What is the appropriate management for a patient complaining of sharp pain behind the left shoulder blade for 3 days?

Management of Sharp Left Scapular Pain

For a patient with 3 days of sharp pain behind the left shoulder blade, begin with standard three-view shoulder radiography (AP internal/external rotation plus axillary or scapular Y view) to rule out fracture or dislocation, while simultaneously conducting a focused assessment to exclude referred pain from life-threatening visceral pathology. 1

Critical Red Flag Assessment

Before attributing this to musculoskeletal pathology, you must actively exclude referred pain sources:

• Screen for systemic symptoms including fever, chills, or constitutional symptoms that could indicate septic arthritis or infectious processes 2
• Assess for neurological symptoms including numbness, tingling, weakness, or radiation down the arm suggesting cervical radiculopathy 2
• Examine the abdomen for left upper quadrant tenderness, as splenic pathology can present as isolated left shoulder pain, particularly in young patients with recent physical exertion 3
• Consider pulmonary and subdiaphragmatic sources including lung neoplasms, pleural infections, or diaphragmatic irritation that refer pain through the phrenic nerve to the scapular region 4

Essential History Elements

Document these specific details to guide your workup:

• Pain location precision: Scapular region pain specifically suggests either referred pain from cervical spine/rotator cuff or visceral sources, rather than primary glenohumeral pathology 2
• Mechanism of injury: Even without recalled trauma, elderly patients can sustain osteoporotic fractures with minimal or unrecognized trauma 2
• Aggravating factors: Overhead activities, cross-body adduction, or throwing motions suggest rotator cuff pathology 2
• Age-based risk stratification: Patients over 35-40 years predominantly have rotator cuff disease or degenerative changes, while those under 35 more commonly have instability or labral pathology 2

Physical Examination Requirements

• Perform a complete neurovascular assessment of the upper extremity including pulse strength, capillary refill, sensation, and motor function 5
• Examine joints above and below the shoulder, specifically the cervical spine and elbow, as this is a commonly missed pitfall 5, 6
• Assess range of motion in all planes and perform provocative testing based on suspected pathology 6

Imaging Algorithm

Standard radiography is your initial imaging modality with three mandatory views 1:

• If radiographs are normal and patient is over 35 years: proceed to standard MRI without contrast (appropriateness rating 7/9) as rotator cuff disease predominates 1
• If patient is under 35 years with suspected instability: MR arthrography is preferred (appropriateness rating 9/9) 1
• If septic arthritis is suspected: ultrasound or X-ray guided arthrocentesis is the procedure of choice (appropriateness rating 9/9) 1

Common Pitfalls to Avoid

• Do not assume absence of recalled trauma excludes fracture, especially in older patients where minimal trauma can cause significant injury 2
• Do not focus solely on the shoulder when scapular pain is the primary complaint—this location demands consideration of referred pain sources 4
• Do not miss visceral pathology by failing to examine the abdomen and assess for systemic symptoms in patients with isolated shoulder complaints 3

Immediate Referral Indications

Refer urgently to appropriate specialist if you identify:

• Neurological deficits suggesting nerve compression or cervical pathology 1
• Unstable or significantly displaced fractures requiring surgical management 1
• Signs of septic arthritis requiring emergent drainage 1
• Suspected massive rotator cuff tears that benefit from expedited repair 1