Shoulder pain is a frequent musculoskeletal complaint with a broad differential diagnosis. Because the shoulder is a highly mobile joint complex—comprising the glenohumeral joint, scapulothoracic articulation, acromioclavicular (AC) joint, and a coordinated network of rotator cuff and periarticular structures—pain can originate from many anatomic sites or reflect referred discomfort from the neck. Clinically, the first step is to classify the pain pattern by onset, trauma association, location (anterior, lateral, posterior), movement-provoked factors, night pain, and functional limitations such as overhead reach, dressing, or push-up activities.
Common causes include rotator cuff tendinopathy, impingement/shoulder bursitis, partial or full-thickness rotator cuff tears, adhesive capsulitis (frozen shoulder), AC joint osteoarthritis or separation, glenohumeral osteoarthritis, and instability syndromes. Tendinopathy and bursitis often present with pain during shoulder abduction or elevation, sometimes with a painful arc between roughly 60 and 120 degrees. Rotator cuff tears may present after age-related degeneration or trauma; weakness with resisted elevation, external rotation, or lift-off maneuvers can be informative. Adhesive capsulitis is characterized by progressive global loss of both active and passive range of motion, often worse with external rotation, and typically includes marked night pain. AC joint pathology can cause focal pain over the top of the shoulder, especially with cross-body adduction.
Shoulder pain can also be secondary to systemic or inflammatory conditions. Inflammatory arthritides such as rheumatoid arthritis can cause chronic pain and morning stiffness. Septic arthritis and osteomyelitis are less common but critical to recognize; they present with severe pain, fever, and limited range of motion, often with elevated inflammatory markers. Calcific tendinitis may cause sudden, intense pain, sometimes following periods of relative quiescence, and can mimic other acute processes.
Importantly, shoulder pain may be referred from the cervical spine (e.g., radiculopathy). Neuropathic or dermatomal features—numbness, tingling, burning pain, or pain radiating past the elbow—support a neurologic source. Myofascial pain and scapular dyskinesis can coexist with other shoulder disorders; abnormal scapular mechanics may perpetuate impingement symptoms and delay recovery.
The evaluation should include a careful history and physical examination. A trauma history (falls, dislocations), age, occupational or sports overhead activity, prior similar episodes, and response to rest versus movement all guide the differential. Red flags include inability to raise the arm after injury (possible large tear), deformity suggesting fracture or dislocation, progressive neurologic deficits, suspected infection (fever, immunosuppression), severe night pain without improvement, unexplained weight loss, and unrelenting pain after significant trauma. When these are present, urgent assessment and imaging may be required.
Initial management typically emphasizes conservative measures for most non-emergent conditions. Activity modification—avoiding aggravating overhead motions while maintaining gentle mobility—helps reduce inflammation and strain. Physical therapy is foundational: targeted rotator cuff strengthening, scapular stabilization, and stretching for posterior capsule or contracted structures can restore mechanics and reduce pain. For adhesive capsulitis, early motion within tolerance is beneficial, and structured stretching regimens are commonly recommended.
Pharmacologic options often include acetaminophen or nonsteroidal anti-inflammatory drugs (NSAIDs), assuming no contraindications such as renal disease, active gastrointestinal bleeding, or anticoagulant use issues. Topical NSAIDs can be a safer alternative for localized pain. Short courses of oral NSAIDs may reduce symptom burden, facilitating participation in rehabilitation. For select patients with persistent bursitis or impingement, subacromial corticosteroid injections can provide temporary pain relief, improving function and enabling therapy; however, they are not curative and should be used judiciously.
Imaging is guided by clinical suspicion and treatment response. Plain radiographs help evaluate AC joint pathology, osteoarthritis, dislocation, and fractures. Ultrasound or MRI can assess rotator cuff integrity, tendinopathy, bursitis, labral lesions, or suspected full-thickness tears. MRI may also be warranted for persistent symptoms despite adequate conservative therapy or when malignancy or infection is a concern.
Surgery is typically reserved for specific indications such as confirmed full-thickness rotator cuff tears with functional impairment, recurrent instability, or failure of extensive conservative management. Even then, postoperative rehabilitation is crucial and often determines long-term outcomes.
Overall, shoulder pain requires a structured, mechanism-based approach: identify probable source (rotator cuff, capsular, AC joint, cervical referral), rule out emergencies, then implement evidence-based rehabilitation with appropriate analgesia. Source: WebMD
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