Shoulder pain

What is shoulder pain?

Shoulder pain refers to pain that originates from your shoulder joint, or the muscles and tendons that are part of your shoulder. Muscle problems in your neck and upper arm can also give you shoulder pain.

The shoulder joint

Your shoulder is the most mobile joint in your body and one that comes under a great deal of stress throughout your lifetime, especially in your teenage years. It is a ball-and-socket joint, connecting the ball of your arm bone (humerus) with your shoulder blade (scapula), the triangular bone that sits on top of your back and slides back and forth when you move your arm. The joint is surrounded by a capsule that helps to hold all the parts of your joint together.

The membrane that lines the inside of the joint capsule secretes synovial fluid, a special type of lubricating fluid that allows smooth movement and stops wear and tear. Liquid-filled sacs around the shoulder joint, each known as a bursa, act as cushioning pads between your bones, muscles and tendons.

The four muscles and tendons that surround your shoulder are called the rotator cuff muscles. These connect your arm to your upper body, controlling movement, but are also where many injuries occur. The most common shoulder issues tend to involve your tendons, with overuse being the main cause of pain. The good news, though, is that the majority of cases can be treated with exercise, physiotherapy and medication.

Causes

Shoulder pain can occur for many reasons, so getting a diagnosis from your doctor is essential. However, among the common causes are:

• Poor posture - sitting incorrectly while reading, watching TV or working, or carrying a heavy bag on one side;
• Rotator cuff injury - these muscles and tendons are responsible for moving/raising your arm and sometimes can become inflamed and swollen, often due to repetitive actions, but sometimes without any obvious reason. This is the most common cause of shoulder pain among young active people;
• Bursitis;
• Tendonitis - inflammation of your tendons, usually due to overuse;
• Frozen shoulder (adhesive capsulitis) - this causes the capsule surrounding your shoulder to develop adhesions (scar tissue that connects internal surfaces that should not be connected) and become thickened. It usually starts as stiffness and aching then, if untreated, often leads to an inability to move your shoulder.
• Shoulder impingement syndrome (SIS) - this is when a shoulder tendon or bursa becomes compressed by the bones of the shoulder. It is very common in sports, such as golf and tennis, where repetitive movements are a predisposing factor;
• Shoulder instability - this common condition often arises after you have dislocated your shoulder. Your muscles and tendons become overly flexible, allowing your bones to move too much and causing an unstable shoulder;
• Acromioclavicular (AC) joint problems - this joint injury is very common among sports people who endure heavy impacts. Throwing objects or lifting heavy weights above your head can also lead to AC joint problems;
• Osteoarthritis - this degenerative condition often appears years after a shoulder injury. It tends to progress slowly and is usually manageable with self care and medication;
• Broken bone - if you have a fracture in the bones of your shoulder, you will usually experience severe pain throughout the shoulder area. The skin surrounding the break may become red or bruised, swollen and extremely painful to touch;
• Dislocation - if you have dislocated your shoulder, you may have torn the surrounding tissues. Get to a hospital immediately to have it fixed. It can lead to ongoing aches and pain in your shoulder until recovery is complete. Do not try to relocate it yourself as this can cause severe damage to nerves and structures if done incorrectly, and;
• Neck problems - problems with muscles or tension in your neck region may cause referred pain in your shoulder.

Less common causes of shoulder pain include:

• Polymyalgia rheumatica - this type of arthritis causes pain and inflammation in many of your joints and muscles, not just your shoulders, and;
• Underlying conditions - in very rare cases, shoulder pain may be due to diseased internal organs. Serious abdominal disease can refer pain to the tip of the shoulder and is often accompanied by other identifying signs and symptoms.

Signs and symptoms

The following are classic symptoms of different types of shoulder pain:

• Inability to perform a particular arm movement, such as combing your hair, opening your bra or reaching above your head;
• Deep aching or throbbing pain in the shoulder and arm;
• Weakness, tingling and numbness in your arm and fingers;
• Sharp, stabbing pain that does not improve with heat or touch;
• A clicking, dragging, rough sensation instead of smoothness when moving the shoulder joint, and;
• Pain that worsens at night, or when you repeat an action with your arm.

Methods for diagnosis

Your doctor may take a full medical history and do a physical examination of your shoulder, to find the cause of your pain.

Musculoskeletal examination

Your doctor may ask you to perform a number of gentle arm movements, to check the range of movement in your shoulder. These movements will involve using each of the different muscles and tendons in your shoulder in a slow, methodical fashion. Quite often these tests are enough to diagnose where your pain is coming from.

Imaging tests

If the cause of your shoulder pain is still unclear, you may have one of the following procedures:

• An ultrasound, which is a scan that uses high-frequency sound waves to produce images of your shoulder's internal structures. Ultrasound is most helpful in assessing soft tissues, muscles, tendons and bursa(e);
• An X-ray, which is helpful in the assessment of the bones and can help diagnose problems such as shoulder fractures, arthritis and dislocations;
• A computerized tomography (CT) scan, which sends X-ray beams from multiple angles using a machine that circles your body. This can give more detailed images of the shoulder, and;
• Magnetic resonance imaging (MRI), which can provide detailed images of the shoulder joint and can be useful in diagnosis of many shoulder conditions, where other imaging tests have not been helpful.

Blood tests

You may be asked to provide a blood sample to rule out the following underlying conditions:

• Diabetes;
• Polymyalgia rheumatica;
• Serious abdominal diseases, and;
• Infection - septic arthritis.

