Shoulder Pain

Shoulder Pain Causes and Symptoms

The shoulder consists of the shoulder joint, the parts of the shoulder blade, upper arm bone and collarbone, ligaments, muscles and nerves. Shoulder pain can arise from any of these structures or the internal organs, such as the heart or gallbladder.

Shoulder pain that is aggravated by applying pressure on the shoulder or moving the arm likely results from the shoulder.

Shoulder pain that is not aggravated by applying pressure can arise from a pinched nerve or a chest or abdominal organ:

• Right shoulder pain can arise from the gallbladder, liver or stomach problems, abdominal infections or lung cancer.
• Left shoulder pain can arise from trapped gas in the intestine, coronary heart disease, pancreatic or splenic problems.

Bilateral shoulder pain can result from anxiety, poor posture, rheumatoid arthritis, systemic lupus erythematosus, cervical spinal stenosis, polymyositis, polymyalgia rheumatica, fibromyalgia or coronary heart disease in women ^[2].

Pain in the front or outer side of the shoulder that radiates below the elbow can be from myofascial pain syndrome, arthritis, a pinched nerve in the neck, brachial neuritis, thoracic outlet syndrome or complex regional pain syndrome.

Conditions that cause pain behind the shoulders include myofascial pain syndrome, trapezius myalgia and suprascapular nerve entrapment.

Pain in the neck and shoulder can result from poor posture, trapezius muscle strain, trapezius myalgia, temporomandibular joint disorder, whiplash injury, a pinched nerve in the neck or shingles.

Pain in the chest and shoulder can result from anxiety, pectoralis muscle strain, pleurisy or coronary heart disease.

Read about shoulder blade pain.

Chart 1. Causes of SUDDEN Shoulder Pain
MUSCLE Pain
Cause	Symptoms
Rotator cuff tear [9,31]	Pain and weakness in the shoulder and arm
Pectoralis muscle strain or tear [33]	Pain and swelling in the front of the shoulder
Trapezius myalgia (due to poor posture at work) [14,15]	Severe pain and spasm between the neck and shoulder, headache, nausea
NERVE Pain
Cause	Symptoms
Shingles [47]	Burning pain and tenderness followed by rash
Brachial neuritis (after vaccination, surgery or injury) [16,17]	Throbbing pain in the shoulder and arm followed by weakness lasting for 1-3 years
JOINT Pain
Cause	Symptoms
Shoulder joint cartilage (labrum) tear [7,23,30]	Shoulder pain, grinding and locking
Shoulder dislocation [5]	Severe pain and deformity in the shoulder
Shoulder separation or acromioclavicular (AC) joint tear [9,30]	Stabbing pain and bump at the top of the shoulder, clicking
Septic arthritis (in impaired immunity, intravenous drug abuse) [10]	Tender, red, swollen shoulder, fever
BONE Pain
Cause	Symptoms
Fracture of the shoulder blade, upper arm bone or collarbone [3]	Severe pain, bruising, deformity and cracking in the shoulder
Osteonecrosis of the humeral head (after trauma, steroid use, alcohol abuse) [20]	Vague pains around the shoulder girdle
Referred Pain From the INTERNAL ORGANS
Cause	Symptoms
Ectopic pregnancy [24] or ruptured ovarian cyst [27]	Pain in the lower abdomen, vaginal bleeding, missed period
Laparoscopic surgery (e.g. gallbladder removal), rupture of the spleen or intestine [27]	Severe pain in the abdomen and shoulder lasting for few days
Pneumonia with pleurisy [27], spontaneous pneumothorax, pulmonary embolism (blood clot in the lungs) [45], pericarditis [46]	Pain in the chest and shoulder aggravated by deep breathing; shortness of breath, cough, fever

