Pain Between the Shoulder Blades: When It Is Muscle, and When Heart, Oesophagus or Gallbladder

The thoracic spine joins twelve vertebrae to the ribs, forming a stiffer structure than the neck or lower back. Between the shoulder blades lie the rhomboid and trapezius muscles and the spinal extensors, and beneath them the costovertebral and intervertebral joints. Any of these structures can be the source of pain: overload from sedentary work, a sudden movement, holding one position for a long time, as well as reflex pain radiating from the neck.

Thoracic spine pain is common, although less studied than neck and lower back pain. In the systematic review by Briggs et al. (BMC Musculoskeletal Disorders, 2009) the proportion of people with pain in this region varied considerably between studies and depended on the definition: one-year prevalence ranged from 3.5% to 34.8% and lifetime prevalence from 15.6% to 19.5%. The authors stressed that thoracic spine pain is a common problem in the general population, and that evidence for a link with biopsychosocial factors (including concurrent pain in other regions, posture and psychological factors) is limited.

Why does pain show up here? The internal organs of the chest and abdomen have sensory innervation that reaches the spinal cord at the same levels as the nerves from the spine and the skin of the back. The brain cannot precisely locate the source of such a signal and may 'place' the pain in the back — this phenomenon is called referred pain. That is why the same area between the shoulder blades is a classic site of pain both in muscle overload and in diseases of internal organs.

No single feature settles the matter, but a set of clues from the history and examination helps the doctor. Mechanical pain (from muscles and joints) usually changes with movement, breathing or position, may be tender when a particular spot is pressed and does not increase with exertion of the body as a whole. Pain referred from organs is usually not reproduced by movement or touch, may increase with exertion (heart) or after a meal (oesophagus, gallbladder) and is often accompanied by general symptoms.

The table is a guide only: in individual people symptoms may look different, and the division does not replace a medical examination. It also happens that mechanical pain coexists with an organ disease — which is why a single feature is not enough to exclude heart disease.

Whether the description of pain alone can distinguish cardiac from non-cardiac pain was the subject of a review published in JAMA. Its results are worth knowing because they show both the usefulness of the history and its limits.

Two practical conclusions follow from these data. First, pain between the shoulder blades that clearly changes with movement, breathing or touch is statistically less likely to be cardiac — but 'less likely' does not mean 'excluded'. Second, pain related to exertion and radiating to the arms or shoulders is more likely to be cardiac. Neither of these elements replaces an electrocardiogram and a troponin measurement, which we discuss in our knowledge base entries on the resting ECG and cardiac markers.

The common picture of a heart attack is severe pain behind the breastbone. Data from a large registry show that this is a simplification: a considerable proportion of patients have no chest pain, and their symptoms may be less obvious, including discomfort in the back, breathlessness or weakness.

The conclusion for a person with pain between the shoulder blades is this: the absence of chest pain does not exclude a heart problem, especially in older people, those with diabetes and women. At the same time this does not mean that every back pain is a heart attack — the vast majority of pains between the shoulder blades are harmless. The point is vigilance towards a combination: new, unexplained pain plus risk factors (age, diabetes, hypertension, smoking, heart disease in the family) plus accompanying symptoms (breathlessness, sweating, nausea, weakness).

The guideline on the evaluation of chest pain (Gulati et al., 2021, AHA/ACC) describes management based on risk assessment and available tests, stressing shared decision-making with the patient. It does not, however, replace urgent assessment if the pain is new, severe or accompanied by warning symptoms.

Aortic dissection is a rare but life-threatening cause of sudden pain, which may be felt between the shoulder blades. The classic description is of abrupt, very severe, tearing pain that reaches its peak at once rather than building gradually. The IRAD registry, the largest collection of such cases, shows that the picture can be misleading.

What does this mean for the reader? Sudden, very severe pain between the shoulder blades that 'shot out' within seconds or minutes does not resemble typical muscle pain and is an indication to call an ambulance at once — even if there is no chest pain and earlier heart tests were normal. The risk is higher with untreated hypertension, known connective tissue diseases and aortic dilatation, but the diagnosis is made by imaging (usually computed tomography), not from the description alone.

Gastro-oesophageal reflux and oesophageal motility disorders can cause pain behind the breastbone radiating to the back; typically it is linked with a meal, lying down or bending over and is sometimes eased by acid-reducing drugs. We write about reflux and its diagnosis in our knowledge base. It should be remembered, however, that oesophageal pain can resemble cardiac pain, so in people with risk factors or new, severe pain the heart is excluded first.

Gallstone disease is classically described as pain in the right upper abdomen or epigastrium that can radiate to the back under the right shoulder blade, comes in attacks (often after a fatty meal) and lasts from tens of minutes to several hours. Detailed guidelines on the diagnosis and treatment of gallstones were published by the European Association for the Study of the Liver (EASL, 2016). Our article on diet in gallstone disease also relates to gallstones. Pain lasting many hours, with fever and chills or with jaundice, needs urgent assessment because it may mean inflammation of the gallbladder or bile ducts.

Pain from the lungs and pleura (pleurisy, pneumonia, pulmonary embolism) usually worsens on deep breathing and coughing. Pulmonary embolism is an emergency: sudden breathlessness, pain on breathing, rapid pulse and sometimes coughing up blood, especially after prolonged immobilisation, surgery or in people with venous thrombosis. Here too the description of the pain is not enough for a diagnosis.

The order of tests depends on the clinical picture. When mechanical pain is suspected (typical history, pain dependent on movement, normal neurological examination and no warning signs) the doctor usually limits themselves to a physical examination, and imaging is not needed at the start. When an organ cause is suspected, tests are planned in line with the suspicion.

We write about the possibilities and limits of imaging tests in our entries on ultrasound, computed tomography and MRI. It is important to remember that a normal result of one test (for example an ECG taken when there is no pain) does not exclude all diseases — which is why the doctor combines the history, examination and results. In aortic dissection the initial chest X-ray and ECG may be normal, as the IRAD registry showed.

We also discuss general principles of strengthening and activity in the context of neck pain and in the article on exercise in chronic lower back pain — for thoracic spine pain the same approach applies: gradual movement instead of rest. There are, however, few well-documented treatment methods specific to the interscapular region, and most recommendations rest on clinical experience and data from other spinal regions.

See a doctor (within days, without sudden urgency) if the pain lasts longer than a few weeks, is getting worse, wakes you at night regardless of position, is accompanied by unintentional weight loss, difficulty swallowing, gait disturbance, or if right upper abdominal pain regularly returns after meals. The doctor will assess the need for tests and possible referral to a cardiologist, gastroenterologist or physiotherapist.

The great majority of pains between the shoulder blades are harmless and result from overload, but this is also an area in which pain can be referred from internal organs. Knowing a few warning features helps avoid both unnecessary fear and dangerous dismissal. When anything raises doubt — new, severe, unexplained pain — it is better to use a medical assessment.