Interscapular Pain: Myofascial Causes, Trigger Points, and Effective Treatment

Interscapular pain - is one of the most common complaints associated with sedentary work, stress, and a sedentary lifestyle. In most cases, the underlying cause is myofascial dysfunction and trigger points in the muscles of the back and shoulder girdle. In this article, we’ll break down which muscles are most often responsible for the pain, how to identify trigger points, and which treatment approaches are most effective for relieving symptoms and preventing recurrence.
Eduard Konkin
Medical speciality: physical therapist
Work experience: 8+ years
Author
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Interscapular Pain: Definition and Why Muscles Are the Primary Cause

Interscapular pain most often presents as pain in the upper back and between the shoulder blades that occurs after prolonged sitting or static load. This condition is typically rooted in back muscle pain associated with overstrain and the formation of trigger points.
Shortening and tightening of the back muscles in the thoracic spine region impair blood circulation, restrict movement, and sustain the pain syndrome. Without specific treatment, this can:
  • become chronic back pain
  • create a sensation of a "stake in the back"
  • limit and restrict movement
  • make it difficult to take a full breath
  • alter posture (contributing to thoracic kyphosis)
  • contribute to the development of spinal osteochondrosis
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Interscapular Muscle Pain
The most common cause of interscapular pain is the formation of trigger points in the muscles of the thoracic spine.

Where Does It Hurt: Right, Left, or Center — What Pain Localization Tells You

The thoracic spine is a large area, and pain can localize to different regions. If pain occurs under the left shoulder blade, one might think of heart pain, the left lung, or pleura. If pain occurs under the right shoulder blade, one might think of the gallbladder or the right lung. If these organs were actually affected, the pain complaints would be accompanied by organ-specific symptoms — cough, shortness of breath (both on inhalation and exhalation), digestive disturbances, or cardiac dysfunction. Typically, these symptoms are absent — only unilateral pain is present.
Pain in the center of the back is commonly attributed to the spine and its joints (costovertebral and facet joints). It is believed that the joints and nerves of the thoracic spine can radiate along the rib and nerve pathway to the lateral part of the torso.
The feeling of stiffness and pain between the shoulder blades is most often caused by a muscular condition myofascial pain syndrome - rather than the spine or organs of the thoracic cavity.

Superficial or Deep Interscapular Pain: How to Distinguish Muscular Pain from Visceral Pain

Interscapular pain differs in depth: it may be superficial muscular pain felt in the skin and subcutaneous fat, or it may be perceived as deep visceral pain.
The back muscles are arranged in several layers — from the superficial trapezius muscle to the deep paravertebral muscles. Depending on which muscles are affected by trigger points, the depth of the pain sensation will also vary. Palpation of the muscles is essential to identify muscle bands and locate the source of pain.
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Palpation of a Trigger Point in the Trapezius Muscle
When palpating the affected muscles of the thoracic spine, pain upon pressure should be identified. These are the trigger points that cause discomfort.

Sharp, Aching, Burning, Pulling Pain — What the Nature of Symptoms Reveals

Pain in the middle of the back caused by trigger points can vary in character and often depends on the form and stage of myofascial pain syndrome, but it is typically an aching back pain.
When trigger points are activated by overexertion or exposure to cold, the character of pain may change: from pulling pain to a burning sensation, shooting pain in the back, cold, piercing, or constricting pain.
The frequency and periodicity of pain also change. Interscapular muscle pain begins with rare, mild episodes of discomfort, then the episodes occur more frequently and may progress to chronic pain syndrome that persists for months.
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Palpation of a Trigger Point Between the Shoulder Blades
Many people believe that a muscular condition means inflammation of the muscles. However, myofascial pain syndrome is a non-inflammatory pathology — pain between the shoulder blades is present, but there are no signs of inflammation.

