What is shoulder pain?
Shoulder pain is a common problem with a number of different causes. It's often a symptom of another problem.
There are a number of reasons why you might be experiencing shoulder pain, which include:
- poor posture
- – a painful condition that reduces normal movement in the joint and can sometimes prevent movement in the shoulder altogether
- rotator cuff disorders – the rotator cuff is a group of muscles and tendons that surround the shoulder joint and help to keep it stable
- shoulder instability – where the shoulder is unstable and has an unusually large range of movement (hypermobility)
- acromioclavicular joint disorders – conditions that affect the acromioclavicular joint, which is the joint at the top of the shoulder
- in the shoulder joints
- a broken (fractured) bone, such as a or
- sternoclavicular joint dislocation – when the breastbone moves out of its normal position next to the collar bone
In some cases, pain in the shoulder isn't caused by a problem in the shoulder joint, but by a problem in another area, such as the neck, that is felt in the shoulder and upper back.
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.Treating shoulder pain
There are things you can do yourself to treat shoulder pain, including using painkillers such as
, or ice packs to reduce inflammation and relieve pain. Avoiding activities that may aggravate your symptoms will also help.Depending on the cause of your shoulder pain, you may need further treatment, such as:
- injections of – a type of medication that contains hormones
- surgery (in some cases)
In most cases, shoulder disorders improve over time if treatment advice is followed.
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.When to see your doctor
You should see you doctor if your pain is the result of an injury, it's particularly bad, or there is no sign of improvement after a couple of weeks.
Go to an emergency department if:
- the skin over your shoulder is red or feels hot, or you have a fever or feel unwell with the pain
- you have had an injury and the pain is severe or your shoulder looks different from your other shoulder
See a doctor urgently if:
- your arm or hand feel weak
- you have numbness or tingling in your arm or hand
- your shoulder is swollen or you can feel a lump
- you also have pain in other joints in your body
- you have had any night sweats or weight loss
- you feel short of breath, have a cough or cough up blood
Shoulder pain can be a long-term problem: up to half of people still have symptoms after 18 months. A correct diagnosis will ensure you receive the right treatment.
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.Shoulder pain causes
Shoulder pain can be caused by a minor injury, bad posture, or an underlying health condition.
Conditions that can cause shoulder pain include:
- rotator cuff disorders
- shoulder instability
- acromioclavicular joint disorders
- a or
- sternoclavicular joint dislocation
Frozen shoulder, also known as adhesive capsulitis, is a painful, persistent stiffness of the shoulder joint which makes it difficult to carry out the full range of normal shoulder movements.
Frozen shoulder occurs when there is thickening, swelling and tightening of the flexible tissue that surrounds your shoulder joint. This leaves less space for your upper arm bone (humerus) in the shoulder joint, and makes movement stiff and painful.
You may find it difficult to carry out everyday tasks such as dressing, driving and sleeping comfortably. Some people are unable to move their shoulder at all.
The symptoms of frozen shoulder can vary greatly but tend to advance slowly. They are usually felt in three stages spread over a number of months or years.
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.Risk factors for frozen shoulder
Most cases of frozen shoulder occur in people aged over 40. The condition is more common in women than in men.
The exact cause of frozen shoulder is not fully understood. However, there are several risk factors that make developing frozen shoulder more likely. These include:
- shoulder injury or surgery – keeping your arm and shoulder still for long periods of time, for example while you recover from an arm injury or arm surgery
- diabetes – if you have diabetes, a condition caused by too much glucose in the blood, you are more likely to develop frozen shoulder, but the exact reason for this is unknown
- other health conditions – these include heart or lung disease, an (hyperthyroidism) and (a condition that causes one or more fingers to bend into the palm of your hand)
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.Rotator cuff disorders
The rotator cuff is the group of muscles and tendons that surround the shoulder joint. Tendons are the tough, rubbery cords that link muscles to bones. The rotator cuff keeps the joint in the correct position, allowing it to move in a controlled way.
Different types of rotator cuff disorder can cause different symptoms, but common features include:
- pain that is worse during activities that involve your arm being above shoulder level – for example, when brushing your hair
- pain when you move your arm in an arc away from your body
- pain on the front and side of your shoulder
- pain at night
The different types of rotator cuff disorders and their slightly different causes are explained below.
Tendonitis and bursitis
is inflammation (swelling) of a tendon. is inflammation of a bursa. A bursa is a small, fluid-filled sac usually found over the joints and between tendons and bones.Rotator cuff tendonitis and bursitis are usually the result of irritation and inflammation caused by a shoulder injury or overuse of the shoulder. For example, these conditions may affect someone whose job involves a lot of overhead lifting, or an athlete who competes in throwing sports, such as the javelin or discus.
