Shoulder pain

There are several possible causes of localized shoulder pain:

• inflammation or damage to the muscles and tendons around the shoulder
• inflammation in the sac of soft tissue (bursa) that normally allows the muscles and tendons to slide smoothly over the shoulder bones
• damage to the bones and cartilage, which can be caused by arthritis.

Shoulder pain isn't always caused by a problem in the shoulder joint. Problems in the neck, for example, can cause pain that is actually felt over the shoulder blade or in the upper outer arm (this is known as referred pain). If your shoulder pain is accompanied by a tingling sensation, this is also more likely to be caused by a problem in the neck.

Specific conditions that affect the shoulder include:

• Acute calcific tendinitis – Inflammation caused by a deposit of calcium in a tendon. It's not yet known why calcium builds up in some people. The condition may not cause any symptoms but can sometimes cause intense pain and restricted movement
• Bicipital tendinitis – This causes pain on bringing the arm forward or flexing the elbow and tenderness over the tendon that lies in front of the shoulder joint. Very occasionally the biceps tendon may rupture causing bruising just above the elbow and causing the biceps muscle to bunch
• Brachial neuritis – This causes severe pain over the shoulder area, a sudden reduction in the range of movement, and wasting of the shoulder muscles
• Frozen shoulder – A 'frozen' shoulder (adhesive capsulitis) is where the joint capsule tightens preventing movement. It's not known why this happens though it sometimes follows an injury, a heart attack or stroke, and is much more common in people with diabetes
• Painful arc syndrome – In this condition pain is usually felt as the arm is lifted away from the body. There is usually inflammation in the tendon (supraspinatus tendinitis) and/or the bursa (subacromial bursitis). Often this occurs because there isn't enough space below the acromion for the tendons to pass freely (impingement syndrome)
• Rotator cuff tear – A torn rotator cuff is most common in people over 40. Although the name suggests an injury most people don't remember hurting themselves beforehand. Typically you may find you can't raise your arm properly especially above shoulder height. It isn't always painful, although some people have pain for a few weeks before they notice any difficulty with movement. The muscles between the neck and the shoulder tend to compensate for lack of movement in the rotator cuff muscles which results in hunching of the shoulder.

• Blood tests are not helpful for most shoulder problems, although they are sometimes used to rule out other conditions or if your doctor suspects arthritis
• X-rays can be useful in certain cases, but they won't show problems in the soft tissues around the joint – muscles, tendons or cartilage. An x-ray may show minor changes, especially in the acromioclavicular joint, but these changes are quite common and may not be the cause of the pain. An x-ray may also show a deposit of calcium in the tendons which sometimes, though not always, causes inflammation and pain (acute calcific tendinitis)
• An ultrasound scan can be very helpful. It allows thickening in the soft tissues of the shoulder to be seen, and can also detect fluid and damage to tendons and muscles. It may also show larger tears in the rotator cuff, although an MRI scan is more reliable in assessing rotator cuff problems. Ultrasound or MRI can also be helpful in confirming a diagnosis of painful arc or impingement syndrome
• Magnetic resonance imaging (MRI) scans may be carried out when the doctor suspects a complex problem in the shoulder, or when specialized treatment is planned. They allow the soft tissues to be seen and are particularly helpful in identifying tears in the rotator cuff tendons. Occasionally a contrast medium is injected into the shoulder before the scan is carried out – this works a bit like a dye and allows more detail to be seen
• Nerve conduction studies can help in diagnosing brachial neuritis. Very small needles are placed in the muscles and a reading is taken of the electrical activity in the muscles and nerves.

Drugs

Steroid injections (cortisone) help many shoulder problems. Often the steroid is given along with a local anaesthetic, and you may find your shoulder pain is quickly reduced.

The injections reduce inflammation and allow you to move your shoulder more comfortably, though you should avoid using your shoulder for anything too strenuous in the first two weeks after an injection.

Sometimes the pain may be worse for a short time immediately following the injection but this doesn't mean that it has gone wrong. You only need to seek advice if the pain continues for more than a day or so after the injection.

Sometimes the injection is carried out with the aid of ultrasound images – these allow the inflamed tissues to be seen on a monitor so that the injection can be directed precisely.