Common Causes of Interscapular Pain: From Myofascial Pain Syndrome to Internal Organ Conditions

It is commonly believed that the main causes of interscapular pain are the spine and nerves, and less frequently, internal organs. Typically, imaging studies are performed and abnormalities in the vertebrae and intervertebral discs are found — in other words, spinal pathology.
Muscular and neurological causes are also considered, but they are evaluated together, and priority is given to the neurological origin of pain.
True neuralgias do occur, but they are extremely rare and, even when present, they cause pain in a different location — along the rib and the nerve pathway — not between the shoulder blades.
Referred pain from internal organs is also rare, but it can be identified by the presence of accompanying symptoms.
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Causes of Interscapular Pain: Trigger Points
The main cause of interscapular pain is muscular pain, without involvement of the spine, nerves, or internal organs.

Myofascial causes are the most common group when it comes to interscapular pain.

Myofascial pain syndrome is a condition affecting the muscular system and fascia of the back, characterized by the formation of localized muscle tightness (myofascial trigger points) . It is a distinct pathology of muscle tissue that creates painful points, which, if the condition becomes chronic and persists over time, can produce referred muscle pain.
Myofascial pain syndrome and trigger points in the back muscles relate to each other in the same way that multiple papules (pimples) form the condition of acne — multiple trigger points constitute myofascial pain syndrome.
In the thoracic spine, the muscles most commonly affected are:
  • Trapezius muscle
  • Rhomboid major and minor
  • Latissimus dorsi (localized muscle tightness in this muscle produces pain between the shoulder blades)
  • Iliocostalis thoracis muscle
  • Infraspinatus muscle
  • Multifidus muscles
Just as multiple pimples form the condition of a rash, so do multiple trigger points in the back form the condition known as myofascial pain syndrome.

Why Does Myofascial Pain Between the Shoulder Blades Appear?

The main cause of trigger point formation is chronic muscle overstrain. Muscle work requires a significant amount of energy. Under static load, this demand is constant, but blood supply cannot keep up — as a result, muscle cells experience hypoxia and become damaged.
Additionally, during stress, stress hormones are released, which excessively increase the excitability of the nervous system, leading to the development of muscle tension in the back — and these tensions are precisely the trigger points.
Many external factors can provoke trigger points and interscapular pain:
  • Exposure to cold (often described as "a muscle or the back was blown out")
  • Muscle fatigue (carrying a heavy backpack or bag)
  • Sedentary lifestyle (muscles require regular full contraction and elongation)
  • Prolonged computer work (office syndrome)
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Myofascial Pain Between the Shoulder Blades — The Presence of Trigger Points
It is important to distinguish between these conditions: trigger points are not muscle hypertonus, and not a spasm of the trapezius muscles.
In a spasm, the muscle is healthy but contracted due to a signal from the nerve. In a trigger point, the muscle tissue itself is damaged.

Thoracic Spine Problems

The spine is highly mobile in the cervical and lumbar regions, but relatively immobile in the thoracic region. Therefore, problems with the spine itself in the thoracic region are rare. Yes, MRI may reveal degenerative changes in the spine, but these are usually age-related norms and do not cause complaints.
Furthermore, over 97% of all protrusions and intervertebral hernias occur in the lumbar spine and neck — in the thoracic spine, they are extremely rare.
The term "thoracic osteochondrosis" is a collective one — it includes all changes and deviations from the so-called norm: disc degeneration, disc bulging, chondrosis. But again, the spine itself almost never causes pain in the thoracic region — even if the MRI report mentions nerve compression, facet joint arthrosis, or spinal curvature.
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How Pain Appears in the Spine and Between the Shoulder Blades
Changes in the spine develop as a result of muscular pathology. Muscles tighten and compress the vertebrae, reducing disc height — this leads to osteochondrosis, functional scoliosis, and postural disorders.
Muscles also influence posture, since body position in space is maintained by muscular activity.
Slouching is a result of damage to the muscles of the anterior torso (pectoral muscles and forward head position), while shoulder asymmetry can be caused by damage to the levator scapulae muscle — for example, from carrying a bag on one shoulder.
Long-standing myofascial pain syndrome can lead to:
  • Radicular syndrome of the thoracic spine (when neuropathic pain and sensory changes may radiate along the rib)
  • Chronic pain (pain may persist for years)

