Simon Johnson, Physiotherapist, from our Langwarrin Clinic, explains one of the common pain presentations he is asked to treat; a nasty stabbing pain behind the shoulder blade.
Physio’s treat people from all walks of life; people who have different jobs and enjoy participating in different sports. But from these different walks, common injuries present.
I have recently returned from a surf trip with a good friend of mine. We travelled to a small island called Simeulue off the coast of North Sumatra. For those who have never been on a surf trip, it basically involves surf, eat, sleep, repeat!
We surfed three times a day for around two hours each session. This was hugely strenuous on the body, particularly the shoulders and neck. It wasn’t long before I noticed my friend trying to squeeze or release the soft tissue on the inside of his shoulder blade. His symptoms started as a dull ache and progressed to a sharp stabbing pain a couple of days later.
This was a classic case of Cloward’s Sign: referral pain originating from inflammation of the neck, specifically C5/C6 facet joints. This was named after Dr Cloward, a neurosurgeon who first published a paper describing the link between the cervical spine and its referral distribution.
Pain behind the inside of the shoulder blade is a very common complaint among patients I see from all backgrounds swimming, surfing, golfers, office workers, VCE students just to name a few! This pain is very similar to sciatica pain in the leg which is really originating from the lower back.
So, why do you experience pain in the shoulder not the neck?
The nerves leaving the neck supply many tissues, such as the muscles surrounding the shoulder blade. When there is an injury to a tissue the
brain produces pain so that we protect the area from further damage. Referral pain is when the brain is alerted to an injury but misinterprets the source. It wrongly identifies the muscle as the injury site instead of the cervical spine which are both supplied by the same nerve!
What causes the neck to become inflamed?
In the case of my friend, we had spent three days with a lot of paddling. When paddling on a surfboard the neck is in an extended position (or head
tilted backwards). This neck position closes or compresses the tiny joints in the neck and if repeated or sustained over a long time may lead to overload of the joint and therefore inflammation. Similarly, these joints can be can irritated by bad posture while working on the computer, sleeping in a bad position, or simple jobs around the house such as hanging the wet washing.
What is the best management?
Firstly, it is critical that the diagnosis is accurate. With a
thorough assessment, a good physio will be able to differentiate between a true shoulder injury and referred pain from the neck. The key to management of referred pain from the neck is to guide the cervical joint back to normal function. Stop activities which are leading to overload of the joint, reduce protective muscle spasm with joint mobilisation and soft tissue release, and reduce inflammation with anti- inflammatory medications.
My friend was fortunate, he had is own private physio! His pain resolved quickly once I showed him ways to modify his paddling technique and asked him to sit and complete gentle stretches whilst waiting for waves. The neck responded well to some manual treatment and he was able to continue surfing pain free for the remainder of the trip. He also avoided meaninglessly poking and prodding his shoulder blade, which he now understands is NOT the origin of his pain!
If you’re experiencing any of these symptoms, don’t delay! Make an appointment at your local clinic.
Medical conditions affecting the heart or lungs can lead to chest and shoulder pain. Not all causes of chest and shoulder pain are medical emergencies. However, it is important that people speak with a doctor if they experience unexpected or severe chest and shoulder pain.
Shoulder pain can occur due to an injury or medical issue with the shoulder, such as a muscle strain. However, it can also occur due to a condition elsewhere in the body.
This article covers the causes and treatments for shoulder pain that occurs due to a condition in another part of the body and is accompanied by chest pain.
Chest and shoulder pain can be a medical emergency if it occurs due to a heart attack or pulmonary embolism.
People should seek emergency medical care if they experience:
- sudden, severe chest and shoulder pain
- chest and shoulder pain that worsens
- chest palpitations
- difficulty breathing
- dizziness or fainting
- extreme fatigue
- coughing up blood
People who have existing heart conditions should be especially conscious of any chest and shoulder pain.
Some causes of chest and shoulder pain can be cardiovascular, or related to the the heart. They include:
Angina
Angina is a symptom of coronary artery disease.
It refers to chest pain or discomfort that occurs when the heart muscle does not receive enough oxygen-rich blood.
According to the National Heart, Lung, and Blood Institute , angina manifests as a pressure or squeezing sensation in the chest.
While angina usually affects the chest, it can spread to the shoulders, neck, and jaw.
Other symptoms of angina include:
- burning or aching in the chest that starts behind the breastbone
- heartburn
- weakness
- sweating
- shortness of breath
Treatment
Depending on the cause and severity of angina, a doctor may recommend a combination of medications and diet and exercise changes.
Learn more about the treatment options for angina here.
Heart attack
A heart attack, also known as myocardial infarction, occurs when the heart does not receive enough blood.
This can happen when a blockage forms in an artery that supplies the heart with oxygenated blood.
Pain in the center or left side of the chest is the main symptom of a heart attack.