Physical therapies

The vast majority of shoulder problems will benefit from physiotherapy. A physiotherapist will make an assessment of your condition and put together a treatment programme tailored to your needs. The aim may be to improve your symptoms or to restore function and might include:

• exercises to ease, or prevent, any stiffness
• exercises to strengthen weakened muscles and improve function
• advice on improving shoulder, neck and spine posture
• exercises to increase the range of joint movement
• ultrasound or other local treatment, such as transcutaneous electrical nerve stimulation (TENS) or heat/cold therapy, to ease pain
• applying adhesive tape to the skin to reduce the strain on the tissues and to help increase your awareness of the position of the shoulder and shoulder blade.

If your shoulder problem is interfering with daily activities, such as dressing, washing and driving, you may find it useful to see an occupational therapist.

Surgery

Most shoulder problems improve without the need for surgery. But some conditions can be helped by surgery.

If an operation is needed it can often be performed using keyhole techniques, which need a smaller incision and often reduce the recovery time needed. Examples include:

• removing loose pieces of bone or a calcium deposit if injections haven’t worked
• releasing the tight capsule of a frozen shoulder
• repairing tears in the rotator cuff
• trimming bone and tissue from the underside of the acromion at the top of the shoulder (subacromial decompression). This can be helpful for severe or recurrent impingement syndrome by giving space for the rotator cuff tendons to move freely.

Conventional surgery may be necessary in some circumstances, for example to repair larger tears in the rotator cuff.

Shoulder joint replacement and shoulder resurfacing are well established and can be very successful, particularly for osteoarthritis and rheumatoid arthritis when severe pain restricts movement and use of the shoulder. Some people regain more movement than others, depending on how severe your shoulder problem was before the surgery.

Physiotherapy and exercises are very important after surgery to help you regain movement.

Painkillers

Simple painkillers or anti-inflammatory tablets and creams that you can buy at the chemist can be helpful, but don't use them for more than two weeks without seeking medical advice.

Ice

If your shoulder is inflamed (warmer to touch than the other side) an ice pack may be helpful. Leave the ice pack in place for 10 minutes or so, making sure you protect your skin from direct contact with the ice.

Rest and exercise

Aim for a balance between rest and activity to prevent the shoulder from stiffening.

A pendulum exercise is good for all shoulder problems:

• Stand with your good hand resting on a table.
• Let your other arm hang down and try to swing it gently backwards and forwards and in a circular motion.
• This exercise can be done two or three times a day and repeated about five times on each occasion.

Another good exercise is to use your good arm to help lift up your painful arm. You may find these exercises more comfortable to do after applying ice.

Try to avoid the movements that are most painful, especially those that hold your arm away from your body and above shoulder height. When raising your arm you can reduce the strain or pull on your shoulder by:

• keeping your elbow bent and in front of your body
• keeping your palm facing the ceiling when reaching up.

To lower your arm, bend your elbow, bringing your hand nearer your body.

Research has shown that people who work hard to keep their muscles strong, and can maintain movement, tend to make a quicker and more complete recovery. It is important to remain generally active even if you have to limit how much you do of certain activities.

Posture

• Don't sit leaning forwards with the arm held tightly by your side. This position can make the problem worse, especially if some of the pain is coming from your neck
• When sitting, keep a pillow or cushion behind your lower back, with your arm supported on a cushion on your lap
• Some people find that placing a cushion or rolled towel under the armpit and gently squeezing onto it can ease the pain.

If your shoulder is painful to lie on, the following positions may reduce the discomfort:

• Lie on your good side with a pillow under your neck. Use a folded pillow to support your painful arm in front of your body. Another pillow behind your back can stop you rolling back onto your painful side
• If you prefer to sleep on your back, use one or two pillows under your painful arm to support it off the bed.

Reducing the strain

Generally it's best to carry out your normal activities, but try not to overdo things. You need to pace yourself to start with. Try to do a bit more each day.

At home...

• When vacuuming, keep your upper body upright with the cleaner close to your body, and use short sweeping movements.
• Only iron essential items, and make sure the ironing board is at waist height.
• Use a trolley or a backpack to carry shopping, or divide the weight between two bags and carry one in each hand.

At work...

• Try to maintain a good posture when sitting or standing. Avoid holding your neck in fixed or twisted postures.

• If you use a computer make sure the keyboard and monitor are directly in front of you, so you don't have to turn your head or twist your body. Keep the mouse within easy reach so you don't have to stretch.
• When using the phone don't trap the receiver between your head and shoulder.
• Avoid any manual work that hurts while you are doing it.

If your job involves repetitive actions and/or awkward postures that might contribute to your shoulder problems it's important to seek advice.

Some companies have an occupational health department who might be able to help. Alternatively, contact your local Jobcentre Plus office who can put you in touch with advisers specializing in physical difficulties at work.