If there is any kind of injury to the shoulder joint, the tendons or bursa may become inflamed. This means there is less space within the joint for the tendons and muscles to move. If the tendons, muscles or surrounding tissue become trapped between the bones in the shoulder, any repeated movement will irritate them.
Tendonitis and bursitis often occur together. When the tendons or bursa are trapped between the bones it is often known as "impingement syndrome".
If the tendon is repeatedly scraped against the shoulder bones, it can gradually weaken and will sometimes tear.
Tears
A torn muscle or tendon will cause severe pain and possible weakness in your arm and shoulder. Some people may also feel a popping sensation when they move their shoulder.
Tendon tears are most common in people aged over 40. Tears that affect younger people are usually caused by an accident. In older people, tears are often caused by impingement syndrome.
It is estimated that around half of people over the age of 60 may have partial or complete rotator cuff tears. This is because your tendons become weaker as you get older.
Rotator cuff syndrome
The term "rotator cuff syndrome" is used to describe any type of damage to tendons in the rotator cuff, including complete tears.
Shoulder instability
The shoulder joint is a ball-and-socket joint. The top of your upper arm bone (humerus) is the ball, which fits into the socket of your shoulder blade.
Shoulder instability occurs when the ball part of the shoulder joint does not move correctly in the socket. This can range from a slipping or "catching" feeling in your shoulder to a full
where the ball comes completely out of the socket.The symptoms of shoulder instability can sometimes be vague. People with shoulder instability often describe symptoms that are similar to having a "dead arm", such as:
- tingling
- weakness
- numbness
- shoulder fatigue
- a clicking, locking or popping sensation
If the shoulder is dislocated (where the ball has come out of the socket), symptoms can include:
- severe pain
- the arm being visibly out of position
- muscle spasms where the muscles contract painfully
- limited movement
Types of shoulder instability
Shoulder instability can be either:
- traumatic – the shoulder is forced out of place by a sudden impact
- atraumatic – the shoulder gradually moves out of place over time
Traumatic shoulder instability is often the result of an accident. Atraumatic shoulder instability tends to occur as a result of repetitive arm movements, such as throwing or swimming. Shoulder instability usually occurs in people aged under 35.
Acromioclavicular joint disorders
The acromioclavicular joint is the joint at the top of your shoulder (not the ball-and-socket joint). Possible acromioclavicular joint disorders include:
- tearing or stretching the ligaments in your acromioclavicular joint – ligaments are the tough bands of connective tissue that link two bones together at a joint
- partially or completely dislocating your acromioclavicular joint
Symptoms of acromioclavicular joint disorder include:
- pain in the joint
- limited movement of the joint
- pain on the top of the shoulder
If the acromioclavicular joint is dislocated it may also look visibly out of position.
Risk factors for acromioclavicular joint disorders
Acromioclavicular joint disorders are more common in men and those between the ages of 20 and 50.
People who play contact sports such as rugby have an increased risk of developing acromioclavicular joint disorders. They are also more likely to occur in people who have fallen on their shoulder – for example, during a skiing accident.
Sternoclavicular joint dislocation
The sternoclavicular joint is where the clavicle (collarbone) meets the breastbone (sternum). A sternoclavicular joint dislocation happens when these bones move out of alignment with each other. This can be caused by a blow to the shoulder, which may push the collarbone forward (an anterior dislocation) or backward (a posterior dislocation) from its usual position.
Symptoms of sternoclavicular joint dislocation can include:
- pain around the joint
- swelling, bruising and tenderness over the joint
- limited range of motion of your arm
- a crunching or grinding sound when you try to move your arm
Diagnosing shoulder pain
Your doctor may be able to diagnose the cause of your shoulder pain by discussing your symptoms with you and examining your shoulder. In some cases, tests may be needed.
As well as asking exactly where the pain is, your doctor will also need to know whether:
- you have had any recent injuries
- anything makes the pain feel better or worse
- the pain is worse at night
- the pain came on gradually or suddenly
- the pain is affecting your everyday life – for example, at work or when exercising
- you have any other symptoms
Physical examination
Your doctor will probably carry out a physical examination of your shoulder area. They will:
- compare your shoulders
- check for any redness, swelling or bruising
- check whether your joint is dislocated (whether the joint has come out of its correct position) – if it is, your shoulder will be in an unusual position
- feel your shoulder bones and joints to see whether this causes any pain
Arm movements
Your doctor may also ask you to do some specific arm movements – for example, placing your hands on the back of your neck and pointing your elbows out to the side. The type of movements that cause pain will help your doctor to determine the underlying cause.
