Shoulder Pain: Signs, Causes, and Treatment Options

There are 11 potential causes of shoulder pain to consider

Woman with shoulder pain
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Shoulder pain is an extremely common problem, and many people in particular experience shoulder pain at night. However, not every painful shoulder has the same cause. While treatments for causes of shoulder pain may have some overlap and similarity, there may also be important differences in treatment based on the diagnosis. For that reason, the first step to managing a painful shoulder is to understand the source of the problem.

Making a Diagnosis

When making a diagnosis of shoulder pain, your doctor will look for signs of different conditions and will examine your upper extremity to test for possible problems. Some of the signs of different types of shoulder problems include:

Location of Pain

Outside of Shoulder: Pain over the outside of the shoulder often extends down the arm. The pain is often a deep muscle ache. The most common cause of pain over the outside of the shoulder is a rotator cuff problem, including tendonitis, bursitis, or a rotator cuff tear.

Front of Shoulder: Pain in the front of the shoulder is most commonly related to the biceps tendon. The biceps tendon attaches deep inside the shoulder; problems of the biceps include biceps tendonitis, SLAP tears, and biceps tears.

Top of Shoulder: The most common cause of pain in the top of the shoulder is an abnormal AC joint. Problems of the AC joint include AC arthritisdistal clavicle osteolysis, and shoulder separations.

Timing of Pain

Constant pain: Most shoulder problems tend to be bothersome with activity. Rotator cuff tendonitis and tears are usually painful with activities such as reaching or throwing. Constant pain is less typical for these conditions. Frozen shoulder can cause constant pain, but it's usually most painful when reaching behind your back or head.

Night pain: Shoulder pain at night is typical of rotator cuff problems. The reasoning is unclear, but it's not usual for patients with rotator cuff tendonitis, or a rotator cuff tear, to be awakened from sleep or have difficulty falling asleep because of shoulder pain.

Mobility

The mobility of your shoulder is limited with many conditions, but in different ways. In general, we talk about active range of motion (what you can do) and passive range of motion (what your examiner can do). Limited active range of motion is typical of a rotator cuff problem. In these conditions, the muscle will not do the appropriate work, so the shoulder feels stiff. But if someone does the work for you by lifting your arm, the shoulder moves normally.

Loss of passive range of motion is typical of a frozen shoulder and arthritis. With frozen shoulder, scar-like tissue builds up around the shoulder, leading to loss of motion—even if someone tries to move it for you. Shoulder arthritis can cause bone spurs and rough cartilage that can also limit mobility.

Strength

With 17 muscles that surround the shoulder, there are many conditions that can limit shoulder strength. There are four rotator cuff muscles that are critical to moving the shoulder.

These are not the big muscles involved with lifting heavy objects, but they are critical to moving the shoulder normally, and problems of the rotator cuff significantly limit shoulder strength.

Your doctor can isolate each of the rotator cuff muscles with specific tests and maneuvers to determine where a problem may exist. Sometimes the rotator cuff muscles don't work normally because of inflammation, and other times because they are detached (torn).

Instability/Popping Out

Shoulders that feel unstable may feel as though they will pop out of joint. If someone has dislocated his shoulder, then the normal ligaments that hold the shoulder in position may be damaged, and the shoulder can have a tendency to pop out of joint again.

Other people have loose ligaments that result in a chronically unstable shoulder called multidirectional instability. These are usually young, athletic women who feel their shoulder not staying tightly in position (subluxation of the shoulder).

Popping, Clicking, Snapping

Shoulder noises tend to occur with one of two conditions. Problems with the labrum or biceps tendon can cause a popping or snapping sensation. When the biceps tendon is unstable, it may shift from its normal position, causing a snapping sensation.

The shoulder labrum is cuff of cartilage that deepens the shoulder socket. Labral tears can catch in the shoulder, causing a click or pop. Shoulder arthritis can cause the smooth cartilage to wear away from the shoulder joint. Exposed bone and uneven cartilage surfaces may cause a grinding sensation called crepitus.