Chart 2. Causes of CHRONIC Shoulder Pain
MUSCLE Pain
Cause	Symptoms
Rotator cuff injury: tendonitis, impingement, subacromial bursitis [4,7,9,30]	Pain at the top or front of the shoulder and arm, clicking
Myofascial pain syndrome (due to bad posture, driving, excessive exercise or stress) [34,35]	Tension in the upper back; pain and tingling in the arm after pressing on the muscle knots
Calcific tendonitis [9]	Sharp pain in the shoulder and upper arm
Biceps tendinopathy [32]	Deep, throbbing ache in the front of the shoulder, upper arm and elbow
Fibromyalgia [12]	Tender points at the top of the shoulders, lower back, hips and knees, fatigue, depression
Polymyositis [21]	Weakness around the shoulder girdle and hips, tiredness, difficulty swallowing
Polymyalgia rheumatica [8]	Stiffness in the shoulders and hips, low-grade fever, fatigue (after 50)
NERVE Pain
Cause	Symptoms
Cervical radiculopathy (a herniated disc with a pinched nerve in the neck spine)	Pain in the neck, shoulder and arm, tingling and numbness in the hand and fingers
Carpal tunnel syndrome (due to wrist overuse) [46]	Pain in the wrist and shoulder, tingling in the first 3 fingers
Supraclavicular nerve entrapment (due to overhead activities) [29,31]	Dull ache and numbness at the back and side of the shoulder
Thoracic outlet syndrome (due to a cervical rib, overhead activities) [11]	Pain in the shoulder, arm or armpit, tingling in the hand aggravated by raising the hands
Complex regional pain syndrome (after an injury, surgery, stroke, heart attack) [42,48,49]	Pain in the shoulder, burning, swelling, redness and stiffness in the hand on one side
JOINT Pain
Cause	Symptoms
Shoulder instability (after repeated strain or injuries) [18,30]	Shoulder hypermobility, clicking or popping
Osteoarthritis [7,30]	Pain and stiffness in the shoulder that increase with activity, clicking
Rheumatoid arthritis [1,7,9]	Bilateral pain, stiffness and swelling in the shoulder, wrist and fingers that decrease with activity
Adhesive capsulitis or frozen shoulder (due to diabetes mellitus, hyperthyroidism, injury or stroke) [6]	Constant pain, followed by stiffness lasting for several months
Referred Pain From the INTERNAL ORGANS
Cause	Symptoms
Trapped gas (in irritable bowel syndrome)	Pain in the upper abdomen and shoulder
Stomach ulcer [36,37]	Pain in the upper central abdomen and right shoulder
Gallbladder disease	Pain in the right upper abdomen and right shoulder, nausea or vomiting
Hiatal hernia [46]	Heartburn
Coronary heart disease (angina pectoris, heart attack)	Pain behind the breastbone, in the left shoulder and arm, shortness of breath, triggered by exercise
Pancreatitis [39,46]	Epigastric pain, pain in the left shoulder, nausea
Cancer: liver [25], lung [26] pancreatic [38], thyroid, breast, kidney, prostate, lymphoma, multiple myeloma [46]	Night sweats, anorexia, weight loss, armpit lumps

What causes shoulder pain at night and in the morning?

Examples of conditions in which shoulder pain can be considerably worse at night include trapped gas, rheumatoid arthritis ^[7], rotator cuff injury ^[31], biceps tendonitis ^[32], shoulder dislocation, adhesive capsulitis (frozen shoulder) ^[6], polymyalgia rheumatica ^[8] or osteonecrosis of the humeral head ^[20].

What causes shoulder pain during breathing, coughing or sneezing?

Shoulder pain that is aggravated by deep inhalation, coughing or sneezing can result from trapped gas in the intestine (hepatic flexure syndrome), pleurisy, hiatal hernia, a blood clot in the lungs, pericarditis, endometriosis or abdominal adhesions after surgery.

Can acid reflux cause shoulder pain?

Gastroesophageal reflux disease (GERD) can cause burning pain behind the breastbone (heartburn) and between the shoulder blades but not likely at the top of the shoulders. However, hiatal hernia (a common underlying disorder in acid reflux) can irritate the diaphragm and cause shoulder pain ^[46].

What causes pain in the left shoulder after eating?

Pain in the left shoulder after eating can be due to the stomach ulcer, pancreatitis or adhesions (internal scars) that develop after surgery for a hiatal hernia or weight loss (gastric sleeve or bypass) ^[40,41].

What can cause clicking in the shoulder?

Painful clicking in the shoulder can be due to shoulder instability or separation, disorders of the rotator cuff tendons or shoulder joint cartilage (labrum), arthritis or broken bones ^[30].

Diagnosis

An orthopedist can perform a detailed shoulder examination. Provocative tests to find the cause of shoulder pain are described on the American Family Physician website.

Investigations that can reveal the cause of shoulder pain:

• An X-ray can show bone fractures and calcific tendonitis.
• An ultrasound can reveal arthritis, rotator cuff tears and biceps tendonitis ^[13].
• Arthroscopy can reveal rotator cuff injuries and a labral tear.
• Magnetic resonance imaging (MRI) can reveal labral tears, rotator cuff impingement and tumors ^[22].

Treatment

Treatment of shoulder pain depends on the cause. Certain conditions, such as myofascial pain, muscle strain, a herniated disc in the neck or frozen shoulder, can heal on its own with time and rest.

An orthopedist or experienced physiotherapist can show you exercises to do at home.

Proper sitting posture (straight back) and office chair (firm seat, no back rest) can help prevent myofascial pain and trapezius myalgia.

Ice packs wrapped in a cloth and held over the shoulder for 15 minutes several times a day can help relieve pain and swelling when applied within 72 hours after ^[50,51]:

• Muscle strain or tear, trapezius myalgia, tendonitis, bone fracture, shoulder dislocation
• Frozen shoulder

Heat pads may help relieve pain in:

• Myofascial pain syndrome ^[51]
• Inflammatory disorders with stiffness, such as rheumatoid arthritis and polymyositis ^[50]
• Osteoarthritis ^[50]

Nonsteroidal anti-inflammatory drugs, such as ibuprofen, can relieve mild shoulder pain.

Steroids by mouth can help in inflammatory conditions, such as rheumatoid arthritis and polymyositis.