The Centers for Disease Control and Prevention (CDC) describe this type of chest pain as an uncomfortable pressure, squeezing, or fullness.
Other signs to look for include:
- pain or discomfort in one or both shoulders or arms
- pain in the jaw, neck, or upper back
- shortness of breath before or alongside the chest pain
- dizziness or fainting
- breaking out in a cold sweat
Compared to males, females are more likely to experience indigestion, nausea, or vomiting during a heart attack.
Learn more about the symptoms of a heart attack in females here.
Treatment
If a doctor suspects a heart attack, they may administer one or more of the following emergency treatments:
- aspirin to prevent blood clots
- nitroglycerin to improve blood flow to the heart
- oxygen therapy
If a doctor confirms a heart attack diagnosis, they will attempt to restore blood flow to the heart using either medication or surgery.
Learn more about the treatment for heart attack here.
Thoracic outlet syndrome
Thoracic outlet syndrome refers to a group of conditions that compress the nerves and blood vessels that pass through the space between the first rib and the collarbone. This is known as the thoracic outlet.
The National Organization for Rare Disorders note that neck injuries, repetitive movements, and poor posture can damage or compress the structures that pass through the thoracic outlet, which can lead to:
- pain, tingling, or numbness in the arm, hand, or fingers
- arm swelling
- a feeling of fullness or aching in the arm
- neck pain
- headache
- pale or white discoloration of the hand and fingers
Treatment
Treatments for thoracic outlet syndrome include:
- Over-the-counter (OTC) anti-inflammatory medications, such as ibuprofen
- thrombolytic drugs that break up blood clots
- surgery
- physical therapy
Learn more about the treatment options for thoracic outlet syndrome here.
Some lung conditions can cause chest and shoulder pain. They include:
Pulmonary embolism
Pulmonary embolism occurs when a blood clot that developed in a different part of the body travels to the lungs and blocks one of the pulmonary arteries.
This blockage restricts blood flow to the lungs, which can lead to lung tissue damage and reduce the level of oxygen in the blood.
The most common symptoms of pulmonary embolism are difficulty breathing and deep chest pain that worsens when breathing, coughing, or sneezing.
Chest pain related to pulmonary embolism can radiate into the neck and shoulder.
Other symptoms of pulmonary embolism include:
- rapid breathing
- increased heart rate
- cough with or without blood
- lightheadedness
- low blood pressure
- fainting
- sweating
Treatment
Treatment aims to prevent the clot from growing and to destroy the existing clot. It also aims to prevent new clots from forming.
A doctor can do this via medications.
A doctor also may perform medical procedures that remove or destroy larger clots.
Learn more about the treatment options for a pulmonary embolism here.
Pneumonia
Pneumonia refers to an infection of the lungs that causes swelling and fluid buildup in the air sacs of the lungs, also called the alveoli.
According to the American Lung Association, pneumonia can lead to a sharp, stabbing chest pain that worsens when breathing deeply or coughing. This chest pain can spread to the shoulder, upper chest, and neck.
Other symptoms of pneumonia include:
- fever
- chills
- cough with or without mucus
- shortness of breath
- fatigue
- loss of appetite
- nausea or vomiting
Treatment
Treatments for pneumonia include at-home management, medications, and emergency care for severe infections.
Learn more about the treatment options for pneumonia here.
Pancoast tumor
A Pancoast tumor is a tumor that develops in the top of the right or left lung. As the tumor grows, it invades nearby connective tissue, nerves, and muscles, leading to chest pain.
A Pancoast tumor can also spread to the upper ribs and upper vertebrae, which can lead to shoulder and arm pain.
The pain can be severe and persistent. A person may also notice tingling and weakness in the arm, hand, and fingers.
Treatment
The type of treatment for a Pancoast tumor depends on the size of the tumor and whether it has spread to other areas of the body.
Chemotherapy and radiation therapy can kill cancer cells and shrink tumors. A doctor may follow up these treatments with surgery.
Learn more about the treatment options for a Pancoast tumor here.
The following abdominal conditions can cause chest and shoulder pain:
Spleen injury
An injured or ruptured spleen can result in referred pain in the left shoulder, which is pain that travels from its original location to another part of the body.
Referred shoulder pain that relates to a spleen injury is known as Kehr’s sign.
Abdominal tenderness is another common sign of a spleen injury. Other symptoms include lightheadedness, blurred vision, and fainting.
Treatment
Doctors can treat a ruptured or injured spleen with surgical intervention or observation.
Learn more about the treatment options for a ruptured spleen here.
Ectopic pregnancy
An ectopic pregnancy occurs when an embryo implants outside of the uterus, potentially in the cervix, fallopian tubes, or even the abdomen.
A ruptured ectopic pregnancy can lead to abdominal pain that radiates to the chest and shoulder. This type of chest pain may feel similar to angina or a heavy pressure behind the chest wall.