Types of treatment

Treatment for shoulder pain depends heavily on the cause and the type of symptoms you are experiencing. Many cases will be dealt with using physiotherapy, massage and pain-relief medications. Surgery is only considered if other methods fail.

Home care

A range of home care measures can be used to treat shoulder pain, including the following:

• Ice or heat packs - these can provide immediate relief from some types of pain, but seek advice from your doctor or therapist as to which is appropriate for you. Icepacks should not be placed directly on your skin, as they may cause nerve damage. First wrap the ice pack in a towel and only use for 10 minutes each time;
• Avoiding triggers - if you have an injury or inflammation due to overuse, avoiding these activities may help the tissues to heal. Gentle movement may still be performed, if tolerated, so as to avoid joint stiffness. Again, seek advice from your health professional regarding appropriate movement and exercises;
• Painkillers - many types of shoulder pain will respond well to painkillers such as anti-inflammatories (eg. ibuprofen) or acetaminophen, and;
• Exercise and stretching - not using your shoulder can result in decreased muscle mass and further stiffness. Your doctor can advise you on how to gently exercise your shoulder and increase blood flow to the area.

Seek medical attention though, if you experience any of the following:

• An acromioclavicular (AC) injury that does not improve within three months;
• A frozen shoulder;
• A tear in your rotator cuff;
• Pain that keeps you awake at night, and;
• Pain that is not improving.

Medications

Medications to treat shoulder pain include:

• Joint injections - these contain local anesthetic and corticosteroids to provide pain relief by reducing inflammation. They tend to be injected right into the area that is most inflamed, which allows movement to return, and;
• Oral corticosteroids - these work in the same fashion as injections, but have a more widespread effect. They work to reduce inflammation and pain, and by freeing-up tendons that have become swollen and immobile. They are generally used as a short-term solution, as there are significant side effects associated with long-term use.

Physiotherapy

A physiotherapist is an expert in how your muscles work and, in particular, how to rehabilitate them after an injury. They can assess the condition of your muscles, tendons and ligaments, then design exercise programs to strengthen them. Strapping your muscles with special tape may help keep your shoulder in place, reducing further injury while you recover. Your physiotherapist can teach you exercises and stretching techniques, which you can then use at home. Most physiotherapists are trained in deep tissue massage; this may be helpful in freeing-up stiff and painful shoulders by increasing blood flow to the area.

A physiotherapist may also make use of any of the following electrotherapies:

• Ultrasound - physiotherapists often use ultrasound to treat muscle injury. The waves pass through your tissues creating vibration and heat at a deep level. Ultrasound increases blood flow to the injured area, reducing inflammation and pain;
• Transcutaneous electrical nerve stimulation (TENS) - this is the use of electrical stimulation to relieve pain. The stimulation is delivered by a low-voltage, battery-operated machine with electrodes attached. The electrodes are taped onto your skin close to the painful area, and;
• Laser therapy - uses directed energy to stimulate your nervous system and reduce pain.

Surgery

Surgery is offered for a number of shoulder complaints such as frozen shoulder, rotator cuff injuries and some ligament problems. Your doctor will usually investigate non-surgical methods first, then, if they do not work, consider the following surgery options:

• Open surgery - a small incision will be made in your shoulder or upper arm to view your shoulder joint, while you are under general anesthetic. Repairs such as bone shaving, removing bone spurs or sewing tendons in place can then be undertaken, or;
• Arthroscopy - an arthroscope is a tiny telescope with a light attached to its end. It is inserted via a small incision and guided to the joint needing examination.

Potential complications

Complications of shoulder pain are uncommon. Untreated injuries or conditions may result in chronic pain or frozen shoulder.

Prognosis

Some shoulder conditions will heal within a few months, but others may take longer, or require specific medical or surgical treatment to heal. If you have arthritis, you may have to manage this for the rest of your life. Old injuries may return, especially as you get older, so trying to stay injury-free is important.

Prevention

Protecting your shoulders in day-to-day activities will help you avoid injury and damage. Wear appropriate padding if involved in high-impact sports, or if you decide to take up rollerblading! Avoid carrying heavy bags and sleeping with an uncomfortable pillow, and slouching instead of sitting upright.

Staying flexible is important; exercise such as tai chi or yoga will help you maintain smooth movement in your shoulders. Your physiotherapist can suggest specific exercises for your condition and help you to avoid further injury.

References

1. Acupuncture for shoulder pain | Cochrane Summaries. Accessed 4 August 2014 from link here
2. Conditions and Symptoms - Shoulder Pain - Arthritis Victoria. Accessed 4 August 2014 from link here
3. General Practice - 31 Jan 1998 - 9487172.pdf. Accessed 4 August 2014 from link here
4. How does the shoulder work? | Arthritis Research UK. Accessed 5 August 2014 from link here
5. Neck and shoulder pain | Better Health Channel. Accessed 5 August 2014 from link here
6. Physiotherapy interventions for shoulder pain - The Cochrane Library - Green - Wiley Online Library. (-a). Accessed 4 August 2014 from link here
7. Physiotherapy interventions for shoulder pain - The Cochrane Library - Green - Wiley Online Library. (-b). Accessed 4 August 2014 from link here
8. Shoulder pain - National Library of Medicine - PubMed Health. Accessed 4 August 2014 from link here
9. Shoulder pain - NHS Choices. Accessed 4 August 2014 from link here
10. Systematic review of randomised controlled trials of interventions for painful shoulder: selection criteria outcome assessment and efficacy. Accessed 4 August 2014 from link here
11. Traumatic causes of acute shoulder pain and injury in children and adolescents. Accessed 4 August 2014 from link here

10 Most frequently asked questions (FAQs)

About this article