Shoulder pain

Shoulder pain is one of the most common types of joint problem.  
In the shoulders, many different muscles, ligaments, tendons, bursae (fluid-filled cushioning sacs) and bones work together. As a result, pain in this area can have several possible points of origin. It is not always possible to identify the exact cause. 

Most shoulder pain occurs in the subacromial space. This term refers to the space above the shoulder’s ball-and-socket joint and below the top-most bone of the shoulder. This type of pain is often referred to as impingement syndrome. However, shoulder pain may also have other underlying causes, such as frozen shoulder or arthritis.  

Pain in the subacromial space may clear up within six months but, in some cases, it persists for longer. It is a good idea to avoid arm movements that place too much strain on the joint until the pain improves.  

Pain often occurs in the subacromial space on the outside of the shoulder. It is often particularly painful when the arm is stretched out to the side of the body. The pain is sometimes worse at night when people lie on their shoulder in bed. This pain can sometimes be so severe that it jolts them awake. 

Shoulder pain has a range of possible causes. 
The subacromial space may become constricted due to bone spurs (osteophytes), wear and tear or calciferous deposits in the tendon of the supraspinatus muscle in the upper back.

However, shoulder pain may also be caused by bursitis (i.e. swelling of the bursae – small, fluid-filled sacs that cushion the bones) or a type III acromion, where the acromion – the bony projection on the very top of the shoulder blade – is more curved and downward-sloping than normal.

Muscle weakness or muscle load imbalance can also lead to a shortening of the ligaments and tendons in the joint capsule, causing pain.

These changes may lead to parts of the shoulder tendons and the bursa becoming trapped (“impinged”) between the head (or ball) of the humerus (the long bone of the upper arm) and the acromion when the arm is raised. 

Different terms are used depending on the cause – for example, shoulder impingement syndrome (impingement syndrome), rotator cuff syndrome, or calcific tendinitis/tendonitis.  

Studies have shown that there is often no clear connection between symptoms and visible abnormalities on an ultrasound scan, x-ray or MRI scan. These sometimes show calciferous deposits and wear and tear on the rotator cuff or labrum in people who have no shoulder pain. As a result, many experts now prefer to use the term “subacromial pain syndrome” instead of “impingement syndrome”. 

People who frequently work above head height, such as painters, electricians, warehouse operatives or shelf stackers, are particularly likely to have shoulder pain. 

Certain sports also increase the risk of subacromial pain. These include sports that involve lots of overhead movement of the arm, such as tennis, basketball or other sports involving throwing. Swimmers who swing their arms high over their heads when doing the crawl or butterfly stroke are also at risk. They may experience shoulder pain during periods of intensive training. 

Weak shoulder muscles, ligaments and tendons can also cause symptoms. Since the shoulder joint is highly mobile and is primarily stabilized by the muscles, weak shoulder muscles may cause the head (ball) of the humerus to escape from its socket and press on the surrounding soft tissue. 

Shoulder pain is one of the most common orthopedic complaints alongside neck and back pain. Subacromial pain is involved in up to 70% of cases.

The outlook for shoulder pain varies considerably. Around half of those affected are pain-free within a period of six months. However, some people continue to suffer shoulder pain for many years.

When a patient presents with shoulder pain, the doctor will ask when the pain occurs, how they are feeling, whether they have had an injury or accident beforehand and whether there are any potential causes, such as working above head height or playing certain sports. 

The discussion will be followed by a physical examination. This consists of several tests where the arms are stretched out to the side of the body and moved up and down and the elbows are turned in or out in various positions. The doctor will also palpate (press on) the shoulder. In most cases, these tests are sufficient in order to diagnose subacromial pain. They also serve to exclude other potential causes, such as radiating neck pain (cervicular radiculopathy) or frozen shoulder (adhesive capsulitis). 

In some cases, however, tests will be followed by a scan. Ultrasound scans can reveal tears of the rotator cuff, while x-rays can visualize the bones and calciferous deposits. If the diagnosis is still unclear, a magnetic resonance imaging (MRI) scan may be performed. 

Scans are not always necessary because there is not always a clear connection between symptoms and visible changes or wear and tear. However, scans can be helpful if the symptoms do not improve despite treatment, surgery is being considered or a different cause of the pain is suspected. For example, an x-ray can reveal important information if arthritis in the shoulder joint is suspected. 

In the case of acute shoulder pain, the recommendations are as follows:

• Rest the shoulder and, in particular, avoid any work or sports where the arm is raised above the head.
• Cool the shoulder.
• Take non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen, although these should not be used for more than 1 to 2 weeks; cortisone injections are an option in cases of severe pain.

Resting the shoulder does not mean keeping it completely immobile. A targeted physiotherapy program can strengthen the shoulder and restore its mobility gradually using various exercises.

The decision aid from gesundheitsinformation.de can help you choose an appropriate treatment for shoulder pain.