Treatment
A doctor can treat an ectopic pregnancy with medications that stop cell growth, such as methotrexate. Otherwise, a doctor can surgically remove an ectopic pregnancy.
Learn more about the treatment for ectopic pregnancy here.
Liver disease
Liver diseases, such as cirrhosis and portal hypertension, can have adverse effects on the heart.
Abnormal liver function can lead to symptoms often associated with cardiovascular diseases, such as shortness of breath, swelling of the legs, and chest and shoulder pain.
Other symptoms of liver disease include:
- swelling and pain in the abdomen
- dark-colored urine
- pale-colored stool
- fatigue
- nausea or vomiting
Treatment
There are few treatment options available for advanced liver disease.
A liver transplant is often the only way to completely cure liver disease. Other treatments may help slow the progression of liver disease.
Gallstones
The gallbladder is a small organ located on the right side of the abdomen.
It stores and concentrates bile, a digestive enzyme produced in the liver. The highly concentrated bile inside the gallbladder can form hardened deposits called gallstones.
Gallstones do not always cause symptoms, but they can lead to severe, intense pain on the upper right side of the abdomen.
This pain can spread to the chest, shoulder, and upper back. Other symptoms of gallstones include fatigue, nausea, and vomiting.
Treatment
Doctors can remove small gallstones located in the common bile duct using a procedure called endoscopic retrograde cholangiopancreatography.
Doctors can also surgically remove the gallbladder.
Learn more about the treatment options for gallstones here.
The following neurologic conditions can contribute to chest and shoulder pain:
Nerve compression
A compressed, or pinched, nerve may result in chest and shoulder pain.
Symptoms of nerve compression vary depending on the type of nerve that is affected.
However, common symptoms include numbness, tingling, or a burning sensation that radiates from the site of injury to nearby areas.
Shoulder injuries, tumors, and inflammation can all put pressure on nerves, resulting in severe shoulder or arm pain, loss of sensation, loss of muscle control, or muscle weakness in the arm, hand, or wrist.
Cervical spine disease
The cervical spine refers to the upper portion of the spinal column.
This part of the spine contains nerves that send and receive information between the brain and the head, neck, shoulders, and upper limbs.
Cervical spine disease includes conditions and injuries that compress or irritate the cervical nerves, resulting in pain, stiffness, or numbness in the neck, shoulders, or limbs.
Cervical spine disease can result from neck or shoulder injuries due to motor vehicle accidents, falls, or sports-related accidents.
Cervical nerve compression can also result from age-related degenerative diseases, such as cervical spondylosis and osteoarthritis.
Herpes zoster
Herpes zoster, or shingles, is an infection that occurs due to the varicella-zoster virus (VZV).
Many people first encounter VZV as children and develop chickenpox. After the initial infection, VZV remains inactive inside bundles of peripheral nerve cells, called neural ganglia.
Shingles occurs when VZV reactivates years later.
Shingles usually causes a painful skin rash that appears on the face and chest.
Treatment
Treatments for nerve-related chest and shoulder pain vary depending on the underlying cause.
Treatments include:
- OTC anti-inflammatory drugs, such as ibuprofen and acetaminophen, to relieve pain and reduce inflammation
- corticosteroids to reduce inflammation
- antiviral medications to treat shingles
- physical therapy exercises and stretches to stretch and strengthen muscles that may be pressing on a nerve
A doctor seeking to diagnose and treat the causes of chest and shoulder pain will start the process by reviewing a person’s medical history for signs of heart disease or lung problems.
They may ask a person if they have a history of:
- heart disease
- heart attack
- infections
- pulmonary embolism
- smoking
- diabetes or metabolic syndrome
- liver or kidney disease
- autoimmune disorders
A doctor will want to know the exact type of chest and shoulder pain a person is experiencing. They may also ask how long a person has been experiencing this type of pain and whether this is the first incident.
Once the doctor knows more about a person’s medical history and symptoms, they will perform a physical exam.
During this exam, a doctor will take a person’s vital signs, such as their blood pressure, heart rate, body temperature, and weight. The doctor will also listen to a person’s heart and lungs.
If a doctor suspects an underlying heart or lung condition, they may order a combination of the following tests:
- chest x-ray, MRI, or CT scan to get detailed images of the heart or lungs
- electrocardiogram (EKG) to measure how fast the heart is beating
- echocardiogram to monitor how well the heart muscle is functioning
- stress test to see how well the heart functions during exercise
- blood tests to look for signs of heart attack or infections
- coronary angiography to identify a narrowed or blocked coronary artery
- biopsy of the lung tissue to look for signs of excess fluid accumulation in the pleura
Pain in the chest and shoulder can have several possible causes, including angina, heart attack, and lung or nerve issues.
People should seek immediate medical attention if they have sudden, severe pain in the chest and shoulder. Although chest and shoulder pain is not always a medical emergency, it is important that people see a doctor to determine the pain’s cause and their best options for treatment.