Causes of Shoulder Pain and Treatment Options

The shoulder is the most flexible joint in your body, and given the number of everyday activities it's involved in—from brushing your hair to reaching up into the cupboard—it's easy to see why shoulder pain is something you'd want to get to the bottom of right away. Shoulder pain can be due to osteoarthritis, muscle tears, tendonitis, and several other causes. The many possibilities are owed to the anatomy involved in allowing your shoulder to do what it does.

The shoulder consists of three bones—your upper arm (humerus), shoulder blade (scapula), and collarbone (clavicle). The top of your upper arm bone (shaped like a ball) fits into a shallow socket in your shoulder blade. While strong ligaments keep the "ball" centered in the socket, your rotator cuff muscles (which also cover the upper arm bone) allow you to lift and rotate your arm. Issues with any part of this architecture can cause you to experience pain in the shoulder.

Shoulder pain, also called deltoid pain, is an extremely common problem. Given the shoulder's complex anatomy, there are many potential causes. To best understand them, it's easiest to explore the possibilities by zeroing in on exactly what part of the shoulder hurts.

The most common cause of pain over the outside of the shoulder is a rotator cuff problem.

Rotator Cuff Problem: 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.

There are three main types of rotator cuff problems: tendonitis, bursitis, and rotator cuff tear. While rotator cuff bursitis and tendonitis refer to inflammation of the bursa (a fluid-filled space) and tendons (which connect your shoulder muscles to your upper arm bone), respectively, a rotator cuff tear occurs when the tendons of the rotator cuff separate from the bone.

In terms of symptoms, rotator cuff problems are usually painful with activities such as reaching or throwing. In addition, the deep, aching shoulder pain from a rotator cuff problem tends to be worse or flare at night. The reasoning is unclear, but it's not unusual 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.

In terms of mobility, a limited active range of motion is typical of a rotator cuff problem. Since the injured or inflamed muscle will not do the appropriate work, the shoulder often feels stiff. But if someone does the work for you by lifting your arm, the shoulder moves normally.

Frozen Shoulder: Also called "adhesive capsulitis," frozen shoulder is a common condition that leads to stiffness of the joint and sometimes constant pain, or just discomfort when reaching behind your back or head. While any shoulder pain can eventually progress to a frozen shoulder, the most common cause is a rotator cuff tendonitis.

Finally, with a frozen shoulder, there is a loss of passive range of motion (what the doctor can do when manipulating the arm), as well as a loss of active range of motion (what the patient can do alone).

Calcific Tendonitis: Calcific tendonitis describes a condition whereby calcium crystals are deposited within a tendon, most commonly within the rotator cuff tendons. This condition typically causes gradual 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.

Pain in the front of the shoulder is most commonly related to the biceps tendon—that which attaches deep inside the shoulder. Problems of the biceps include biceps tendonitis, SLAP tears, and biceps tears.

Bicep Tendonitis: People with bicep tendonitis usually develop gradual pain at the front of the shoulder that moves down over the biceps muscle. The pain is often worse with repetitive lifting, carrying heavy bags, or overhead activities. Problems with the biceps tendon may also cause a clicking sound when the shoulder is rotated in an arc, and like rotator cuff problems, the pain may be worse at night.

Bicep Tendon Rupture: More seriously, a bicep tendon rupture may occur, which means that the bicep muscle breaks free near the joint. The symptoms of a bicep tendon rupture include a sudden "pop" along with an acute worsening of pain, as well as bruising, swelling, and often the formation of a lump that forms just above the antecubital fossa (your elbow pit).

SLAP Tears: A superior labrum anterior posterior tear, more commonly referred to as a SLAP tear, is a specific type of glenoid labrum (shoulder joint) tear. The most 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. Symptoms may include a deep shoulder pain, a catching sensation, and a popping sound with movement (called crepitus).

Shoulder Osteoarthritis: With shoulder osteoarthritis, a person often describes a deep shoulder pain or a pain at the front of the shoulder, along with stiffness. There is generally a loss of both active and passive range of motion. Shoulder arthritis is relatively uncommon and is usually preceded by an injury to the arm, neck, or shoulder that occurred years prior.