Causes of Shoulder Pain

  1. Bursitis | Rotator Cuff Tendonitis
    The most common diagnosis in patients with shoulder pain is bursitis or tendonitis of the rotator cuff.
  2. Rotator Cuff Tear
    Rotator cuff tears occur when the tendons of the rotator cuff separate from the bone. Surgery is sometimes necessary for this condition.
  3. Frozen Shoulder
    Also called 'adhesive capsulitis,' this is a common condition that leads to stiffness of the joint. Physical therapy and stretching are extremely important aspects of treatment.
  4. Calcific Tendonitis
    Calcific tendonitis is calcium deposits within a tendon -- most commonly within the rotator cuff tendons. Treatment of calcific tendonitis depends on the extent of symptoms.
  5. Shoulder Instability
    Instability is a problem that causes a loose joint. Instability can be caused by a traumatic injury (dislocation), or may be a developed condition.
  6. Shoulder Dislocation
    A dislocation is an injury that occurs when the top of the arm bone becomes disconnected from the scapula.
  7. Shoulder Separation
    Also called an AC separation, these injuries are the result of a disruption of the acromioclavicular joint. This is a very different injury from a dislocation!
  8. Labral Tear
    There are several patterns of a torn labrum and the type of treatment depends on the specific injury.
  9. SLAP Tear
    The SLAP lesion is also a type of labral tear. The most common cause is a fall on an outstretched hand.
  10. Shoulder Arthritis
    Shoulder arthritis is less common than knee and hip arthritis, but when severe may require a joint replacement surgery.
  11. Biceps Tendon Rupture
    A proximal biceps tendon rupture occurs when the tendon of the biceps muscle ruptures near the joint.

When Should You See a Doctor?

If you are unsure of the cause of your shoulder pain, or if you do not know the specific treatment recommendations for your condition, you should seek medical attention. Treatment of these conditions must be directed at the specific cause of your problem. Some signs that you should be seen by a doctor include:

  • Inability to carry objects or use the arm
  • Injury that causes deformity of the joint
  • Shoulder pain that occurs at night or while resting
  • Shoulder pain that persists beyond a few days
  • Inability to raise the arm
  • Swelling or significant bruising around the joint or arm
  • Signs of an infection, including fever, redness, warmth
  • Any other unusual symptoms

Treating Shoulder Pain

The treatment of shoulder pain depends entirely on the cause of the problem. Therefore, it is of utmost importance that you understand the cause of your symptoms before embarking on a treatment program. If you are unsure of your diagnosis, or how severe your condition is, you should seek medical advice before beginning any treatment.

Not all treatments listed here are appropriate for every condition, but may be helpful in your situation.

  • Rest: The first treatment for many common conditions that cause 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 cause a frozen shoulder.
  • Ice and Heat Application: Ice packs and heat pads are among the most commonly used treatments for shoulder pain. So which one is the right one to use, ice or heat? And how long should the ice or heat treatments last? Read on for more information about ice and heat treatment.
  • Stretching: Stretching the muscles and tendons that surround the joint can help with some causes of shoulder pain. A good routine should be established, and following some specific suggestions will help you on your way.
  • Physical Therapy: Physical therapy is an important aspect of treatment of almost all orthopedic conditions. Physical therapists use different modalities to increase strength, regain mobility, and help return patients to their pre-injury level of activity.

    Some specific exercises may help you strengthen the muscles around the joint and relieve some of the pain associated with many conditions.
  • Anti-Inflammatory Medication: Nonsteroidal anti-inflammatory pain medications, commonly referred to as NSAIDs, are some of the most commonly prescribed medications, especially for patients with shoulder pain caused by problems such as arthritis, bursitis, and tendonitis.
  • Cortisone injections: Cortisone is a powerful medication that treats inflammation, and inflammation is a common problem in patients with shoulder pain. Discuss with your doctor the possible benefits of a cortisone injection for your shoulder pain condition.

Sources:

Tonino PM, et al. Complex Shoulder Disorders: Evaluation and Treatment. J Am Acad Orthop Surg March 2009 ; 17:125-136.

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