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Pain, shoulder Content Supplied by NHS Choices
Introduction

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
  • frozen shoulder - 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 may have an unusually large range of movement (hypermobility)
  • acromioclavicular joint disorders - conditions, including osteoarthritis that affect the acromioclavicular joint, which is the joint at the top of the shoulder
  • osteoarthritis in the shoulder joints
  • a broken (fractured) bone, such as a fracture of the humerus (upper arm bone) or broken collarbone

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.

Read more about the causes of shoulder pain.

Treating shoulder pain

There are things you can do yourself to treat shoulder pain, including using painkillers such as ibuprofen, 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:

In most cases, shoulder disorders improve over time if treatment advice is followed.

Read about how shoulder pain is treated.

When to see your GP

You should see your GP if your pain is the result of an injury, is particularly bad, or there is no sign of improvement after a couple of weeks.

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.

Read more about diagnosing shoulder pain.


Causes of shoulder pain

Shoulder pain can be caused by a minor injury, bad posture or an underlying health condition.

Conditions that can cause shoulder pain include:

Frozen shoulder

Frozen shoulder, also known as adhesive capsulitis, is a painful persistent stiffness of the shoulder joint that makes it very 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.

Read more detailed information about the symptoms of frozen shoulder.

Risk factors for frozen shoulder

Most cases of frozen shoulder occur in people over the age of 40.

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 - you are more likely to develop frozen shoulder if you have diabetes, but the exact reason for this is unknown
  • other health conditions - these include heart or lung disease, an overactive thyroid (hyperthyroidism) and Dupuytren's contracture (a condition that causes one or more fingers to bend into the palm of your hand)

Read more information about the causes of frozen shoulder.

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

Tendonitis is inflammation (swelling) of a tendon. Bursitis 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 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 shoulder dislocation 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:

  • osteoarthritis - a condition that causes the joints to become painful and stiff, and is the most common cause of acromioclavicular joint disorders
  • tearing or stretching the ligaments in the 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.

Diagnosing shoulder pain

Your GP 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 GP 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 GP 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 GP 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 GP to determine the underlying cause.

Investigations 

If you need any imaging tests to examine your shoulder in more detail, your GP may refer you for hospital tests. 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.

Read more about X-rays 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 images of the body especially useful for soft tissues like tendons and ligaments.

Read about magnetic resonance imaging (MRI) scans for more information about the procedure.

Ultrasound scan

An ultrasound scan uses high frequency sound waves to create an image of part of the inside of the body and can be used to diagnose problems with joints, ligaments and tendons.

Read about ultrasound scans 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:

  • polymyalgia rheumatica - 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 frozen shoulder

Read more information about blood tests.


Treating shoulder pain

There are several types of treatment for shoulder pain, depending on the cause of your shoulder pain and your symptoms.

Some treatment options, such as heat or ice packs and painkillers, may help to reduce pain and treat minor injuries at home.

You should see you GP if your pain is either the result of an injury, it's particularly bad, or there is no sign of improvement after a couple of weeks.

Your GP may refer you for specialist treatment with an orthopaedic surgeon (a specialist in conditions that affect the bones and muscles) or a rheumatologist (a specialist in conditions that affect the muscles and joints) if you have:

  • a frozen shoulder
  • a rotator cuff disorder
  • an acromioclavicular joint disorder
  • 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
  • physiotherapy
  • arthrographic distension (hydrodilatation)
  • surgery (in some cases)

The various treatments for shoulder pain are outlined below. You can also read a summary of the pros and cons of the treatments for shoulder pain, allowing you to compare your treatment options.

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.

Read more about treating frozen shoulder.

Avoiding activities

Depending on what is causing your shoulder pain, your GP may recommend that you avoid certain activities or movements that could 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 and stretching vigorously. 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 or bench pressing.

If you have sprained your acromioclavicular joint (the joint at the top of your shoulder), you may be advised to avoid activities that involve moving your arm across your body (such as a golf swing or weightlifting). You should keep the shoulder mobile with light tasks if possible, but avoid heavy lifting and contact sports for 8 to 12 weeks. You may also be given a sling (a supportive bandage) to wear to support your arm for up to a week after your injury. Osteoarthritis is the most common cause of acromioclavicular joint disorders.

Ice packs

If you injure your shoulder - for example, while playing sport - you can apply an ice pack to the affected area to reduce pain and inflammation.

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 damp towel to avoid it directly touching your skin and causing ice burn.

Painkillers

If your pain is mild, taking painkillers such as paracetamol 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 GP may recommend or prescribe a non-steroidal anti-inflammatory drug (NSAID), such as ibuprofen, 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 pain and swelling.

You may be prescribed corticosteroid tablets for frozen shoulder. Some evidence suggests that 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.

Read more about the side effects of corticosteroids.

Corticosteroid injections

If your shoulder pain is very severe, oral painkillers may not be enough to control the pain.

Corticosteroid injections in and around your shoulder joint may help to relieve the pain and increase your range of movement for several weeks at a time. However, the injections cannot cure your condition completely, and your symptoms may gradually return.

Some experts believe that the use of corticosteroid injections should be delayed for as long as possible, and there is little evidence to suggest that this is an effective treatment. However, they may help to reduce pain, thereby allowing you to do your physiotherapy and rehabilitation more effectively.

Cautions

After having a corticosteroid injection, you may experience side effects at the site of the injection, including:

  • 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.

Read about corticosteroids for more information.

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.

However, the National Institute for Health and Care Excellence (NICE) does not recommend hyaluronate to treat osteoarthritis (a condition that affects the joints). It found that hyaluronate only helped a little and that corticosteroid injections were a better treatment choice. Therefore, hyaluronate may not be used for this condition.

Physiotherapy

Physiotherapy uses a number of different physical methods to promote healing. If you are referred to a physiotherapist, they should explain to you what treatment they will use and how it will work.

Possible treatments include:

  • specific shoulder exercises - for example, if you have shoulder instability, you may be given exercises to strengthen your shoulder
  • massage - where the physiotherapist uses their hands to manipulate your shoulder

Read more about some of the different techniques used in physiotherapy.

Shoulder exercises

If you have shoulder pain, it's important to keep your shoulder joint mobile with light and gentle movement. 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 GP 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 GP 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 that long-term physiotherapy was as effective as surgery for impingement syndrome (any type of damage to the tendons in the rotator cuff).

Arthrographic distension (hydrodilatation)

Arthrographic distension or hydrodilatation may sometimes be recommended to treat frozen shoulder. A special fluid, which shows up clearly on X-rays, is injected into your shoulder joint at the beginning of the procedure. Under continuous X-ray guidance, a mixture of saline, corticosteroid and local anaesthetic is then injected into the shoulder joint. This procedure usually only takes about 15 minutes, is done under local anaesthetic, and you can go home the same day. Physiotherapy may be recommended afterwards to help you regain a good range of movement in your shoulder.

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 general anaesthetic. 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, which is a type of keyhole 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's possible that having surgery earlier will lead to a quicker recovery, although there is currently not enough research into whether early surgery is beneficial.

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
  • arthroscopic surgery - 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 tightening it with 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.

Joint replacement (arthroplasty) for osteoarthritis of the shoulder

Joint replacement therapy, also known as an arthroplasty, is the most common treatment for osteoarthritis of the shoulder. During an arthroplasty, your surgeon will remove your affected joint and replace it with an artificial joint (prosthesis) made of special plastics and metal. An artificial joint can last for up to 20 years. However, it may eventually need to be replaced.

 
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