Neurological Causes of Interscapular Pain

Neuralgia in the thoracic spine is extremely rare. However, we will describe the mechanism by which nerve root entrapment in the thoracic spine develops, should it occur.
  • From muscle overload, trigger points form in the back muscles
  • The muscles become inelastic, hard, and excessively compress the spine
  • Myofascial back pain appears, which may radiate — this pain can already be confused with intercostal neuralgia
  • The already limited mobility of the thoracic spine and chest area is further reduced
  • The muscles compress the spine, causing nerve root entrapment and can contribute to disc herniation (this occurs in any part of the spine)
  • Herniation formation is a mechanical injury (similar to a compression fracture), leading to edema and inflammation. The inflammation involves nerve tissue, resulting in nerve compression and radicular syndrome
  • Additionally, the herniation itself, apart from the inflammation around it, can mechanically cause nerve entrapment
  • It is important to understand that nerve involvement (entrapment) is accompanied by a reduction or loss of its function — numbness, tingling, and sensory changes along the nerve pathway.
Even if neurological manifestations in the thoracic spine are present, they develop on the basis of muscular pathology. Muscles first cause shooting pain, and later lead to the formation of osteochondrosis and disc herniation.

When Pain Is Associated with Internal Organs

Muscles are not the only possible source of interscapular pain. There are also thoracic and visceral pains — that is, pain caused by internal organs (thorax meaning chest, viscera meaning internal organs).
It is important to consider that the thoracic cavity contains organs which, when affected, can produce somatic pain between the shoulder blades (soma meaning body).
Organs that can acutely cause such pain:
  • Heart disease — in angina or myocardial infarction, there may be pressing, squeezing chest pain that can radiate to the interscapular region
When organs of the thoracic or abdominal cavity are affected, pain between the shoulder blades may occur, but it will take a back seat to other complaints: chest pain, shortness of breath, digestive disturbances, and so on.
Pathologies of the lungs and pleura — in pneumonia, the leading complaints will be cough and fever (significant rise in temperature), shortness of breath, and pain during breathing. Pain complaints are less pronounced.
Diseases of the stomach and pancreas — the stomach is located below the mediastinum, but it can refer pain to the left interscapular region. However, the main complaints in gastritis and pancreatitis are in the epigastrium (just below the solar plexus, in the upper abdomen). Additionally, muscular pain is not related to food intake, whereas in gastritis, pain may appear after eating.
Diseases of the gallbladder — cholecystitis (inflammation of the gallbladder) can cause pain under the right shoulder blade, but the main pain is in the right hypochondrium.
Interscapular pain can originate from the spine and nerves, or from organs of the thoracic and abdominal cavities. But the most common and most frequent pain is pain from trigger points in the back muscles.

Symptoms Accompanying Interscapular Pain: How to Identify the Cause

Interscapular pain may be accompanied by other complaints:
  • Increased pain with breathing — during inhalation, some muscles contract (diaphragm and intercostals), while others must stretch. If active trigger points are present, they restrict stretching and relaxation of the muscles, causing pain upon stretching. This is why pain appears with inhalation or deep breathing due to trigger points.
  • The same mechanism applies to increased pain with movement and torso rotation — muscle tightness becomes irritated during rotation, causing discomfort and spreading pain.
  • Restricted mobility and stiffness (especially in the morning) — a typical manifestation of trigger points in the muscles. During the long night hours, the back muscles barely move, blood circulation slows, and metabolic waste products accumulate in the muscle cells.
  • Trigger points in the middle of the back can cause radiating complaints — pain radiating to the arm, a sensation of "crawling goosebumps," numbness in the hands. This is a typical complaint when the infraspinatus muscle is affected.
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Palpation for Interscapular Pain
Trigger points in the muscles of the middle back can cause non-pain complaints: paresthesias (altered sensation), mimicking neurological symptoms.
Specialists often mistakenly believe that pain is a sign of an inflammatory process. In reality — not every pain is inflammatory. Trigger points are a pathology, but a pathology without inflammation — meaning the condition exists, but there is no inflammation.
In rare cases, the clinical picture may be accompanied by true inflammation (infection, bacterial or viral). However, it can be identified by signs of complications: swelling, localized tenderness, redness, localized increase in temperature. These are symptoms that accompany inflammation.
Symptoms of interscapular pain can be divided into two groups: painful and non-painful. Trigger points can produce both types of complaints and can masquerade as other conditions.