Investigations
Further investigations are not usually necessary. However, if you do need any imaging tests to examine your shoulder in more detail, your doctor may refer you to your local hospital. You may also need some blood tests. These are explained below.
X-ray
You may have a shoulder X-ray if the inside of your shoulder joint needs to be examined to rule out other damage. An X-ray uses radiation to detect problems with your bones.
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for more information about the procedure.Magnetic resonance imaging (MRI) scan
A magnetic resonance imaging (MRI) scan uses strong magnetic fields and radio waves to produce a detailed image of the inside of your body.
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for more information about the procedure.Blood tests
A sample of your blood may be tested to rule out conditions that can cause shoulder pain or similar symptoms, such as:
- – a condition that inflames the tissues of the joints, causing symptoms of muscle pain and stiffness
- a cancerous tumour
- diabetes – a condition caused by too much glucose in the blood, which makes you more likely to develop
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.Treatment for shoulder pain
The type of treatment offered for your shoulder pain will depend on the underlying cause and your symptoms.
Options such as heat or ice packs and painkillers may help reduce pain and treat minor injuries at home.
You should see your doctor if your pain is the result of an injury, it's particularly bad, or if there is no sign of the pain improving after a couple of weeks.
Your doctor may refer you to an orthopaedic surgeon (a specialist in conditions that affect the bones and muscles) or rheumatologist (a specialist in conditions that affect the muscles and joints) if you have:
- a frozen shoulder that does not improve after six months
- a rotator cuff disorder that does not improve after three to six months
- an acromioclavicular joint disorder that does not improve after three months
- a rotator cuff tear
- shoulder instability and you are under 30 years old
Treatment options
The main treatment options for shoulder pain include:
- avoiding activities that make your symptoms worse
- using ice packs
- painkillers
- anti-inflammatories
- surgery (in some cases)
These are described in more detail below.
As well as pain, you may also have reduced strength or movement in your shoulder. In this case, a combination of different treatments may be used.
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.Avoiding activities
Depending on what is causing your shoulder pain, your doctor may recommend you avoid certain activities or movements that may make your symptoms worse.
For example, in the early, painful stage of frozen shoulder, you may be advised to avoid activities that involve lifting your arms above your head. However, you should continue using your shoulder for other activities, because keeping it still could make your symptoms worse.
If you have shoulder instability, you may be advised to avoid any movements that are likely to make the instability worse, such as overarm throwing.
If you have sprained your acromioclavicular joint (the joint at the top of your shoulder), you may be advised to avoid moving your arm across your body. You may also be given a sling (a supportive bandage) to wear to support your arm for up to a week after your injury.
Ice packs
If you injure your shoulder, for example while playing sport, you can apply an ice pack to the affected area to reduce inflammation and pain.
You should apply the ice pack for 10-30 minutes. A bag of frozen peas, or similar, will also work well. Wrap the ice pack in a towel to avoid it directly touching your skin and causing ice burn.
Painkillers
If your pain is mild, taking painkillers such as
or codeine may be enough to control it. Always follow the dosage instructions on the packet to ensure the medicine is suitable and that you do not take too much.If your shoulder pain is more severe, your doctor may recommend or prescribe a
such as , diclofenac or naproxen.As well as easing the pain, NSAIDs can also help reduce swelling in your shoulder capsule. They are most effective when taken regularly rather than when your symptoms are most painful.
Corticosteroid tablets
Corticosteroids are medicines that contain steroids, which are a type of hormone. Hormones are powerful chemicals that have a wide range of effects on the body, including reducing swelling and pain.
You may be prescribed corticosteroid tablets for frozen shoulder. Some evidence suggests these may provide short-term pain relief for a few weeks. However, it is not clear whether corticosteroid tablets are any better than other treatment options, such as corticosteroid injections.
Corticosteroid tablets can also cause a number of side effects.
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.Corticosteroid injections
If your shoulder pain is severe, such as in certain cases of frozen shoulder, painkillers may not be enough to control the pain. In this case, you may have corticosteroids injected into and around your shoulder joint.
Corticosteroid injections can help relieve pain caused by frozen shoulder and increase your range of movement for several weeks at a time, particularly during the first stage of symptoms. However, the injections cannot cure your condition completely and your symptoms will gradually return.
Research also suggests that corticosteroid injections can provide pain relief for up to eight weeks for
(inflammation of a tendon). They may also improve your ability to use your shoulder, although they may not be as effective as some other treatments, such as NSAIDs.One study found corticosteroid injections may be most effective if used within 12 weeks of tendonitis symptoms starting. However, some experts believe the use of corticosteroid injections should be delayed for as long as possible.
