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Shoulder pain is a common symptom in primary care. It can be due to an intrinsic shoulder problem but pain can also be referred from other structures, such as the diaphragm, heart or the neck. Common shoulder problems share overlapping clinical features. When assessing shoulder pain, it is important to look for any 'red flags' that mean investigation and diagnosis need a more focused or urgent approach.
Anatomy of the shoulder joint
The humerus, glenoid, scapula, acromion, clavicle and surrounding soft tissues make up the shoulder. There are three significant articulations: the sternoclavicular joint, the acromioclavicular joint and the glenohumeral joint. The glenohumeral joint is the most commonly dislocated major joint in the body.
Ligaments and surrounding musculature, including the rotator cuff muscles, contribute to shoulder joint stability. The rotator cuff is composed of the four muscles: supraspinatus, infraspinatus, teres minor and subscapularis. These muscles help with internal and external rotation of the shoulder and also depress the humeral head against the glenoid.
- Shoulder pain is the third most common cause of musculoskeletal consultation in primary care.
- 1% of adults with new shoulder pain consult their GP each year.
- Self-reported prevalence of shoulder pain is between 16% and 26%.
- Physical factors related to occupation including repetitive movements and exposure to vibration from machine tools.
- Psychosocial factors related to work may also be risk factors for shoulder pain, including stress, job pressure, social support and job satisfaction. However, in a systematic review, results were not consistent.
- Athletes who are involved in throwing sports, sports that involve repetitive arm movements or high-impact contact sports, eg rugby and swimming/diving, are prone to shoulder pain.
- Occupations particularly prone to shoulder pain syndromes include: cashiers, garment makers, bricklayers/construction workers, pneumatic tool operators, welders, meat/food-processing workers, hairdressers, plasterers, assembly/production line workers, and workers using keyboards for long periods, eg IT, secretarial.
Patients presenting in primary care often have a combination of different shoulder problems.
- Intrinsic shoulder pain:
- Rotator cuff disorders: rotator cuff tendinopathy, impingement (trapping of the rotator cuff tendon, particularly the supraspinatus, in the subacromial space), subacromial bursitis, rotator cuff tears, calcific tendonitis.
- Glenohumeral disorders: adhesive capsulitis ('frozen shoulder'), arthritis.
- Acromioclavicular disorders.
- Biceps tendonitis.
- Infection (rare).
- Shoulder instability - associated with hypermobility including subluxation or dislocation (see also separate article Shoulder Dislocation).
- Extrinsic shoulder pain:
The four most common causes of shoulder pain and disability in primary care are rotator cuff disorders, glenohumeral disorders, acromioclavicular joint disease and referred neck pain.
Rotator cuff disorders
Impingement syndrome (or rotator cuff syndrome) is used for rotator cuff lesions, including all stages of tendon disease from early degeneration through to complete tears.
- Most often present in patients aged 35-75 years.
- Rotator cuff tendinopathy is the most common cause of shoulder pain:
- There may be a history of heavy lifting or repetitive movements, especially above shoulder level. However, it often occurs in the non-dominant arm and in non-manual workers.
- On examination there may be muscle wasting with pain on movements and a partial restriction of active movements (passive movements are full but painful). Particularly pain on abduction with thumb down, and the pain is worse against resistance.
- A painful arc (between 70 to 120° of active abduction) is not specific or sensitive but increases the likelihood of a rotator cuff disorder.
- A rotator cuff tear:
- Usually follows trauma in young people. It is usually atraumatic in elderly people and caused by attrition from bony spurs on the undersurface of the acromion or intrinsic degeneration of the cuff.
- Partial tears may be difficult to differentiate from rotator cuff tendinopathy on examination.
- The drop arm test (see 'Examination', below) may be used to detect a large or complete tear.
- Adhesive capsulitis most often presents between the ages of 40 to 65 years, and osteoarthritis in those aged 60 years or older.
- Adhesive capsulitis (frozen shoulder) and arthritis often present with a history of non-adhesive capsulitis symptoms, cause deep joint pain, and restrict activities such as putting on a jacket - because of impaired external rotation.