The most common cause of pain in the top of the shoulder is an abnormal acromioclavicular joint (AC) joint. Problems of the AC joint include AC arthritis, AC separation, and distal clavicle osteolysis.

AC Arthritis: Shoulder arthritis is less common than knee and hip arthritis, but when severe, may require a joint replacement surgery. It can cause bone spurs and rough cartilage that limits mobility, as well as a wearing away of smooth cartilage. Exposed bone and uneven cartilage surfaces may cause a grinding sensation (crepitus), especially when reaching overhead or across the chest.

AC Separation: People who develop an AC separation (also called a shoulder separation) usually report a history of falling right onto their shoulder, the result of which is an injury to the ligaments that surround the AC joint. Depending on the severity of the ligament injury, a bump may form above the shoulder due to the separation of the shoulder blade from the collarbone.

Distal Clavicle Osteolysis: Distal clavicle osteolysis is an uncommon condition that causes a sharp or aching shoulder joint pain at the end of the collarbone (clavicle). It's most commonly seen in weightlifters or others who repeatedly lift or carry heavy objects.

Your shoulder depends on strong tendons, ligaments, and muscles to keep it stable. If these tissues become loose or torn, shoulder instability or dislocation may occur.

Shoulder Instability: Instability is a problem that causes a loose joint. Instability can be caused by a traumatic injury (dislocation) or from overuse. Shoulders that feel unstable may feel as though they will pop out of joint.

Some 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). They often describe a "dead arm" and have excessive range of motion of their shoulder.

Shoulder Dislocation: A dislocation is an injury that occurs when the top of the arm bone becomes disconnected from the scapula. If someone has dislocated his 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.

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.

Since there are many potential causes for shoulder pain, a careful review of symptoms, physical examination, and sometimes imaging tests are needed to make a proper diagnosis.

Physical Examination: After reviewing your symptoms and medical history, your doctor will perform a thorough exam of your shoulder. He will press on different areas of your shoulder to evaluate for tenderness or deformity. He will also test your arm strength and the range of motion of your shoulder.

In order to rule out non-shoulder related causes for your pain, he may also examine others areas of your body like your neck or abdomen.

Imaging: In addition to a physical examination, your doctor may order imaging tests to confirm a diagnosis.

• X-ray: An x-ray of the shoulder can detect whether or not there are any injuries to the bones that make up your shoulder joint, as well as look for subtler clues like bone spurs that could suggest a diagnosis of osteoarthritis.
• MRI: An MRI (magnetic resonance imaging) of the shoulder can provide 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 even 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 poorly localized or difficult to pinpoint, may be related to a non-musculoskeletal issue, like a herniated disc in the neck or gallbladder disease. More worrisome, shoulder pain can be a symptom of a heart attack or bleeding from the liver or spleen.

If your doctor believes your shoulder pain is referred and/or to ensure he is not missing a life-threatening diagnosis, he may order a number of different tests. 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.

The treatment of shoulder pain depends entirely on the cause of the problem. And while one protocol may be useful for one issue, it may prove harmful (or at least not as or at all helpful) 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 may be helpful in your situation.

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 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). In these cases, the ice is applied right after the overhead activity to diminish the onset of any 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 as to when to do each treatment, and how long it should last, is important for optimizing your shoulder healing.

Physical therapy is an important aspect of treatment of almost all orthopedic conditions. Physical therapists use different modalities to increase strength, restore mobility, and help return patients to their 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.

NSAIDs: NSAIDs, some of which are available over-the-counter (for example, ibuprofen), and others which are only prescribed, like Voltaren (diclofenac), 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.

Steroid Injection: With a steroid injection, your doctor will give you a shot of cortisone—a powerful steroid medication that treats inflammation—into the area of your shoulder where you are experiencing pain. An injection can not only alleviate pain but help you engage in physical therapy sessions more easily.

In some cases, surgery will need to be performed if conservative measures are not working or a shoulder injury is too severe from the start. If your shoulder requires surgery, an orthopedic surgeon should be consulted.

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 key to your recovery.

Lastly, if you develop a shoulder ailment, you can hopefully rest assured knowing that the vast majority of people fully recover, as long as they adhere to their treatment plan.