Shoulder pain

The shoulder is the most mobile joint in the body, and the price of that mobility is stability: it is held together not by bone but by muscles, tendons and ligaments that are easy to overload. That is why most shoulder pain comes from the shoulder itself and involves the tendons of the rotator cuff. But not all of it. The neck, the heart, the gallbladder and the diaphragm all refer pain into the shoulder, so the first thing to do with a new pain is work out whether the shoulder is really what hurts.

When shoulder pain is not about the shoulder

Referred pain gives itself away by not depending on movement: you turn the arm, lift it, press on the shoulder — and the pain stays exactly as it was. That is the main sign that the source is somewhere else.

• Heart attack. Pain in the left shoulder and arm, often together with pressure or burning behind the breastbone, breathlessness, cold sweat, feeling sick and light-headed. It can spread to the jaw, neck and back, and it can last for minutes without easing at rest. Call an ambulance immediately: the single European number 112 or your local emergency number.
• Gallbladder disease. Pain in the right shoulder and under the right shoulder blade, along with pain in the right upper abdomen, feeling sick and vomiting, often an hour or two after a fatty meal. With a high temperature, shivering, or yellowing of the skin and the whites of the eyes, go to hospital the same day.
• Injury to a lung or the spleen after trauma. Shoulder pain that appears after a fall or a blow to the chest or abdomen, particularly with breathlessness, is an ambulance call. Left shoulder pain after a blow to the abdomen can be the only visible sign of a ruptured spleen, and increasing breathlessness with shoulder pain a sign of lung injury.
• Other causes in the chest and abdomen. Aortic dissection, pleurisy, a perforated ulcer and ectopic pregnancy can all refer to the shoulder, and in every case there is a second, more serious complaint: chest or abdominal pain, fainting, sudden weakness.

What cannot wait until Monday

Get help the same day if any of this appears:

• The shoulder looks different: the joint is deformed, the arm hangs in a forced position and any movement causes severe pain. That is what a dislocation or a fracture looks like. Do not try to put the shoulder back yourself and do not let anyone untrained do it — nerves and vessels can be damaged.
• The arm stopped lifting after a fall, a jerk or lifting something heavy. Especially if there was a snap at the time, followed by bruising and weakness. That is how a tendon rupture shows itself, and the time to surgery matters.
• The joint is hot, swollen and red, with fever and shivering. Infection in a joint destroys cartilage within days. It is particularly worrying in people with diabetes, with a weakened immune system, or after an injection into the joint.
• Numbness, weakness or coldness of the whole arm, with a pale or bluish hand.
• Pain after an injury that keeps you awake and does not settle with ordinary pain relief.
• Shoulder pain with unexplained weight loss, night sweats, or a past history of cancer.

Rotator cuff and impingement

This is the commonest cause. The rotator cuff is four muscles with their tendons that hold the head of the upper arm bone in place and rotate the arm. When a tendon is irritated, inflamed or partly torn, a recognisable picture appears: it hurts to raise the arm out to the side from roughly shoulder height upwards, it is painful to reach behind your back or across for a seat belt, and difficult to comb your hair, hang out washing or reach a high shelf. Nights are worse, especially lying on that side, and it is often the night pain that finally brings people in.

Impingement is the pinching of the tendon and the bursa in the narrow space beneath the tip of the shoulder blade, and by feel it is indistinguishable from cuff tendonitis. Bursitis is a close relation: inflammation of the bursa often goes with it. All of this develops either from repeated work with the arms overhead — painting, building, sport — or simply with age, because tendons receive less blood and repair less well. A cuff tear can also come on gradually, with no injury at all; then the main complaint is not pain but weakness, with the arm unable to hold itself up.

Frozen shoulder

This condition has another, more accurate name — adhesive capsulitis: the capsule of the joint becomes inflamed, thickens and contracts, and the joint becomes literally too tight for its own head of bone. One feature separates it from every other cause: not only active movement is limited, but passive movement too. If someone else's hand also cannot take your shoulder out to the side or rotate it outwards, this is capsulitis and not a tendon.