- Adhesive capsulitis is more common in people with diabetes and may also occur after prolonged immobilisation.
- There is usually generalised shoulder pain and a restriction of passive and active movements.
See also separate article Acromioclavicular Joint Problems.
- They are usually caused by trauma or osteoarthritis.
- Dislocation of the joint may occur after injury. Pain and tenderness are localised to the acromioclavicular joint and there is a restriction of passive, horizontal movement of the arm across the body when the elbow is extended.
- Acromioclavicular osteoarthritis may cause subacromial impingement.
Referred neck pain
See also separate article Neck Pain (Cervicalgia) and Torticollis.
- Typically, this presents with pain and tenderness of the lower neck and suprascapular area, with pain referred to the shoulder and upper arm.
- There may be a restriction of shoulder movement and movement of the neck and shoulder may reproduce more generalised upper back, neck, and shoulder pain.
- There may also be upper limb paraesthesia.
Assessment of shoulder pain
When assessing shoulder pain, take a history and perform an examination with these questions in mind:
- Is the pain arising from the shoulder, neck or elsewhere?
- Are there any 'red flag' symptoms/signs? (See box 'Red flag symptoms/signs', below.)
- Is the pain localised to the acromioclavicular joint? If yes, there is acromioclavicular joint disease.
- Is there global pain and restriction of all active and passive movements? If yes, this suggests glenohumeral joint disorder (either 'frozen shoulder' or arthritis).
- Is there pain on abduction with thumb down, worse against resistance and/or is there a painful arc? If yes, this suggests a rotator cuff disorder.
Points to cover in the history include:
- The nature of the pain including:
- How the pain started.
- Any specific injury.
- Whether it is acute or chronic.
- Any impact on function/activities of daily living.
- Whether the pain is on the side of the dominant hand.
- Whether there is pain at rest or on movement.
- Whether there is night pain that affects sleep.
- Any associated pain - for example, neck, chest or other upper limb or joint pain.
- Any history of shoulder pain/instability/dislocation.
- The patient's occupation.
- The patient's sporting activities.
- Any signs or symptoms of systemic illness.
- Past medical history (particularly any history of diabetes, ischaemic heart disease, cancer).
- Drug history and adverse drug reactions.
Pain from generalised capsulitis is felt at the outer aspect of the upper arm or deltoid region and may keep the patient awake. Anterior capsulitis usually causes well-localised pain felt anteriorly over the upper biceps insertion. Rotator cuff/supraspinatus pain is also felt in the upper aspect of the arm or deltoid region and will be accompanied by a painful arc.
See separate article Shoulder Examination for further details.
- Examine the neck, axilla and chest wall.
- Examine the cervical spine and assess range of movement.
- Inspect from the front, side, and behind for muscle wasting, swelling and deformity, or bruising.
- Palpate the sternoclavicular, acromioclavicular and glenohumeral joints. Look for tenderness, swelling, warmth and crepitus.
- As an initial screening test, ask the person to place the palms of their hands at the base of the neck with elbows pointing laterally and then to put their arms down and try to put the back of the hands between the shoulder blades. However, be aware that this also involves joints other than the shoulder (ie elbow, wrist).[RR63610]
- Assess the power, stability and range of movement (active, passive and resisted) in both shoulders.
- Look for a painful arc (pain between 70 and 120° of abduction).
- Test passive external rotation (reduced in 'frozen shoulder'). With the elbow held into the side, turn the arm outwards as far as possible.
- Perform the 'drop arm test': passively abduct the patient's shoulder. Then ask the patient to lower the abducted arm slowly to the waist. This can identify a rotator cuff tear. They may be able to lower the arm slowly to 90° because this uses mostly the deltoid muscle but, below 90°, the arm will drop to the side.
- Perform the 'cross-arm test': this isolates the acromioclavicular joint. Ask the patient to raise the arm to 90° straight in front of them. Then ask the patient to adduct the arm across the chest. If there is an acromioclavicular joint problem, there will be pain in the area of the joint.
Red flag symptoms/signs
- History of malignancy or symptoms/signs consistent with neoplasia, eg weight loss, deformity, mass or swelling, abdominal discomfort/swelling.
