Differential Diagnosis for Scapula Pain Worse in the Morning

• Single most likely diagnosis
  • Subacromial Bursitis or Rotator Cuff Tendinitis: Morning stiffness and pain in the scapula region can be indicative of inflammatory conditions such as subacromial bursitis or rotator cuff tendinitis. These conditions are common and often worsen with rest, explaining the increased pain in the morning.
• Other Likely diagnoses
  • Scapulothoracic Bursitis: Inflammation of the bursae located between the scapula and the thoracic wall can cause scapular pain, especially if the patient has been in a position that irritates these bursae during sleep.
  • Muscle Strain: Strains in the muscles around the scapula, such as the trapezius, rhomboids, or levator scapulae, can cause pain that is worse in the morning due to overnight stiffness.
  • Thoracic Outlet Syndrome: Compression of the nerves and/or blood vessels that pass through the thoracic outlet can cause pain in the scapular region, which might be exacerbated by certain sleeping positions.
• Do Not Miss (ddxs that may not be likely, but would be deadly if missed.)
  • Pulmonary Embolism: Although less common, referred pain from a pulmonary embolism can sometimes be felt in the scapular region. Morning worsening could be due to increased venous stasis during sleep.
  • Myocardial Infarction: In rare cases, myocardial infarction can present with referred pain to the back, including the scapular area. The pain might worsen in the morning due to increased cardiac demand after waking.
  • Spinal Cord Compression or Cauda Equina Syndrome: These are neurological emergencies that can present with back pain, including scapular pain, which may worsen in the morning due to prolonged recumbency.
• Rare diagnoses
  • Tietze's Syndrome: An inflammatory condition of the cartilages and surrounding tissues of the ribs, which can cause chest and scapular pain that might be worse in the morning.
  • Sickle Cell Crisis: In patients with sickle cell disease, a crisis can cause severe pain episodes, including pain in the scapular region, which might have a morning worsening pattern due to increased blood viscosity during sleep.
  • Pancoast Tumor: A type of lung cancer located at the apex of the lung, which can cause shoulder and scapular pain due to local invasion of the brachial plexus and adjacent structures. Morning worsening could be due to increased pain sensitivity after rest.