Shoulder pain: the symptoms and what usually causes them

Shoulder pain is usually a problem with the tendons around the joint, and it is famously poor at describing itself. The pattern of what hurts at what angle, and what a person can no longer do, sorts it better than a scan.

The patterns and what they mean

• Pain on lifting the arm between about sixty and a hundred and twenty degrees, with the arc easing at the top, worse reaching overhead and worse lying on that side: the rotator cuff being pinched, the commonest picture by a wide margin.
• A shoulder that has become stiff in every direction, including the ones somebody else moves for you, after weeks of pain: frozen shoulder. It progresses through a painful stage and a stiff stage, takes months to years, and is markedly more common in diabetes.
• Pain after a fall on an outstretched hand or a sudden pull, with weakness and an inability to hold the arm out to the side: a cuff tear, and a full-thickness tear in a younger person is a surgical question with a time limit on it.
• Deep ache with grinding, in someone over sixty, worse at the end of the day and hardest with the arm behind the back: the shoulder joint itself wearing, or the joint where the collarbone meets it.
• Sudden, exquisite pain with a person holding the arm rigidly against the body, unable to move it at all: calcific tendinitis, which is among the most painful things a joint does, and which settles.
• Pain that is not in the shoulder at all: from the neck, arriving with a particular neck movement, with tingling down to the fingers, and often with the shoulder examination entirely normal.
• Right shoulder-tip pain after a fatty meal, with upper abdominal discomfort: referred from the gallbladder. Left shoulder pain with exertion, sweating and breathlessness: cardiac. Both of these are dangerous causes presenting as a shoulder.
• A shoulder that aches at night with weight loss, or that is hot, red and swollen with fever: not a tendon problem.

What we ask

• How it started, and whether it was a fall, a lift, a new activity, or nothing at all.
• Where the pain is exactly, and whether it goes above the neck or below the elbow. Pain below the elbow is a nerve until disproved.
• What a person cannot do: reach a shelf, fasten a bra or a belt, put on a jacket, wash the back, sleep on that side. Function is the honest measure here.
• How long the stiffness has been present, and whether pain or stiffness is the leading complaint.
• Diabetes, thyroid disease, a previous injury, and the same shoulder having been treated before.
• Work and sport: painting, plastering, teaching, swimming, throwing, carrying, and hours at a keyboard with the arm held out.
• Whether the neck, the elbow or the upper back has been hurting first.

What we look at

• Movement in three planes, and the arc in which pain appears, with the same tests done passively. A shoulder that cannot be moved by somebody else either is stiff; one that the examiner can move but the patient cannot lift is weak, and those are different problems.
• Strength against resistance, tested side to side, since asymmetry is the finding that matters.
• The neck, the shoulder blade position, the collarbone joints, and the nerves below it, including a quick check of the whole arm and hand.
• The other shoulder, because a symptomatic one usually has an asymptomatic twin.
• X-ray for a post-fall shoulder, for a deformity, for grinding in an older joint, and before an injection. Ultrasound for the cuff, which is genuinely useful and cheap. MRI when a tear needs defining or when the diagnosis has not settled after a proper trial.
• Bloods where the picture suggests inflammation, infection, or a referred cause, and an ECG where the story is exertional left shoulder pain with sweating.

Red flags

• A fall with deformity, an inability to lift the arm at all, or severe pain with any movement. Dislocation or fracture, and it needs imaging the same day.
• Chest pain, breathlessness, sweating or nausea with shoulder or jaw pain, particularly on exertion. Emergency care.
• A hot, red, swollen, exquisitely painful shoulder with fever. Infection in the joint, and cartilage is destroyed in days.
• Progressive weakness, wasting of the muscles above and below the collarbone, or a shoulder that is dropping, with neck pain or tingling. A nerve, and it needs a specialist.
• Night pain unaffected by position, with weight loss, or a history of cancer.
• A shoulder that has gone completely rigid in a person with diabetes, or one that has not improved after three months of proper treatment.

What helps

• For the cuff and the impingement picture: relative rest from the overhead activity, not from movement, plus a progressive programme for the cuff and the shoulder blade, three to four times a week, over eight to twelve weeks. This is the treatment. Injections and tablets exist to make the exercises possible.
• For a frozen shoulder: pain control first, then gentle stretching into the end of the range several times a day, then, if progress stalls, an intra-articular injection or distension, and only rarely a procedure under anaesthesia. Aggressive forced movement in the painful stage makes it worse and is a common cause of a bad month.
• For a cuff tear in a younger person after an injury: a surgical opinion early, because the outcome of a repair depends on how long the tendon has been retracted.
• For neck-driven pain: the neck is treated, not the shoulder.
• Sleep position, with the arm supported on a pillow rather than hanging, and a change of side.
• Heat before the exercises and ice after, if either helps, and neither is a substitute for the programme.
• Diabetes control, which genuinely changes how a frozen shoulder behaves and how long it lasts.

Where Ayurvedic care sits

• Medicated oils applied over the shoulder and the outer upper arm, with gentle warmth and a slow massage before the exercise session. This is the strongest part of the herbal contribution and it is external, not internal.
• Dashamoola kwath as the base for the aching, and it tolerates the weeks a shoulder actually takes.
• Yogaraja guggulu for the stiff, cold, slow picture; kaishora guggulu where the pain is sharp, hot and worse at night.
• Ashwagandha where sleep has gone, which with night-time shoulder pain it nearly always has.
• Guduchi as general anti-inflammatory support, and triphala at night for the bowel.
• What no preparation does is reattach a torn tendon, un-fuse a frozen joint, or treat an infected one, and a shoulder that is losing strength should be scanned rather than given another course.

How we judge it

• Which activities have come back: the shelf, the jacket, the seatbelt, sleeping on that side.
• The arc through which pain appears, measured the same way at each review.
• Strength against resistance, side to side, and whether wasting has changed.
• Whether the exercise programme has actually been done, since a shoulder that has not improved at twelve weeks has nearly always been given rest rather than loading.
• A shoulder that is weaker, stiffer or more painful after three months of proper conservative care goes for imaging and an orthopaedic opinion rather than a fourth month of the same.