- Overlying skin erythema may suggest tumour or infection.
- Symptoms/signs of systemic illness: ask specifically about symptoms that may indicate polymyalgia rheumatica/giant cell arteritis.
- Fever can suggest malignancy or infection.
- History of trauma or recent convulsion/electric shock may suggest an unreduced dislocation.
- Change in shoulder contour with loss of rotation suggests dislocation.
- Trauma with acute disabling pain and positive 'drop arm test' suggest an acute rotator cuff tear.
- The presence of a significant sensory or motor deficit suggests a neurological lesion.
- Blood tests and radiology are generally only necessary if there are 'red flag' symptoms/signs.
- Plain X-rays may help diagnose massive rotator cuff tears, shoulder instability, and shoulder arthritis.
- Magnetic resonance imaging and ultrasonography are preferred for rotator cuff disorders.
- If referred neck pain is suspected then cervical spine X-rays may be helpful.
- If there are relevant 'red flags' to indicate systemic illness then consider blood tests including FBC, ESR/CRP and further investigations such as chest X-ray as appropriate.
See also separate article Shoulder Joint Replacements.
Management in primary care is usually conservative, with rest, attention to any contributing factors and medication for pain relief. The evidence for steroids and physiotherapy is relatively weak. Steroid injections have only a marginal short term effect on pain. Surgery may be required when conservative measures fail.
- Corticosteroid injections may be of short-term benefit when either used alone or as an adjuvant to physiotherapy. See separate article Joint Injection and Aspiration.
- Physiotherapy may be effective for shoulder pain in some cases but further high quality trials are needed.
- There is not enough evidence to say whether acupuncture works to treat shoulder pain or if it is harmful.
- Rotator cuff disorders:
- Advise relative rest of the affected arm and modification of activities, including reducing precipitating movements (eg reaching overhead).
- Offer analgesia; paracetamol with or without codeine, or an oral non-steroidal anti-inflammatory drug (NSAID).
- Refer to physiotherapy if self-care measures and analgesia are not effective.
- Consider a subacromial corticosteroid injection if the person has a poor response to initial treatment after several weeks and requires further pain relief, or has very limited function because of pain. Do not give a corticosteroid injection if:
- The person has previously received a corticosteroid injection with minimal or no benefit.
- The person has already had three or more injections in the same shoulder in the previous year.
- A rotator cuff tear is suspected.
- Corticosteroid injection is contra-indicated (eg infection, adjacent osteomyelitis).
- Evidence shows that physiotherapy and steroid injections may be equally helpful in the short-term. Injections may be repeated if the initial response is good.
- Rotator cuff tears:
- Physiotherapy and steroid injections may be helpful for minor tears. However, there is no proven harm or benefit from steroid injection if a rotator cuff tear is present so they should be avoided if there is a positive 'drop arm test'.
- Suspected acute, severe tears of the rotator cuff tendons may benefit from early referral for orthopaedic input.
- Surgical treatment usually involves rotator cuff tendon repair ± subacromial decompression, either through open surgery or arthroscopically.
- Calcific tendonitis:
- Crystalline calcium phosphate is deposited in a tendon, most commonly in the supraspinatus tendon of the rotator cuff.
- When calcific tendonitis is symptomatic, it may present as chronic, relatively mild pain in the shoulder, with sporadic episodes of pain radiating down the arm or to the neck, or with severe acute pain due to an inflammatory response.
- Treatment for calcific tendonitis includes non-steroidal anti-inflammatory drugs (NSAIDs), corticosteroids, physiotherapy, aspiration or lavage. For patients refractory to these treatments, open or arthroscopic shoulder surgery may be offered.
- Extracorporeal shock wave lithotripsy (ESWT) is recommended by the National Institute for Health and Clinical Excellence (NICE) as a non-invasive alternative to surgery.
- Glenohumeral disorders: see separate article Adhesive Capsulitis of the Shoulder.
- Acromioclavicular disease (see separate Acromioclavicular Joint Problems article):
- Acromioclavicular injury usually responds to rest and simple analgesia, unless there is significant disruption of the joint, in which case orthopaedic referral is necessary.
