Everything you need to know about shoulder pain
Shoulder pain has many different causes and treatments. It isn’t easy to know the difference between different types of shoulder pain, like a frozen shoulder, shoulder blade pain, or symptoms of a rotator cuff tear. This is why you need to get medical attention if you have shoulder pain and the treatment is tailored to the cause, your overall health, and your level of activity.
Shoulder pain can be due to osteoarthritis, muscle tears, tendonitis, and many other causes.
Your shoulder joint has three bones:
- Humerus (upper arm)
- Scapular (shoulder blade)
- Clavicle (collarbone)
Shoulder pain is an extremely common problem. Given your shoulder joint’s complex anatomy, there are many potential causes. And the location of your shoulder pain can help zero in on which part of the joint is affected.
The top of your humerus is shaped like a ball, and it fits into a shallow socket in your scapula. Strong ligaments keep the ball centered in the socket, and your rotator cuff muscles (which also cover the upper arm bone) lift and rotate your arm.
A problem with any part of this shoulder joint architecture can cause pain, weakness, or instability in the shoulder.
Outside of the Shoulder
Several issues can cause pain on the outside of the shoulder, and the most common cause is a rotator cuff tear.
Rotator Cuff Problem
There are four rotator cuff muscles that move your shoulder, including your deltoid muscle.
There are three main types of rotator cuff problems
- Tendonitis: Inflammation of the tendons (which connect your shoulder muscles to your upper arm bone)
- Bursitis: Inflammation of the bursa (a fluid-filled space)
- Rotator cuff tear: The tendons of the rotator cuff become damaged at their insertion to the bone.
Rotator cuff problems cause pain, especially with activities like reaching or throwing. The deep, aching shoulder pain tends to worsen or flare up at night, and it can wake you up from sleep or make it difficult to fall asleep.
Rotator cuff problems can be associated with a limited active range of motion.4 Since it’s hard to voluntarily move your injured or inflamed muscle, your shoulder may feel stiff. But if someone does the work for you by lifting your arm (passive movement), your shoulder will likely move normally.
Also called adhesive capsulitis, frozen shoulder is a common condition that leads to joint stiffness and pain, which can be constant. While many shoulder conditions, including rotator cuff tendinitis, can be associated with frozen shoulder, the cause is often unknown.
With a frozen shoulder, there is a decrease of both active and passive range of motion.5
Calcific tendonitis occurs when calcium crystals are deposited within a tendon, most commonly within the rotator cuff tendons. This condition typically causes progressive shoulder pain that is worse at night and with overhead motions, like putting on a shirt. While some people develop a chronic case, for many people the symptoms resolve on their own over three to six months.
Front of the Shoulder
Pain in the front of the shoulder is most commonly related to the biceps tendon a tendon that attaches deep inside the shoulder. Conditions include biceps tendonitis, SLAP tears, and biceps tendon tears.
Biceps tendon problems usually cause gradual pain at the front of the shoulder that can continue down over the biceps muscle. The pain is often worse with repetitive lifting, carrying heavy bags, or overhead activities, and it can be worse at night.
Problems with the biceps tendon may also cause a clicking sound when the shoulder is rotated in an arc.
Biceps Tendon Rupture
A biceps tendon rupture may occur if the biceps muscle breaks free near the joint. The symptoms of a biceps tendon rupture include a sudden “pop,” along with an acute worsening of pain, bruising, swelling, and often a lump just above the antecubital fossa (in front of your elbow).
A superior labrum anterior-posterior tear (SLAP tear) is a specific type of glenoid labrum (cartilage in the shoulder joint) tear. One common cause is a fall on an outstretched hand.
It’s also a common tear in athletes who throw overhead (for example, baseball pitchers) or workers involved in repetitive overhead activities.9 Symptoms may include deep shoulder pain, a catching sensation, and a popping sound with movement.
With shoulder osteoarthritis, you can have deep shoulder pain or pain at the front of your shoulder, along with stiffness. There is generally a decrease in both active and passive range of motion. Shoulder arthritis can sometimes be preceded by an injury to the arm, neck, or shoulder that occurred years prior.
Top of Shoulder
Shoulder arthritis is less common than knee and hip arthritis, and when severe, it may be treated with joint replacement surgery.
The most common cause of pain in the top of the shoulder is an abnormality of the acromioclavicular joint (AC) joint. Problems of the AC joint include AC arthritis, AC separation, and distal clavicle osteolysis.
Arthritis can cause wearing away of smooth cartilage, cartilage roughness, and bone spurs, which may limit mobility.
Exposed bone and uneven cartilage surfaces may cause crepitus (a grinding sensation), especially when you reach overhead or across your chest.
AC separation (also called a shoulder separation) can occur after a fall right onto your shoulder that injuries the ligaments surrounding your AC joint.11 Depending on the severity of your ligament injury, a bump may form above your shoulder due to the separation of your shoulder blade from your collarbone.
Distal Clavicle Osteolysis
Distal clavicle osteolysis causes sharp or aching pain at the end of the collarbone (clavicle). It most commonly affects weightlifters or others who repeatedly lift or carry heavy objects.
All Over the Shoulder
The tendons, ligaments, and muscles in your shoulder keep it stable. If these tissues become loose or torn, shoulder instability or dislocation may occur.