Video: Treatment for Interscapular Pain

This video demonstrates 4 main treatment methods for myofascial pain between the shoulder blades — the most common type of interscapular pain.
The techniques shown include:
  1. Massage of trigger points in the muscles of the middle back
  2. Dry needling of muscle bands
  3. Passive stretching of contracted muscle fibers
  4. Joint mobilization

Interscapular Pain in Different Patient Groups

Interscapular pain can occur in different patient groups, but the mechanisms of its development are largely associated with the formation of trigger points in the back muscles. These localized areas of tension arise due to overload, postural disorders, and chronic muscle stress. Below are the main risk groups and factors contributing to the development of pain:

Pregnancy:
Pain between the shoulder blades during pregnancy is often caused by the protruding abdomen, which must be supported by tension in the back muscles. Trigger points develop in the rhomboid and trapezius muscles, leading to aching or pulling pain that worsens toward the end of the day.

Office workers:
The key factor here is sedentary work. Prolonged static posture and physical inactivity contribute to stagnation of blood circulation in the back muscles. This creates favorable conditions for the formation of trigger points, which manifest as a sensation of stiffness, burning, or a "lump" between the shoulder blades.
Myofascial pain between the shoulder blades affects all groups of people: young and elderly, athletes and office workers, pregnant women and men.
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The infraspinatus muscle causes pain between the shoulder blades
In athletes, pain is more often associated with muscle overload and sports injuries. Intense training without adequate recovery leads to microdamage to muscle fibers. In response, painful trigger zones form, especially in the upper back region, which can restrict mobility.

Diagnosing Interscapular Pain: How to Identify Myofascial Pain Syndrome

All diagnostics for interscapular pain can be divided into: physical, instrumental, functional, and laboratory. First, a general examination is performed, including medical history, complaints, causes and duration of pain, and provoking factors.
Depending on the complaints and clinical suspicion (red flags for interscapular pain), additional diagnostic methods are ordered:
Imaging diagnostics
  • MRI of the thoracic spine — prescribed in the presence of neurological manifestations, as well as for all patients over 40 years of age. It allows assessment of the spine itself, the presence of inflammatory pain, and soft tissue swelling.
  • X-ray of the spine — functional tests can be performed to evaluate the spine in flexion and extension, as well as to detect vertebral fractures.
  • CT of the spine — prescribed when there are contraindications to MRI, such as the presence of a metal implant. CT is focused on bony structures and does not visualize soft tissue in detail.
  • Ultrasound of the abdominal cavity — if there are complaints from the abdominal organs: pain, bloating, possible fever, changes in stool.
  • ECG — evaluates heart function if there are complaints of rhythm disturbances or breathing difficulties, as well as in cases of acute chest pain and suspected heart attack.
  • Echocardiography (EchoCG) — ultrasound of the heart for the same complaints. It can reveal valve insufficiency and myocardial thickness (heart muscle).
  • Blood tests — to clarify general health status and identify concomitant diseases.
Myofascial examination is the primary diagnostic method for interscapular pain. The physician must palpate the sources of pain and compare them with pain in other trigger points. The patient, in turn, must recognize their own pain complaints in the muscle bands.
Осмотр врача при боли между лопатками
How a Physician Should Perform an Examination for Interscapular Pain
Next comes the most important stage — myofascial examination.
  1. The physician performs palpation, shifts the skin fold, and assesses the range of motion in the muscles and joints of the back.
  2. First, the physician palpates healthy muscles (comparative palpation) to demonstrate pain from trigger points in other locations.
  3. Next, the physician searches for muscle bands in the area of the patient’s complaints. The ideal result is the identification of trigger points — the pain at these sites should resemble the pain experienced in the previously examined areas where trigger points are present.
  4. Then, diagnostic needling is performed to elicit a local twitch response (LTR), along with a deep massage test.
  5. If an LTR is present and the muscle is tender to deep massage but becomes softer and more elastic — these are indeed trigger points.
  6. The final stage of the myofascial examination is to determine what additional evaluations are needed:
  • Orthopedic examination — if there is skeletal asymmetry: scoliosis, pronounced thoracic kyphosis, or flattened lumbar lordosis.
  • Neurological examination — if there are sensory disturbances, rashes along the nerve pathway (shingles), or persistent weakness in specific muscles.

