Chronic Shoulder Pain

Common causes of chronic shoulder pain

Rotator cuff problems

The rotator cuff is a group of four muscles and tendons that hold the ball of the upper arm in the shallow socket and help lift and rotate the arm. With age and overuse, the tendons can become painful (tendinopathy) and can tear. Shoulder impingement describes pain when lifting the arm between about 60 and 120 degrees, as the tendon and bursa are compressed. Rotator cuff problems cause most chronic shoulder pain in adults.

Frozen shoulder

Frozen shoulder (adhesive capsulitis) is inflammation and thickening of the joint capsule. It passes through phases: a painful "freezing" phase, a stiff "frozen" phase, and a gradual "thawing" phase, often lasting 1 to 3 years in total. It is much more common in people with diabetes or thyroid disease.

Arthritis

Osteoarthritis of the main shoulder joint is less common than in the hip or knee and often follows previous injury. Rheumatoid arthritis and other inflammatory conditions can also affect the shoulder.

Other causes

• Calcific tendinitis: calcium deposits in the rotator cuff, causing severe flare-ups
• Overhead athletes: see thrower's shoulder
• Polymyalgia rheumatica: aching and stiffness of both shoulders and hips in people over 50
• Referred pain from the heart, lungs, gallbladder or diaphragm (right or left shoulder tip pain)
• Nerve problems: suprascapular nerve entrapment, brachial neuritis
• Rarely, tumors of the bone or lung (Pancoast tumor)

Symptoms that point to the cause

• Pain when lifting the arm, with full but painful movement: rotator cuff tendinopathy
• Weakness lifting or rotating the arm: rotator cuff tear
• Stiffness in all directions, with someone else unable to move the arm further either: frozen shoulder or arthritis
• Pain at the top of the shoulder: AC joint
• Pain that spreads below the elbow with tingling: neck
• Night pain lying on the shoulder: rotator cuff problems and frozen shoulder

Diagnosis

A doctor or physical therapist will ask about injury, activities, night pain and other joints, then examine movement (active and passive), strength and specific tests for the rotator cuff, AC joint and biceps. They will also check the neck.

• X-ray: shows arthritis, calcium deposits and the position of the ball in the socket
• Ultrasound: good for rotator cuff tears, bursitis and guiding injections
• MRI: for suspected tears, labral injuries, or before surgery
• Blood tests: for inflammation if polymyalgia or inflammatory arthritis is suspected

Treatment

Exercise and physical therapy

A structured, progressive exercise program is the first treatment for nearly all chronic shoulder pain. It typically includes:

• range-of-motion and stretching exercises
• rotator cuff and shoulder blade (scapular) strengthening
• posture and movement retraining
• gradual return to overhead activity

Expect 6 to 12 weeks of consistent exercise before judging the effect.

Pain relief

• NSAIDs (oral or topical gel) for flare-ups, following the label dose. Avoid oral NSAIDs with stomach ulcers, kidney disease or heart failure.
• Acetaminophen (paracetamol).
• Heat before exercise and ice after activity.
• Activity modification: reduce repetitive overhead work temporarily rather than stopping all movement.

Injections

• Corticosteroid injection into the bursa or joint can reduce pain for weeks to months and allow more effective exercise. Repeated injections are limited because they can weaken tendons.
• Hydrodilatation (injecting fluid to stretch the capsule) for frozen shoulder.
• Barbotage to break up calcium deposits.
• Suprascapular nerve block for pain in some cases.

Surgery

• Rotator cuff repair for full-thickness tears, especially in younger, active people or after a sudden injury.
• Shoulder replacement (anatomic or reverse) for advanced arthritis or large irreparable cuff tears.
• Capsular release for frozen shoulder that does not improve.
• AC joint excision for severe AC joint arthritis.
• Subacromial decompression alone for impingement has shown little benefit over placebo surgery in high-quality trials and is now used much less.

Frequently asked questions

What causes chronic shoulder pain?

The most common causes are rotator cuff tendinopathy and tears, frozen shoulder, and arthritis of the shoulder or AC joint. Neck problems can send pain into the shoulder. Less often, pain comes from inflammatory conditions or organs such as the heart, lungs or gallbladder.

Why won't my shoulder pain go away?

Shoulder pain often persists because rotator cuff tendons heal slowly, frozen shoulder takes 1 to 3 years to resolve, or arthritis is progressing. Continuing aggravating activities or avoiding all movement can also delay recovery. A tailored exercise program usually helps.

What is the best treatment for chronic shoulder pain?

A progressive exercise program with a physical therapist is the best first treatment for most causes. Pain relief and a steroid injection can help you exercise. Surgery is used for specific problems such as large rotator cuff tears or severe arthritis.

How do I know if my shoulder pain is a rotator cuff tear?

Rotator cuff tears cause pain on the outer upper arm, night pain, and weakness when lifting or rotating the arm. A sudden tear often follows a fall. An ultrasound or MRI confirms a tear, though many older adults have tears without pain.

Can neck problems cause shoulder pain?

Yes. Irritated nerves or joints in the neck can cause pain over the shoulder blade and top of the shoulder. Pain that spreads below the elbow, with numbness or tingling in the hand, points to the neck rather than the shoulder itself.