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Pain between the spine and the shoulder blade, or tucked underneath the blade where a hand cannot reach, is one of the more frustrating places to hurt. If you searched for "pinched nerve in shoulder blade Montgomery AL," there is a good chance you have already pressed on the spot or had it worked on, and found that it changed very little.
That detail is a clue. When an irritated nerve is involved, the sore spot is often where the pain is felt, not where the problem sits.
In my office the first question is the same every time: is this pain coming from the muscle and joint tissue at the spot that hurts, or from a nerve being irritated somewhere else? The two answers lead to different examinations and different conclusions, and telling them apart is what this post covers.
"Pinched nerve" is the phrase most patients use, and it is a fair description of the sensation. Clinically, it usually refers to irritation or compression of a spinal nerve root. The nerve root is the short segment of nerve that branches from the spinal cord and exits between two vertebrae, the stacked bones of the spine, on its way out to the body.
When a root is irritated and symptoms travel along the path that nerve supplies, the clinical term is radiculopathy. That means a problem at the nerve root that shows up elsewhere along the nerve's route. In the neck it is called cervical radiculopathy.
Most often the root involved exits the cervical spine, the vertebrae of the neck. Less often it exits the upper thoracic spine, the section behind the chest. A root can be irritated by a narrowed exit space, a disc bulge that crowds it, or changes at the joint edges of the vertebrae.
Here is the idea that surprises most people. Nerve roots in the lower neck supply muscle and skin around the shoulder blade, as well as the arm and hand. When one of those roots is irritated, pain can be felt around or under the shoulder blade while the neck itself feels normal, with no stiffness and no ache.
Think of a flickering lamp. The lamp is where you see the problem, but the fault may be in the wiring behind the wall. Pressing on the lamp tells you nothing about the wiring. This is why pressing on and massaging the painful spot sometimes changes very little: the tissue under your fingers may not be the source.
It is also why I examine the neck for a shoulder blade complaint. My neck and shoulder pain care starts from where the signal originates, not only where it is felt.
How referred pain differs from local tissue pain. Local tissue pain comes from the irritated tissue itself. A strained muscle or a loaded joint is tender where it hurts, and the pain follows what is done to that tissue.
Referred pain works differently. Each nerve root supplies a map of skin and muscle. The skin territory is called a dermatome, an area of skin supplied by a single nerve root. The muscle territory is called a myotome, the group of muscles that same root activates. Irritation at the root can be experienced anywhere along that map, including places far from the neck.
The same principle applies elsewhere in the body. When symptoms travel into the hand, the wrist is not always the origin, which I describe in my perspective on carpal tunnel syndrome as another example of a nerve problem felt away from its source.
One candid point: the two can coexist. Muscles around an irritated nerve often tighten and guard, so a patient can have both at once.
The table contrasts the two presentations. No single row decides anything. I look for a pattern across all of them.
| What I ask about | More typical of nerve irritation | More typical of muscle or joint tissue | |---|---|---| | Quality of the pain | Burning, electric, sharp, shooting | Deep, dull, aching, tight | | Numbness, tingling, pins and needles | Often present, following a nerve path | Uncommon, and usually vague when present | | Arm or hand involvement | Symptoms may travel into the arm or fingers | Pain usually stays local | | What makes it worse | Neck movement, looking up, turning the head, coughing or sneezing | Direct pressure, use of a specific muscle, a sustained position | | What changes it | Certain neck or arm positions may shift the symptoms | Resting the muscle or changing the load on it | | Pressing on the painful spot | Often does not reproduce the pain | Usually reproduces the pain | | Morning versus end of day | May be present on waking and track neck position more than the clock | Often builds with use through the day | | Measurable weakness | May appear in the muscles one root supplies | Pain can limit effort, but weakness rarely follows a root pattern |
Quality matters because nerve tissue tends to report in sensory language such as burning or shooting, while muscle and joint tissue tend to report in deep, dull terms. Numbness and tingling are signals from the nerve itself, and where they appear on the arm or hand suggests which root to suspect.
Pressing on the spot is the row patients find most telling. If firm pressure reproduces the exact pain, local tissue is a strong candidate. If the spot is sore but pressure does not reproduce the pain, or a head turn, cough or sneeze provokes it instead, I look toward the neck. Coughing and sneezing briefly raise pressure inside the spine, which can stir up an irritated root.
Weakness can be measured rather than described. Pain limits effort in almost any sore muscle, but weakness that follows the muscles of a single root when I test them one at a time is a different finding.
Postural and mechanical contributions, such as how sustained positions load the shoulder, are covered separately in can poor posture cause shoulder pain, so I do not repeat them here. When the examination points to the joint or rotator cuff instead of a nerve, that is a different assessment, described in how I examine persistent shoulder joint pain.
Diagnosis comes before treatment. For shoulder blade pain, my sequence is:
Only after these steps do I state a conclusion about whether nerve, muscle, joint or a combination is driving the pain. If the findings fall outside what I should be managing, I refer the patient to a physician.
Some presentations call for medical assessment rather than a chiropractic appointment. Please see a physician promptly for:
Shoulder blade pain accompanied by chest tightness, breathlessness, jaw pain or sweating needs emergency medical assessment. Call 911 rather than booking an appointment. Pain in this region can come from the heart, lungs and other organs, which is why I never assume a shoulder blade complaint is musculoskeletal.
Yes, it is possible. A root in the lower neck supplies tissue around the shoulder blade, so irritation at the root can be felt there. Muscle and joint tissue can produce similar pain, so the examination is how I determine which is happening in a given person.
If the source is a nerve root in the neck, the tender area under your fingers is where the pain is felt, not where it starts.
No. Some patients have pain alone. That is why I test sensation, strength and reflexes instead of relying on the story alone.
Not automatically. I take in-house digital X-rays when the history and physical findings indicate that seeing the bones would add useful information. The image shows bone, not nerve, so it is read alongside the examination.
No. Muscle, the joints of the upper back and the shoulder joint itself can all be the source, and some causes are not musculoskeletal at all. That is why the red flags above matter.
If you have pain between or under the shoulder blade and want to know whether a nerve, muscle or joint is behind it, I am at Chiropractic Care Clinic, 2569 Bell Rd, Montgomery, Alabama. Call (334) 997-7463 or request an appointment online.
I will examine you, explain what the findings mean and tell you plainly if you should see a physician instead.