Treatment for Interscapular Pain: How to Relieve Muscle Spasms and Trigger Points

To effectively treat interscapular pain, myofascial pain syndrome must be treated. It is necessary to locate the affected muscle cells in the back muscles and restore them.
Here are the main treatment methods:
  1. Myopressure or myotherapy — a method of deep massage and manual therapy. Painful knots in the muscles are massaged for a long time, deeply, and with strong pressure until the muscle becomes soft, elastic, and painless to massage. This method is extremely painful.
  2. Trigger point dry needling (not to be confused with acupuncture). The trigger point is gripped between the fingers and punctured with a needle multiple times (the "sewing machine" technique).
  3. Forced muscle stretching (post-isometric relaxation) — a manual therapy method. Muscles are excessively contracted and cannot stretch to their full anatomical relaxation length. The physician stretches the affected muscle using external force.
  4. Physiotherapy: shockwave therapy for trigger points. The shockwave therapy device is positioned over the muscle tightness and delivers 200–400 impulses per site. It is important to target the trigger point precisely.
Trigger points in the treatment of interscapular pain are treated only mechanically: massage, dry needling, muscle stretching, and shockwave therapy. Medications are supportive, symptomatic methods.
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Dry Needling of the Latissimus Dorsi Muscle for Interscapular Pain
Let's examine other treatment methods for their effectiveness:
Medications: used only as symptomatic treatment.
  • NSAIDs may slightly reduce complaints, as there is no inflammation in myofascial interscapular pain.
  • Muscle relaxants do not treat the muscles, because a trigger point is not a spasm. In a trigger point, there is damage to muscle tissue, whereas in a spasm, the muscle tissue is healthy but tense. This is like a stomach ulcer not being a spasm of the stomach.
  • Painkillers help relieve pain if it is unbearable, but they do not replace the main treatment methods.
  • Warming compresses and ointments increase blood circulation, so pain mediators are more quickly eliminated from the affected muscle cells — but this effect is temporary.

Exercises for Interscapular Pain: Relieving Muscle Tension at Home

Exercises for interscapular pain are one of the effective methods for treating and preventing trigger points at home. Regular exercise helps relieve muscle tension, improve blood circulation, and eliminate local tightness in the back muscles that cause pain. It is especially important for people with a sedentary lifestyle to perform these exercises, as static posture is the most common trigger for the formation of trigger zones.
The exercises are based on self-massage and stretching:
Self-massage of the thoracic spine using massage balls: tennis balls, foam rollers, or rubber balls. Techniques include pressure application and longitudinal-transverse kneading. Duration: 20–30 minutes per session, with an interval of once every 3–5 days.
  • Stretching exercises are performed after self-massage. These include twists, bends, bringing the chin to the chest, bringing the arms together in front of the body and "hugging yourself," alternately bringing the arms behind the head.
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Twists for Interscapular Pain
It is important to understand: strengthening the back muscles and stabilizing the spine is not required. The goal is to treat the muscles, not to strengthen them or stabilize the spine.