It runs in long phases: pain builds over months, then the pain recedes but the stiffness stays and lasts considerably longer, and finally the range of movement returns slowly. Overall this is a drawn-out process measured in far more than weeks, and it is worth knowing that in advance so as not to write the treatment off as a failure.

Frozen shoulder occurs noticeably more often in people with diabetes, and also with thyroid disease and after a spell of forced immobility of the arm — after a fracture, an operation or a stroke. If the diagnosis is made in someone with no known diabetes, it is reasonable to check the blood sugar: capsulitis is sometimes the first reason it comes to light.

Osteoarthritis and inflammatory joint disease

Osteoarthritis of the shoulder is less common than in the knee or hip, but it looks similar: deep pain in the joint, stiffness after sleep and after sitting still, creaking and clicking on rotation, and a steady narrowing of what the arm can do. It more often develops where the joint was damaged in the past — after a dislocation, a fracture or years of heavy work. Separate from that is osteoarthritis of the small joint between the collarbone and the shoulder blade right at the top of the shoulder: there the pain is pinpoint, exactly at that spot, and increases when you bring the arm across the chest.

A different combination should raise a flag: prolonged morning stiffness, swollen joints, pain symmetrical on both sides, hands or feet involved, tiredness and a slightly raised temperature. That looks less like wear and more like inflammatory disease — rheumatoid arthritis, polymyalgia rheumatica in older people, psoriatic arthritis. These are managed by a rheumatologist, and treatment works better the earlier it starts.

When the shoulder hurts but the cause is in the neck

Changes in the neck part of the spine are a very common source of pain that people confidently call shoulder pain. The clues are these: the pain runs as a band from the neck across the top of the shoulder to the shoulder blade and onwards down the arm; it changes with turning or tilting the head rather than with shoulder movement; there is tingling, numbness or weakness in particular fingers; and it hurts after a long stretch at a desk or behind the wheel. The joint itself, meanwhile, moves fully and is not tender to touch.

Separating the two matters, because the tests and the treatment differ: shoulder exercises will not help if a nerve root in the neck is trapped. And if the pain comes with weakness in the arm that is getting worse, unsteady walking, or trouble passing urine, seek help urgently.

What helps and what to avoid

The general rule is that a shoulder tolerates neither overload nor rest. Complete immobility leads straight to stiffness, so the arm is kept in use as far as it can go without sharp pain.

• Keep moving the shoulder gently within the pain-free range; a sling is used only if a doctor advises it, and only briefly.
• Drop for now whatever clearly triggers the pain: work with the arms overhead, heavy bags on that side, push-ups and pressing weights.
• Cold helps in the first days after an injury or a flare-up; heat helps when stiffness dominates. Always apply through a cloth, never on bare skin.
• Paracetamol is usually enough for the pain, and for inflammatory pain a non-steroidal anti-inflammatory by mouth or as a gel on the skin. Agree the dose and the duration with your doctor, especially with stomach, kidney or heart problems, or if you take blood-thinning medicines.
• Sort out your sleep: a pillow under the forearm and a small roll under the elbow ease night pain better than a tablet.
• Do not set yourself strenuous exercises and do not train through pain. The programme is chosen by a doctor or physiotherapist for the specific cause — it differs between capsulitis and a cuff tear, and the wrong one only drags recovery out.

If the pain is not easing, or it stops you sleeping and working, you need to be examined. The doctor will check the range of movement, carry out cuff and instability tests and, where appropriate, arrange an X-ray, an ultrasound scan or an MRI scan. Depending on the cause, the discussion may turn to physiotherapy, an injection into the joint or the bursa, and less often surgery.

Online consultation

At an online appointment the doctor will ask in detail which movements hurt and exactly where, ask you to show how far the arm rises, and go through how any injury happened and what your work involves. That is usually enough to separate a cuff problem from capsulitis and from the neck, decide whether imaging is needed, explain reports you already have, and adjust pain relief around your other conditions.

The online format is not suitable for acute situations: a deformed joint, an arm that will not lift after an injury, a hot swollen joint with fever, and above all shoulder pain together with breathlessness, sweating or nausea all mean calling an ambulance or going to hospital.

This material is for information only and does not replace medical advice.