The shoulder is the most mobile joint in the body and depends on soft tissues, not bony shape, for stability, which makes it prone to pain. Four conditions account for most cases: rotator cuff related pain (tendinopathy, impingement, bursitis and tears), frozen shoulder (adhesive capsulitis), osteoarthritis of the main joint or the small acromioclavicular joint on top, and instability after dislocation. Calcific tendinitis can produce sudden, very severe pain.
Age is a useful guide: instability and labral tears under 30, rotator cuff problems and frozen shoulder between 40 and 60, cuff tears and arthritis after 60. Most shoulder pain improves with a structured exercise programme over 3 to 6 months. Trials have shown that surgery to shave bone for impingement (subacromial decompression) is no better than placebo surgery, so operations are reserved for specific problems such as significant tears, recurrent dislocation and advanced arthritis.
Symptoms
- Pain on the outer upper arm, worse when lifting the arm to the side or reaching overhead
- A painful arc in the middle range of lifting
- Night pain and inability to lie on the affected side
- Progressive stiffness, with difficulty reaching behind the back or fastening a bra, typical of frozen shoulder
- Weakness lifting the arm or holding it away from the body, suggesting a cuff tear
- Clicking, a feeling of slipping or apprehension in certain positions
- Pain on top of the shoulder when reaching across the body
- Sudden excruciating pain without injury, as seen in calcific tendinitis
Causes and risk factors
Rotator cuff tendons degenerate with age and repetitive overhead work or sport; tears may follow a fall or develop gradually, and many older adults have painless tears. Frozen shoulder is strongly associated with diabetes and thyroid disease and may follow injury or surgery. Instability follows a traumatic dislocation or reflects naturally loose joints. Osteoarthritis may be primary or follow long-standing massive cuff tears. Pain felt at the shoulder can also be referred from the neck, and occasionally from the heart, the diaphragm, the gallbladder or the top of the lung.
How it is diagnosed
- Examination: Active against passive movement is the key: both restricted, especially outward rotation, indicates frozen shoulder or arthritis; passive movement preserved points to the rotator cuff.
- X-rays: Show arthritis, calcium deposits, the position of the ball under the acromion and fractures.
- Ultrasound: A good, dynamic test for rotator cuff tears, bursitis and calcific deposits in experienced hands.
- MRI or MR arthrogram: Defines tear size, tendon retraction and muscle quality before surgery, and labral tears in instability.
- Diagnostic injection: Local anaesthetic into the subacromial space or acromioclavicular joint confirms the source of pain.
- Neck assessment or nerve studies: When symptoms suggest a trapped nerve in the neck.
Treatment options
- Exercise-based physiotherapy: Rotator cuff and shoulder blade strengthening over at least 12 weeks; first-line for cuff-related pain and effective even for many degenerative tears.
- Pain relief and activity modification: Anti-inflammatories and temporary avoidance of repeated overhead loading.
- Steroid injection: Subacromial injection for cuff pain, or into the joint for frozen shoulder in the painful phase. Best limited to one or two.
- Hydrodilatation: Stretching the capsule with fluid under imaging for frozen shoulder, followed by physiotherapy.
- Barbotage: Ultrasound-guided needling and washing out of calcium deposits.
- Arthroscopic rotator cuff repair: For acute traumatic tears and for symptomatic tears that fail rehabilitation. Requires a sling for 4 to 6 weeks and 4 to 6 months of recovery.
- Stabilisation surgery: Arthroscopic labral repair or a Latarjet procedure for recurrent dislocation.
- Shoulder replacement: Anatomic replacement for arthritis with an intact cuff; reverse replacement for arthritis with a deficient cuff.
When it is urgent
Call emergency services for shoulder or arm pain accompanied by chest tightness, breathlessness, sweating or nausea, which may be a heart attack. Seek same-day care locally for deformity or inability to move the arm after an injury, sudden loss of the ability to lift the arm after a fall, or a hot, swollen shoulder with fever.
Travelling to Türkiye for treatment
A visit of 2 to 3 days can provide examination, ultrasound or MRI and a firm diagnosis when shoulder pain has persisted for months. Planned operations such as rotator cuff repair, stabilisation or shoulder replacement are feasible on a trip of about 7 to 10 days, but the months of physiotherapy that follow decide the outcome and must be arranged at home. Frozen shoulder largely resolves with time over 1 to 3 years; hydrodilatation or a capsular release can speed things up in selected cases, though travelling solely for it is rarely necessary.
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Frequently Asked Questions
How long does a frozen shoulder last?
Commonly 1 to 3 years through painful, stiff and thawing phases. Most people recover good function, though some keep mild stiffness.
Does every rotator cuff tear need repair?
No. Many degenerative tears are managed well with exercise. Acute traumatic tears in active people are usually repaired early.
Why is shoulder pain worse at night?
Lying down changes the position and pressure on inflamed tendons and the bursa, and there are fewer distractions. A pillow under the arm can help.
Can my neck be the real cause?
Yes. Pain that spreads below the elbow with tingling in the fingers, or that changes with neck movement, suggests a nerve root problem in the neck.