Preventing Interscapular Pain: How to Avoid Myofascial Pain Syndrome

Prevention of interscapular pain plays a key role in preventing myofascial pain syndrome and the formation of trigger points.
To keep the back muscles in a healthy state, it is recommended to:
  • Monitor your posture. Proper posture is neutral posture — when the minimum number of muscles is involved in maintaining it. This reduces the risk of muscle overstrain and the formation of trigger points in the interscapular region.
  • Ensure workplace ergonomics directly affect the condition of the back muscles. The correct height of the desk and proper monitor position (at eye level) help avoid prolonged static load.
  • Engage in regular physical activity — an important part of back pain prevention.
Stretching exercises and self-massage of the muscles help improve blood circulation, relieve tension, and prevent the development of trigger zones. Even 2–3 short sessions per day of 5 minutes each can significantly reduce the load on the back.

When Interscapular Pain Is a Benign Muscle Spasm — and When to See a Doctor

In most cases, interscapular pain is a benign condition that does not pose a danger to life or health. Even though the pain caused by trigger points can be extremely severe — people rate it 8–9 out of 10 on the pain scale — it remains benign.
However, there are warning symptoms, danger signs, and serious conditions that warrant concern:
  • Cardiovascular diseases: angina and myocardial infarction
  • Aortic diseases: aneurysm or dissection of the thoracic aorta
  • Lung pathologies: pulmonary embolism, pneumonia
  • Gastrointestinal diseases: gastroesophageal reflux disease, gallstone disease, pancreatitis, cholecystitis
  • Tumors and metastases
However, these are rare conditions and they present with other complaints that are more prominent than the back pain.
With interscapular pain, one must always be vigilant for serious diseases, but at the same time, it is essential to perform diagnostics for myofascial trigger points — as the primary culprit of pain in the thoracic spine.

Frequently Asked Questions About Interscapular Pain

1. How to distinguish muscle pain from spinal problems?
The best way is to perform palpation and identify trigger points, conduct diagnostic dry needling, and also use tapping and percussion to determine whether pain is present in the spine itself.
2. Can stress cause pain in the upper back?
Yes. Stress leads to an increase in stress hormones, which increase muscle tension and lead to the formation of trigger points that cause pain.
3. Does massage help with interscapular pain?
Yes, massage treats trigger points. What matters is the dosage of massage: force of impact, depth, technique, and duration. The massage technique is called myopressure.
4. What examinations are necessary for chronic interscapular pain?
It is important to perform a general examination (which will indicate what additional diagnostic methods are needed), and most importantly — an examination to identify trigger points (myofascial examination).
5. Can I eliminate trigger points on my own?
Yes, you can. But the question "can it be done" and "will it work for you specifically" are different questions. The best approach is to use firm rubber massage balls and roll out one trigger point for at least 3–4 minutes.
6. What exercises help relieve back muscle spasm?
It is important to understand that spasm and trigger point are different conditions. What is commonly referred to as a spasm is usually a trigger point. Therefore, exercises should focus on kneading (self-massage) and stretching of the affected muscles.

Sources and References

List of Sources and References:
  1. Travell J.G., Simons D.G., Simons L.S. Myofascial Pain and Dysfunction: The Trigger Point Manual. 1999.
  2. Bron C., Dommerholt J.D. Etiology of Myofascial Trigger Points. Current Pain and Headache Reports, 2012.
  3. Gerwin R.D. Diagnosis of Myofascial Pain Syndrome. Physical Medicine and Rehabilitation Clinics, 2014.
  4. World Health Organization (WHO) WHO Guideline for Non-Surgical Management of Chronic Low Back Pain. 2023.
  5. American College of Physicians Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain. 2017.
  6. Mayo Clinic Upper Back Pain: Causes and When to See a Doctor.
  7. Cleveland Clinic Thoracic Back Pain: Symptoms, Causes and Treatment.
  8. McGill S.M. Low Back Disorders: Evidence-Based Prevention and Rehabilitation. 2016.