Shoulder Pain

What tends to cause it

• Rotator cuff problems. Pain on the outer upper arm, weakness reaching overhead, and pain lying on that side at night. Ranges from irritation to a full tear.
• Frozen shoulder. Pain first, then stiffness that gets steadily worse in every direction, including when someone else moves the arm for you. More common in people with diabetes, and it runs a long course.
• Instability. A shoulder that has dislocated, or that feels like it is slipping. Usually younger patients, often after a first dislocation in sport.
• Arthritis. Deep, aching pain with grinding and gradual loss of movement.
• Acromioclavicular joint problems. Pain right on top of the shoulder, worse reaching across the body.
• Referred pain from the neck. Common, and often missed. Pain that travels below the elbow, or comes with pins and needles, points here.

A frozen shoulder and a rotator cuff tear can feel much the same to you, yet they need almost opposite treatment. Telling them apart is a large part of what the examination is for; how to tell frozen shoulder from a cuff tear explains the test.

When it needs seeing sooner

• The shoulder is out of joint after an injury. Go to an emergency department, not a clinic.
• You cannot lift the arm at all after a fall, particularly over the age of sixty.
• The shoulder is hot and swollen and you feel unwell.
• There is numbness, weakness or coldness in the hand.
• Shoulder pain comes with chest tightness, sweating or breathlessness. This needs emergency assessment, because the cause may be the heart.

How it gets assessed

Examination separates what you cannot do from what you will not do because it hurts. The key question is whether the shoulder is still stiff when someone else moves it. Stiff in every direction, even then, suggests a frozen shoulder or arthritis. A shoulder that moves freely when someone else lifts it, but that you cannot lift yourself, points at the rotator cuff.

The neck is always examined too. It is a common source of shoulder pain, and treating the wrong structure wastes months.

X-rays show arthritis, bone spurs and old fractures. Ultrasound and MRI show the cuff tendons. If the shoulder has dislocated more than once, a CT scan is usually needed to measure bone loss, because that changes which operation will work.

What treatment usually looks like

Most shoulder problems are managed without surgery. The physiotherapy is built around the diagnosis instead of being a generic set of shoulder exercises.

• A structured programme for the rotator cuff and the muscles controlling the shoulder blade
• For frozen shoulder, a stretching programme, and an injection early on where pain is holding progress back
• Activity modification, particularly less overhead loading for a while
• Anti-inflammatory medication for a defined period
• Injections in selected cases, used to make rehabilitation possible and not as a treatment in themselves

Surgery is discussed in four situations. For a cuff tear that is not healing and is causing real weakness, the operation is a rotator cuff repair. For a shoulder that keeps dislocating, it is a shoulder stabilisation. For arthritis that has stopped responding, it is a shoulder replacement if the rotator cuff is intact and a reverse shoulder replacement if it is not. The last is a frozen shoulder that has still not moved after a long, proper trial of everything else.

Common questions

Related procedures

Where an operation does turn out to be the right answer, these are the ones this problem most often leads to.