Shoulder Pain

What are the possible causes of shoulder pain?

See also the separate leaflet called Joint Pain. Shoulder pain is a common problem with a number of different causes which include (starting with the four most common):

• Frozen shoulder. This is sometimes called adhesive capsulitis of the shoulder. It is a condition where a shoulder becomes painful and stiff. Without treatment, symptoms usually go but this may take up to 2-3 years.
• Rotator cuff disorders. The rotator cuff is a group of muscles and tendons that surround the shoulder joint and help to keep it stable. Rotator cuff disorders are one of the most common causes of shoulder pain. Most people can be successfully treated and have complete recovery.
• Pain coming from a problem in the neck. See the separate leaflets called Neck Pain and Whiplash Neck Sprain.
• Acromioclavicular joint disorders - some conditions (such as a shoulder injury or osteoarthritis) may affect the acromioclavicular joint, which is the joint at the top of the shoulder (see the diagram at the end of this leaflet). Problems with this joint are usually due to wear and tear of the joint or because of injury.
• Osteoarthritis (wear and tear) in the shoulder joint.
• Septic arthritis. This is an infection in the joint. Symptoms include pain and tenderness over a joint, pain on moving the joint, and feeling unwell. Septic arthritis is uncommon but needs urgent hospital treatment.
• Arthritis affecting a number of other different joints as well as the shoulder - eg, rheumatoid arthritis.
• Polymyalgia rheumatica. This is a condition which causes pain, stiffness and tenderness in large muscles, typically around the shoulders, upper arms and hips.
• Injury (trauma):
• A broken bone (fracture), such as a fracture of the upper arm bone (humerus) or a broken collarbone (clavicle).
• A soft tissue injury such as an injury to a ligament, tendon or muscle around your shoulder joint. This may be caused in many different ways, such as a sports injury, a road traffic accident or a shoulder strain following heavy lifting or carrying.
• Shoulder dislocation. This means the ball of the joint has moved out of its socket. See the separate leaflet called Joint Dislocations.
• Shoulder instability. The shoulder is unstable because the joint does not keep the bones close together. The humerus often 'pops out' of position.
• Referred pain. This means a pain which is caused by a problem somewhere else in the body, but is felt in the shoulder due to the nerve pathways. The neck is the most common source of referred pain. (See the links above for more information). Occasionally pain may be felt in the shoulder when the source is the heart, or the diaphragm (the muscle which separates your chest area from your tummy area). A problem within the tummy area can cause an irritation of the diaphragm, which can sometimes be felt in the shoulder. Usually there is a pain in the tummy area as well. Similarly if the problem starts in the chest area, there is usually chest pain along with the shoulder pain.

How do I know what is causing my shoulder pain?

As you can see above, there are lots of possible reasons for shoulder pain, so you may need to see a doctor to help you work it out. Some general guidelines which may help are as follows. However, remember there are always exceptions to every rule!

• A shoulder pain usually - but not always - comes from a problem with the shoulder. It is more likely to be due to the shoulder itself if it hurts more when you move your shoulder, of when you touch the shoulder, or if you can see something doesn't look right with the shoulder. For example, if the shape looks different to the other side or if it is hot or red. If your shoulder hurts when you lift your arm, it is likely to be due to a problem with the shoulder joint itself, such as a frozen shoulder, rotator cuff problem or shoulder injury.
• If you have had pain following a fall or injury of some type, it is likely that the trauma is causing the pain. Probably a bone, joint, ligament, muscle or tendon is damaged in some way, which may be minor or major.
• Shoulder pain is very common and can affect all ages. Some causes of shoulder pain, such as osteoarthritis, frozen shoulder and rotator cuff disorders, mainly affect middle-aged and older people. Shoulder pain caused by sports injuries is more common in younger age groups. Sports that may cause shoulder injuries include sports with repeated throwing or bowling, or contact sports such as rugby. Shoulder instability and acromioclavicular joint disorders often affect people who play regular sport.
• If you have pain in other joints as well as the shoulder, it is more likely to be a more general problem.
• If you have pain and stiffness in both shoulders which is worse in the mornings, you may have polymyalgia rheumatica. 
• Clues that suggest shoulder pain is coming from some other problem than the shoulder itself include:
• If there is a blistery rash which is painful, it might be shingles.
• If the shoulder pain is coming from the neck, you are likely to have some neck pain and/or stiffness as well.
• If the pain is in the left shoulder, and if it comes with a pain or tightness in your chest, it may be coming from your heart. Usually with angina or a heart attack, there are other symptoms as well as or instead of shoulder pain. See the separate leaflets called Angina and Heart Attack (Myocardial Infarction) for details.
• If all your joints are achy and if you feel hot one minute and cold the next, you may have a high temperature (fever) due to an infection - for example a cold, flu, a chest infection or a kidney infection.
• If you have tummy pain and pain at the tip of your shoulder blade, it might be coming from your tummy or liver or gall bladder
• If you have chest pain or feel out of breath or have a persisting cough with pain in your shoulder, it might be due to a problem with your lungs rather than your shoulder.