Cautions
After having a corticosteroid injection, you may experience side effects at the site of the injection. These may include:
- temporary pain
- lightening of your skin
- thinning of your skin
Having too many corticosteroid injections can damage your shoulder. Therefore, you may only be able to have this treatment up to three times in the same shoulder in one year.
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for more information about this type of medication.Hyaluronate injections
Hyaluronate is another medicine that can be injected into your shoulder to treat shoulder pain. One review of a number of studies found that hyaluronate was effective at reducing pain.
Physiotherapy
If you are referred to a physiotherapist, they should explain to you what treatment they will use and how it will work. Learn more about
.Possible treatments include:
- massage – where the physiotherapist uses their hands to manipulate your shoulder
- laser therapy – where the energy from lasers is used to stimulate your nervous system and reduce pain
TENS is a type of physiotherapy where small electrical pads (electrodes) are stuck to the skin over your shoulder. The TENS machine delivers small pulses of electricity through the electrodes, which numb the nerve endings and control your pain.
As well as these treatment methods, your physiotherapist may also recommend shoulder exercises specific to your needs. For example, if you have shoulder instability, you may be given exercises that will strengthen your shoulder.
Shoulder exercises
If you have shoulder pain, it is important to keep your shoulder joint mobile by doing gentle, regular exercise. Not using your shoulder can cause your muscles to waste away and may make any stiffness worse. Therefore, if possible, you should continue using your shoulder as normal.
If your shoulder is very stiff, exercise may be painful. Your doctor or physiotherapist can give you exercises to do without further damaging your shoulder.
You may be given exercises to do on your own, or you may complete the exercises with supervision from your doctor or physiotherapist. You may also have manual therapy, where the healthcare professional moves your arm for you. Manual therapy uses special techniques to move the joints and soft tissues in your shoulder.
One review of a number of studies found long-term physiotherapy was as effective as surgery for impingement syndrome (any type of damage to the tendons in the rotator cuff).
Surgery for frozen shoulder
If other treatments for frozen shoulder have not worked, you may be referred for surgery. There are two possible surgical procedures explained in more detail below.
Manipulation
Manipulation involves having your shoulder moved while you are under
. During the procedure, your shoulder will be gently moved and stretched while you are asleep.Afterwards, you will usually need to have physiotherapy to help maintain mobility in your shoulder. Manipulation may be used if you are finding the pain and disability from your shoulder difficult to cope with.
Arthroscopic capsular release
An alternative procedure to manipulation is arthroscopic capsular release. This is a type of keyhole, or non-invasive, surgery. The surgeon will carry out the procedure after making an incision that is less than 1cm (0.4in) long. A special probe opens up your contracted shoulder capsule and any bands of scar tissue are removed. This should greatly improve your symptoms.
As with manipulation, you will need physiotherapy after the surgery to help you regain a full range of movement in your shoulder joint.
Surgery for a rotator cuff tear
Surgery may be used to treat rotator cuff tears if the tear is large or if other treatment options have not worked after three to six months. It is possible that having surgery earlier will lead to a quicker recovery, although at the moment there is not enough research into whether early surgery is beneficial or not.
During the procedure, a small amount may be shaved off the bones in your shoulder. Damaged tendons and bursae (fluid-filled sacs found over joints and between tendons and bones) may also be removed. This creates more space within the joint to allow your rotator cuff to move freely.
The operation can be performed as:
- open surgery – a large incision is made in your shoulder
- mini-open surgery – a small incision is made in your shoulder
- – a type of keyhole surgery that uses a camera to look inside your shoulder joint
Evidence suggests that people return to work about a month earlier if they have mini-open surgery rather than open surgery.
As with frozen shoulder surgery, you will need physiotherapy after your operation to help you regain a full range of movement in your shoulder joint.
Surgery for shoulder instability
If your shoulder dislocates (the ball comes out of the socket) regularly or severely, you may need surgery to prevent it happening again and to prevent surrounding tissues and nerves from becoming damaged. Depending on the type of instability you have, surgery may involve:
- tightening stretched ligaments or reattaching them if they have torn (ligaments are tough bands of connective tissue that link two bones together at a joint)
- tightening the shoulder capsule by using heat to shrink it or tightening it with sutures (stitches)
Surgery for shoulder instability can either be done using keyhole or open surgery. After the operation, your shoulder will need to be immobilised (prevented from moving) using a special sling for several weeks. You will also need physiotherapy to improve your strength. Full recovery may take several months.