Instability, as the name suggests, causes loosening of the joint. It can be caused by a traumatic injury (dislocation) or from overuse. Shoulders that feel unstable may feel as though they will pop out of the joint.
Multidirectional instability can result from chronically loose ligaments.13 This usually affects young, athletic women, and it can make you feel like your shoulder is not staying tightly in position (subluxation of the shoulder). The sensation is often described as a “dead arm” with excessive shoulder range of motion.
A dislocation is an injury that occurs when the top of the arm bone becomes disconnected from the scapula. If someone has dislocated their shoulder, then the normal ligaments that hold the shoulder in position may be damaged, and the shoulder has a tendency to pop out of the joint again.
When to See a Doctor
If you have new, worsening, or severe shoulder pain, you should seek medical attention.
Some signs that you should be seen by a doctor include:
- Inability to carry objects or use your arm
- An injury that causes joint deformity
- Shoulder pain that occurs at night or while resting
- Shoulder pain that persists beyond a few days
- Inability to raise your arm
- Swelling or significant bruising around your joint or arm
- Signs of an infection, including fever, skin redness and warmth
- Any other unusual symptoms associated with your shoulder pain like abdominal pain or trouble breathing
Since there are many potential causes of shoulder pain, your doctor will do a careful review of symptoms, physical examination, and sometimes imaging tests to make a proper diagnosis.
After reviewing your symptoms and medical history, your doctor will perform a thorough exam of your shoulder. They will press on different areas of your shoulder to evaluate for tenderness or deformity. They will also test your arm strength and your shoulder range of motion.
Your doctor may also examine other areas of your body, like your neck or abdomen, to rule out non-shoulder related causes of your pain.
You might need one or more of the following:
- X-ray: A shoulder x-ray can visualize bone injuries or subtle problems, like bone spurs, that could suggest a diagnosis of osteoarthritis.
- Magnetic resonance imaging (MRI): This test provides detailed images of the tendons, ligaments, and muscles that surround the shoulder joint. For instance, an MRI can provide information about the location, size, and relative age of a rotator cuff tear.
While it seems logical that shoulder pain would stem from the shoulder, this is not always the case. Pain in the general shoulder area, often difficult to pinpoint, can sometimes be related to a herniated disc in the neck or gallbladder disease. In rare cases, shoulder pain can be a symptom of a heart attack or bleeding from the liver or spleen.16
If your doctor has concerns about another cause that’s outside your shoulder joint, they may focus on that diagnosis. For example, an electrocardiogram (ECG), along with cardiac enzymes may be ordered for a suspected heart attack, while an abdominal ultrasound may be ordered for suspected gallbladder disease.
In the end, teasing out the cause of your shoulder pain is often tricky and not as straightforward as you may think.
The treatment of shoulder pain depends entirely on the cause of the problem. And while one treatment protocol may be useful for one issue, it may not be helpful, or can even be harmful, for another.
It is of the utmost importance that you seek medical advice so you know what you are treating and how you need to treat it before embarking on a program. Not all treatments listed here are appropriate for every condition, but some may be helpful in your situation.
The first treatment for many common types of shoulder pain is to rest the joint and allow the acute inflammation to subside. It is important, however, to use caution when resting the joint, because prolonged immobilization can lead to stiffness.
Ice and Heat Application
Ice packs are most often used to reduce the swelling and pain from an acute shoulder injury, but they can also be used to treat shoulder overuse injuries (for example, rotator cuff tendinitis or bursitis).18 In these cases, the ice is applied right after the overhead activity to minimize the onset of inflammation.
Heat pads are also used to treat chronic shoulder conditions, but generally before the overhead activity is performed. Heat can relax the muscles, ease stiffness, and reduce pain.
Before applying ice or heat, talk with your doctor or physical therapist. Developing a specific plan for the timing and duration of each treatment is important for optimizing your shoulder healing.
Physical therapy is an important aspect of shoulder pain treatment.20 Your physical therapists may use different modalities to increase your strength, restore mobility, and help you get to your pre-injury level of activity.
The two most common medications used to ease shoulder pain and swelling are nonsteroidal anti-inflammatories (NSAIDs) and steroid injections.
Some NSAIDs are available over-the-counter (for example, ibuprofen), and others are only prescribed, like Voltaren (diclofenac). These are commonly used to treat shoulder problems like arthritis, bursitis, and tendonitis.
That said, it’s important to only use them for a short duration and only under the guidance of your doctor. NSAIDs are associated with some risks; be sure to notify your doctor if you are pregnant or have any health problems like high blood pressure, asthma, or a history of kidney disease, liver disease, or stomach ulcers.
With a steroid injection, your doctor will give you a shot of cortisone a powerful steroid medication that reduces inflammation into your shoulder. An injection can help alleviate pain and help you engage in physical therapy sessions more easily.
In some cases, surgery will be needed if conservative measures are not working or if your shoulder injury is too severe from the start. If you are considering shoulder surgery, you will need to see an orthopedic surgeon.
A Word From Verywell
While sorting out the “why” behind your shoulder pain can be a challenging process, try to remain patient. The shoulder is a complex structure and getting the right diagnosis is ultimately the key to your recovery.
If you develop a shoulder ailment, you should rest assured knowing that the vast majority of people find relief from their symptoms.
Jonathan Cluett, MD for VeryWellHealth
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