Shoulder Pain

Most common causes: Rotator cuff problems, frozen shoulder, impingement and arthritis.
Often missed: Pain referred from the neck, which no shoulder treatment will fix.
Most cases: Settle without surgery, given the right diagnosis and rehabilitation.

Is it the shoulder, or the neck?

Nerves from the neck supply the shoulder and arm, so a problem in the cervical spine is often felt in the shoulder. People spend months treating a shoulder that was never the source.

	From the shoulder	From the neck
Where it sits	Over the shoulder itself, often down to the upper arm	Often past the elbow, into the forearm or hand
What provokes it	Moving the arm — reaching, lifting, dressing	Neck position; turning or tilting the head
Movement	Restricted, and painful at certain angles	Usually full, though painful
Other symptoms	Weakness when lifting, night pain lying on it	Pins and needles or numbness in a hand pattern
Where to start	Shoulder examination, and ultrasound or X-ray	Neck pain and cervical radiculopathy

Both can be true at once. A stiff neck and a worn rotator cuff often arrive together in the same decade of life. The examination is what separates which one is producing the pain you have come about.

The shoulder from the front, showing the rotator cuff tendon passing under the acromion with the bursa between them. — The rotator cuff tendon passes under the bony arch of the acromion, with the bursa cushioning the gap between them.

That gap is where most shoulder pain begins. The tendon and the bursa are squeezed under the acromion when the arm comes up, which is why reaching overhead hurts before anything else does.

One thing the picture cannot show is the capsule — the sleeve around the joint that tightens in a frozen shoulder. That is why stiffness, rather than any structure you can point to, is the clue that separates it.

The common shoulder problems

Rotator cuff

The tendons that lift and rotate the arm
Painful arc when raising the arm, weakness lifting
Wear with age, or a tear after a fall
Night pain, especially lying on that side

Frozen shoulder

The capsule tightens and the joint stiffens
Movement is limited even when someone else moves the arm
More common in diabetes, and after a period of not using the arm
Runs a long course: painful, stiff, then thawing

Impingement and bursitis

Tendons and the bursa pinched under the bony arch
Worse reaching overhead or behind the back
Often follows repetitive overhead work or sport

Arthritis and instability

Wear in the joint: deep ache, stiffness, grinding
After a dislocation, the shoulder may feel it could slip again
Collarbone joint pain sits on top of the shoulder

Stiffness is the most useful single clue. If the arm moves freely when someone else lifts it, the capsule is not the problem; if it does not, a frozen shoulder is likely regardless of what else is going on.

How it is assessed

History. How it started, what movements hurt, whether it wakes you, and what you have already tried
Examination. Active and passive movement, strength testing of the cuff, impingement tests, and a neck examination
X-ray. For arthritis, calcium deposits, fractures and bone shape
Ultrasound or MRI. Where a cuff tear is suspected or the diagnosis is unclear
Scans are ordered where they will change the plan, not as a matter of routine

Shoulder pain treatment

Most shoulder problems are treated without surgery. What differs is the rehabilitation, which is why the diagnosis matters more than the medication.

First steps

Relative rest from the provoking movement rather than a sling, anti-inflammatory medication for a short period, and a physiotherapy programme aimed at the specific problem.

Injections

A guided injection can settle inflammation enough to let rehabilitation work, and is particularly useful in frozen shoulder and impingement.

When surgery is considered

A significant cuff tear with weakness, recurrent dislocation, or pain that has not responded to a proper course of non-surgical treatment. Advanced arthritis is a separate conversation about joint replacement.

When to see someone about it

Pain lasting more than a few weeks without improving
Weakness lifting the arm, or difficulty reaching overhead
Night pain that wakes you or stops you sleeping on that side
Stiffness that is getting worse, particularly with diabetes
Pain after a fall or a dislocation

Why see us about it

The neck is examined too. Shoulder pain that comes from the cervical spine is common, and it is the reason treatment sometimes fails.
Diagnosis before a scan. The examination narrows it; imaging confirms it where it will change something.
Surgery last. Most shoulders are treated without an operation.
Any of our orthopaedic surgeons sees shoulder conditions, so the first appointment is the one you can get soonest.

Common questions

Why does my shoulder hurt most at night?

Lying on the shoulder compresses the tendons and bursa, and the arm loses the muscle support it has when upright. Night pain is typical of rotator cuff problems and frozen shoulder.

How do I know if it is a frozen shoulder?

The giveaway is stiffness that is there even when someone else moves your arm for you. With most other shoulder problems the joint still moves; it just hurts.

Do I need an MRI?

Not usually at the first visit. X-ray and ultrasound answer most questions, and an MRI is arranged where a tear is suspected or surgery is being considered.

Will I need surgery?

Most people do not. Surgery is considered for a significant tear with weakness, a shoulder that keeps dislocating, or pain that has not responded to a proper course of treatment.

How long does a frozen shoulder last?

Longer than anyone wants: months rather than weeks, through a painful phase, a stiff phase and a thawing phase. Treatment aims to shorten it and keep movement.

Do I need a referral to see a shoulder pain doctor?

No. Bring any X-ray, ultrasound or MRI reports, and a note of what treatment you have already had.

Related conditions

Neck pain · Cervical radiculopathy · Myofascial pain · Rhomboid pain · Neuropathic pain