- Consider providing a sling for 5-7 days if an acromioclavicular joint sprain is suspected.
- Consider referring to physiotherapy after 4-6 weeks if the person responds poorly to rest and analgesia.
- Degeneration of the humeral head:
- The humeral head may degenerate as a result of a range of conditions, eg osteoarthritis, rheumatoid arthritis or avascular necrosis. The whole or only part of the articular surface of the humeral head may be affected.
- Conservative treatment includes physiotherapy, pain relief, topical or oral NSAIDs and corticosteroid injections.
- Patients who do not respond to conservative treatments may need surgery, which involves either shoulder arthroplasty using a stemmed humeral head prosthesis, or fusion of the joint.
- Shoulder resurfacing arthroplasty replaces only the damaged joint surfaces, with minimal bone resection, and is recommended by NICE as a surgical option.
Criteria for referral to secondary care
Consider referral for orthopaedic or other appropriate specialist review for people who present with shoulder pain in the following circumstances:
- Pain and significant disability for >6 months, despite appropriate conservative management.
- History of joint instability.
- Acute severe post-traumatic acromioclavicular pain.
- Suspected unreduced dislocation.
- Diagnostic uncertainty.
- 'Red flags' indicating systemic illness or a condition requiring urgent investigation.
- The prognosis of chronic shoulder pain depends on the underlying cause.
- Increasing age, female sex, symptoms of gradual onset, prolonged symptoms, severe or recurrent symptoms and associated neck pain are associated with a worse outcome.
- Recovery in shoulder pain is generally slow. Studies have shown complete recovery at one month in 23% of patients, and at 18 months in 59% of patients.
Further reading & references
- Shoulder Disorders, Wheeless' Textbook of Orthopaedics
- Woodward TW, Best TM; The painful shoulder: part I. Clinical evaluation. Am Fam Physician. 2000 May 15;61(10):3079-88.
- Mitchell C, Adebajo A, Hay E, et al; Shoulder pain: diagnosis and management in primary care. BMJ. 2005 Nov 12;331(7525):1124-8.
- van der Windt DA, Thomas E, Pope DP, et al; Occupational risk factors for shoulder pain: a systematic review. Occup Environ Med. 2000 Jul;57(7):433-42.
- Shoulder pain, Prodigy (November 2008)
- Burbank KM, Stevenson JH, Czarnecki GR, et al; Chronic shoulder pain: part I. Evaluation and diagnosis. Am Fam Physician. 2008 Feb 15;77(4):453-60.
- Burbank KM, Stevenson JH, Czarnecki GR, et al; Chronic shoulder pain: part II. Treatment. Am Fam Physician. 2008 Feb 15;77(4):493-7.
- Green S, Buchbinder R, Hetrick S; Physiotherapy interventions for shoulder pain. Cochrane Database Syst Rev. 2003;(2):CD004258.
- Green S, Buchbinder R, Hetrick S; Acupuncture for shoulder pain. Cochrane Database Syst Rev. 2005 Apr 18;(2):CD005319.
- Green S, Buchbinder R, Glazier R, et al; Interventions for shoulder pain. Cochrane Database Syst Rev. 2000;(2):CD001156.
- Ejnisman B, Andreoli CV, Soares BG, et al; Interventions for tears of the rotator cuff in adults. Cochrane Database Syst Rev. 2004;(1):CD002758.
- Extra-corporeal shockwave lithotripsy for calcific tendonitis (teninopathy) of the shoulder, NICE (2003)
- Simovitch R, Sanders B, Ozbaydar M, et al; Acromioclavicular joint injuries: diagnosis and management. J Am Acad Orthop Surg. 2009 Apr;17(4):207-19.
- Shoulder resurfacing arthroplasty, NICE Interventional Procedure Guideline (July 2010)
Disclaimer: This article is for information only and should not be used for the diagnosis or treatment of medical conditions. EMIS has used all reasonable care in compiling the information but make no warranty as to its accuracy. Consult a doctor or other health care professional for diagnosis and treatment of medical conditions. For details see our conditions.
Dr Michelle Wright
Dr Colin Tidy
Dr John Cox