Physiotherapy may relieve pain and stiffness in rotator cuff tendinitis, adhesive capsulitis and calcific tendinitis but more research is warranted ^[52].

Steroid injections may provide a short-term pain relief in rotator cuff injuries and adhesive capsulitis ^[43].

According to a 2005 Cochrane review of studies, there is insufficient evidence about the effectiveness of acupuncture in the treatment of shoulder pain ^[44].

Arthroscopy is a procedure that involves inserting a tube with light and instruments at the end into the shoulder joint. The procedure can be used to repair rotator cuff, ligament or labral tears or to remove bone spurs or inflamed material from the joint ^[19].

Open surgery may be needed to treat complete tendon tears, adhesive capsulitis, complicated fractures and herniated discs in the neck.

• References

  1. Arthritis of the shoulder  OrthoInfo
  2. Bilateral shoulder pain  FreeMD
  3. Broken arm symptoms and causes  Mayo Clinic
  4. Nossov S et al, Subacromial bursitis  UNC School of Medicine
  5. Shoulder dislocation  Mayo Clinic
  6. Siegel BL et al, 1999, Adhesive Capsulitis: A Sticky Issue  American Family Physician
  7. Millet PJ et al, 2008, Shoulder Osteoarthritis: Diagnosis and Management  American Family Physician
  8. Questions and Answers about Polymyalgia Rheumatica and Giant Cell Arteritis  National Institute of Arthritis and Musculoskeletal and Skin Diseases
  9. Bayam L et al, 2011, Pain Mapping for Common Shoulder Disorders  The American Journal of Orthopedics
  10. Ryan MK et al, Septic Arthritis About the Shoulder: Glenohumeral, Acromioclavicular, and Sternoclavicular Joints  Cancertherapy Advisor
  11. Thoracic outlet syndrome information page  National Institute of Neurological Disorders and Stroke
  12. Fibromyalgia  MedlinePlus
  13. Shoulder ultrasound technique  ShoulderDoc
  14. Trapezius myalgia  Physiopedia
  15. Anderson LL, 2008, PhD thesis: Physical exercise in the rehabilitation of Physical exercise in the rehabilitation of trapezius myalgia  Pennsylvania State University
  16. Fransz DP et al, 2014, Parsonage-Turner syndrome following post-exposure prophylaxis  BioMed Central
  17. Feinberg JH et al, 2010, Parsonage-Turner Syndrome  PubMed Central
  18. Chronic shoulder instability  OrthoInfo
  19. Shoulder arthroscopy  OrthoInfo
  20. Zuckerman JD et al, Osteonecrosis of the humeral head  MDedge
  21. Polymyositis  John Hopkins Medicine
  22. Magnetic resonance imaging (MRI) – shoulder  RadiologyInfo
  23. Shoulder Joint Tear (Glenoid Labrum Tear)  OrthoInfo
  24. Symptoms of ectopic pregnancy  The ectopic pregnancy trust
  25. Liver cancer symptoms  Cancer Research UK
  26. How can lung cancer cause shoulder pain  MedicalNewsToday
  27. 2008, Referred shoulder pain  GP Online
  28. 2006, Referred pain  Anatomy Notes
  29. Trojian TH, Suprascapular neuropathy, clinical presentation  Emedicine
  30. Funk L, Painful Clicking, Snapping and Popping of the Shoulder  ShoulderDoc
  31. Bernstein J, 2011, Shoulder pain differential diagnosis  OrthopedicsOne
  32. Biceps tendonitis  PhysioWorks
  33. Pec strain Virtual sports Injury Clinic
  34. Philips CD, Cervical myofascial pain, clinical presentation  Emedicine
  35. Bron C et al, 2011, Myofascial Pain in Athletes Clinical Presentation  PubMed Central
  36. Valenzuela GA et al, 1989, Shoulder pain: an unusual presentation of gastric ulcer  PubMed
  37. Peptic ulcers  Physiopedia
  38. Pancreatic cancer  Healthtalk.org
  39. Pancreatitis  Physiopedia
  40. Pain in left shoulder after eating  HeallingWell
  41. Pain in left shoulder after eating  MedHelp
  42. Lindgren I et al, 2007, Shoulder pain after stroke  Stroke
  43. Buchbinder R et al, 2003, Corticosteroid injections for shoulder pain  Cochrane
  44. Green S et al, 2005, Acupuncture for shoulder pain  Cochrane
  45. Chandrasekhar AJ, Pulmonary embolism  Loyola University Chicago
  46. Shoulder pain  FPnotebook
  47. Shingles symptoms  Mayo Clinic
  48. Complex regional pain syndrome (reflex sympathetic dystrophy)  FPnotebook
  49. Complex Regional Pain Syndrome (Reflex Sympathetic Dystrophy)  OrthoInfo
  50. Should You Use Ice or Heat for Pain?  Cleveland Clinic
  51. Chandola HC et al, 2009, Fibromyalgia and Myofascial Pain Syndrome-A Dilemma  PubMed Central
  52. Green S et al, 2003, Some physiotherapy interventions are effective for shoulder pain in some cases  PubMed