Shoulder pain: causes, red flags and when to seek help

Three questions narrow down shoulder pain quickly. Does it hurt when you use your arm, or at rest and at night? Can you move the arm freely, or is it stiff in every direction? And is there any weakness, tingling or a sense of the joint catching or giving way?

The NHS gives a pattern guide: pain and stiffness that does not go away over months or years suggests frozen shoulder or arthritis (osteoarthritis or rheumatoid arthritis), pain that is often worse while using the arm or shoulder suggests tendonitis, bursitis or impingement, a tingling, numb or weak arm with clicking or locking suggests shoulder instability, sometimes from hypermobility, and sudden very bad pain with inability to move the arm, sometimes with a changed shape, suggests a dislocated shoulder, broken bone or torn tendon. Pain on top of the shoulder, where the collarbone meets the shoulder joint, suggests a problem in the acromioclavicular joint.

Rotator cuff tendinopathy and impingement are the commonest, causing a deep ache on the outer shoulder, a painful arc when the arm is raised sideways, and pain lying on that side at night. Frozen shoulder is different, with stiffness in all directions, including when someone else tries to move the arm. Osteoarthritis tends to cause grinding and stiffness in older adults. Acute tears follow a fall or a heavy lift.

Not all shoulder pain starts in the shoulder. Neck problems can refer pain into the shoulder and down the arm, usually with neck stiffness or tingling in the hand. Pain from the heart, lungs, gallbladder or diaphragm can be felt in the shoulder tip.

The NHS says the 2 main symptoms are shoulder pain that can be worse at night and disturb sleep, and stiffness that makes it difficult to move. It says it can take months or years to get better but the pain and stiffness will usually go away eventually. It happens when the tissue around the shoulder joint becomes inflamed, then gets tighter and shrinks, and it is often not clear why; it can follow an injury or surgery that stops you moving the arm normally, and it is associated with diabetes.

Treatment, the NHS says, works in three steps: pain relief with paracetamol and, if that does not help, an NSAID such as ibuprofen, then stronger painkillers or a steroid injection if needed, and getting movement back with gentle exercises and physiotherapy, which usually lasts at least 6 weeks.

The NHS says to ask for an urgent GP appointment or get help from NHS 111 if you have sudden or very bad shoulder pain, cannot move your arm, your arm or shoulder has changed shape or is badly swollen, you have pins and needles that do not go away, there is no feeling in your arm or shoulder, your arm or shoulder is hot or cold to touch, the pain started after an injury or accident such as a fall, you develop severe pain in both shoulders, or you feel feverish or unwell. It says these can be signs of something serious, like a broken or dislocated bone or a torn ligament or tendon.

Shoulder or arm pain together with chest pain, breathlessness, sweating, nausea or jaw pain may be heart pain and needs 999. Pain in the tip of the shoulder with severe abdominal pain after an injury, or a hot, red, very painful shoulder with fever suggesting joint infection, should be assessed in an emergency department. A new weak, wasted shoulder after illness or with severe nerve pain needs prompt specialist input.

The NHS says a health professional will examine you to work out what is causing your shoulder pain, and may send you for tests such as an X-ray. They will ask about injury, occupation, sport, hand dominance, night pain, other joints, neck pain and medical conditions such as diabetes and thyroid disease. They look at both shoulders, feel for tenderness, test active and passive movement, check strength and nerve function and examine the neck.

X-rays show arthritis, calcium deposits and fractures. Ultrasound or MRI show tendon tears and inflammation and are used when pain persists, weakness is marked or surgery is being considered.

The NHS suggests staying active and gently moving the shoulder, trying shoulder exercises for 6 to 8 weeks to stop pain returning, standing straight with the shoulders down and gently back, sitting with a cushion behind the lower back, resting the arm on a cushion in the lap and using pain relief to keep moving, such as paracetamol and ibuprofen and heat or cold packs. It says a frozen peas pack wrapped in a tea towel for up to 20 minutes 3 times a day or a hot water bottle wrapped in a tea towel for up to 20 minutes 2 to 3 times a day can help.

It says you usually need to do these things for 2 weeks before pain starts to ease. It advises against completely stopping using your shoulder, doing things that seem to make it worse, making up strenuous exercises or using heavy gym equipment, and slouching when sitting.

Treatment depends on the cause. The NHS lists stronger medicine or injections to ease pain and swelling, physiotherapy or exercises, advice about things to avoid and referral to a specialist for tests or treatment. It says physiotherapy is available through the NHS but waiting times can be long, and you can pay to get it privately, and that you can go back to your GP or refer yourself back to community musculoskeletal services if you are still in pain after sessions end.