofascial pain syndrome of the rhomboids can cause pain between the shoulder blades.

Acid Reflux --- Gastroesophageal reflux disease (GERD) may cause referred pain to the back in the region between the shoulder blades. Symptoms of GERD may also include chest pain, hoarseness, and difficulty swallowing. Not only can untreated GERD cause dicomfort, but is associated with the later development of esophageal cancer. Inflammation of the pancreas may also cause this type of pain due to irritation to the underside of the diaphragm.

Scoliosis - Scoliosis of the thoracic spine may cause pain in this region.

Thoracic aorta rupture or aortic dissection - The pain that goes along with a thoracic aortic dissection (when a tear in the wall of the blood vessel allows blood to leak between the walls of the aorta) is often rapid and very severe, and is a medical emergency. This is often felt as a sudden sharp and tearing pain in the upper middle back.

Pulmonary embolism - Pulmonary emboli occur when clots in the legs (deep venous thrombosis) break off and travel to the lungs. The pain is often sudden in onset, sharp, and may be associated with severe shortness of breath. It is often preceded by symptoms of blood clots in the legs incuding pain, redness, and swelling.

Thoracic vertebral compression fractures - Compression fractures, often due to osteoporosis, may cause interscapular pain.

Shingles - Shingles can cause pain nearly anywhere in the body, depending upon which nerve roots the virus affects, and may occur before a rash is noticed. The pain may be most pronounced in the region between your shoulder blades, but tends to concentrate on one side of the body or the otehr.

When to Call Your Doctor or 911

Some of the causes of pain between the shoulder blades are serious and can be life-threatening. If your symptoms are accompanied by shortness of breath, chest pain, lightheadedness, or even if you just have a "gut feeling" that something bad is happening in your body, call 911 right away. Don't wait. Many of the causes of pain discussed above are treatable with urgent medical treatment.

A few of the most serious conditions giving rise to pain in this area include heart attacks (myocardial infarctions), dissecting aortic aneurysms (a condition often found in men with Marfan's syndrome in which blood penetrates between the layers lining the aorta), and pulmonary emboli (blood clots (thromboses) in the legs which break off and travel to the lungs.

Otherwise, talk to your doctor about your pain even if you think there is a good reason why it is occuring. Pain is a symptom that is telling you something is wrong. That something could simply mean you are overusing a muscle, or it could mean that you need immediate medical attention. Since there are so many causes of pain in this region, including pain referred from other areas of the body, it's especially important to see your doctor if your symptoms are persisting. It is also worth noting that spinal pain in the thoracic area (between the shoulder blades) is often due to more serious conditions than pain which occurs in the neck or lower back. 

As a final note, make sure to be your own advocate in your health care. Even if your doctor does not think your symptoms are serious, if you do - and if the pain persists - get a second opinion. Doctors are human, and rare conditions can be difficult to diagnose. In addition, when you add up all of the rare conditions together, they are actually quite common. Listen to what your body is saying and persist in asking questions until you have an answer that satisfies you.

Questions Your Doctor May Ask About Pain Between Your Shoulder Blades

  • When did the pain begin?
  • Did the pain begin suddenly or more gradually?
  • How severe is the pain? It can help if you describe your pain on a scale of 1 to 10, with 1 meaning you have minimal pain, and 10 describing the worst pain you can imagine.
  • What other symptoms are you experiencing, such as chest pain, shortness of breath, unexplained weight loss, difficulty swallowing, pain in your jaw or arm pain?
  • Do you (or anyone in your family) have a history of disc disease or osteoporosis?
  • Is the pain burning in character, sharp or dull, stabbing or nagging?
  • Is there anything that makes the pain worse or makes the pain better?
  • Have you experienced any trauma?
  • Did you begin any new exercise?
  • Have you done any heavy lifting?
  • Do you have any risk factors for heart disease such as a family history, high cholesterol, or high blood pressure?
  • Do you or have you ever smoked?

Treatment

Treatment will depend on the underlying cause of your symptoms.

Sources:

National Institute of Health. MedlinePlus. Thoracic aortic aneurysm. Updated 05/27/14. https://medlineplus.gov/ency/article/001119.htm

O’Keefe-McCarthy, S. Women’s experiences of cardiac pain: a review of the literature. Canadian Journal of Cardiovascular Nursing. 2008. 18(3):18-25.

Sultan, H., and G. Younis-El-Tantawi. Role of dorsal scapular nerve entrapment in unilateral interscapular pain. Archives of Physical Medicine and Rehabilitation. 2013. 94(6):1118-25.

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