When should I see a doctor about my shoulder pain?

It is not possible to give rules which cover every situation - it will depend on how unwell you feel and how much pain you are in. Generally speaking:

See a doctor urgently (straightaway) if:

• The pain follows an injury or trauma and is a bad pain (severe) or you are unable to move the shoulder at all.
• If your shoulder is hot to touch, or red.
• If you have chest pain or difficulty breathing or feel generally very unwell (call 999/112/911).

See a doctor as soon as you can if:

• The pain affects both shoulders and is worse in the mornings.
• The pain is not improving with simple painkillers.
• The pain is affecting your daily activities.
• You have other symptoms as well as your shoulder pain, such as:
• Tummy pain
• A persisting cough
• Night sweats
• Weight loss
• A blistery rash
• You have a high temperature (fever) which is not responding to simple measures such as paracetamol, or if there is no obvious simple cause.
• You have a past history of cancer and you have a persisting pain in the bone area of your shoulder.
• You have pain in more than one joint.
• There is any swelling of the shoulder.

What can I do to relieve shoulder pain?

Initial treatment for some of the more common shoulder problems includes taking simple medicines for pain relief, such as ibuprofen or paracetamol. Ice packs can also be used to reduce or relieve pain. You should avoid activities that may cause more pain in your shoulder, such as heavy lifting and carrying. If these measures are not working, see a health professional.

What are the treatments for shoulder pain?

This of course is going to depend on the cause of the pain. You should see a doctor if your shoulder pain is very bad, does not resolve within a few weeks or was caused by an injury. Depending on the cause of your shoulder pain, further treatments may be needed.

Treatments may include physiotherapy and/or a steroid injection into your shoulder.

In some cases, you may need to be referred to a bone and joint specialist (orthopaedic specialist or rheumatology specialist) to see if any further treatment is required, such as a surgical operation to treat the cause of your shoulder pain. However, surgery is not needed for most causes of shoulder pain.

In a few cases an operation may be required. Most commonly, this is done through a 'keyhole' procedure - an arthroscopy. During an arthroscopy, the parts of the shoulder joint can be examined to see what is the cause of the problem. Damaged tissues may be repaired or removed.

Decompression is one surgical option for shoulder tip (subacromial) pain. Decompressing means removing bone spurs and soft tissue through a thin telescope introduced through the keyhole cut. The findings of a large recent study, however, show there is little value in this particular operation for pain, and this should be discussed with you during the shared treatment decision-making process.

Occasionally, shoulder joints can be replaced with an artificial joint, particularly if the problem is wear and tear (osteoarthritis).

If the pain is thought to be due to inflammation, such as in rheumatoid arthritis or polymyalgia rheumatica, then medicines are used to treat you. You may be under the care of a rheumatologist. See the specific leaflets about these conditions for more information about treatment options.

There is no evidence at the moment that acupuncture is helpful for shoulder pain.

What is the outcome (prognosis)?

The outcome will depend on the underlying cause. Shoulder pain may only last for up to a few weeks, may last a few years or may be a lifelong problem. However, if the cause of your shoulder pain is diagnosed and treated early then this can often help to resolve or greatly reduce the pain in your shoulder.

The shoulder joint

Rotator cuff

There are three bones in the shoulder region - the collarbone (clavicle), the shoulder blade (scapula) and the upper arm bone (humerus). The scapula is a triangular-shaped bone that has two important parts to it: the acromion and the glenoid. The three bones in the shoulder region form part of two main joints:

• The acromioclavicular joint between the acromion of the scapula and the clavicle.
• The glenohumeral joint between the glenoid of the scapula and the humerus.

There are also a number of muscles, ligaments and tendons around the shoulder. Ligaments are fibres that link bones together at a joint. Tendons are fibres that attach muscle to bone.