Causes of Shoulder Pain and When Is It Serious?

Reasons for why your shoulder hurts can vary, but where you feel pain can help narrow down the cause. You may have an ache from something as simple as poor posture at the computer. You may have a case of shoulder bursitis due to repetitive motion, a sudden injury, or even a completely different medical condition. Or, your shoulder can hurt due to:

• Frozen shoulder
• Impingement involving your shoulder blade
• A broken arm
• Athletic injuries
• Cervical radiculopathy (a pinched nerve)
• Arthritis

Shoulder pain can be mild to severe and can come on suddenly or build up over time. Treatment for shoulder pain causes (fractures, tissue inflammation, ligament instability) will vary, too. These treatment options may include rest, medication, and physical therapy. In some serious cases, such as a rotator cuff tear, surgery may be recommended.

This article explains some of these shoulder pain causes. It also suggests when it's time to see a healthcare provider and the various tests they may order to help make a diagnosis and develop a treatment plan for you.

Shoulder Pain Causes

Understanding why your shoulder hurts is made easier by considering your shoulder joint's complex anatomy.

The location of your shoulder pain can help your healthcare provider understand which part of the shoulder is affected. It can also help determine whether the diagnosis is due to a specific activity or event (like swimmer's shoulder) or related to a more serious condition (like breast cancer treatment).

Pain Outside of the Shoulder

Several issues can cause pain on the outside of the shoulder. The most common cause is a tear in the rotator cuff, which helps lift and rotate your arm.

Rotator Cuff Problem

Four rotator cuff muscles move your shoulder, including the deltoid muscle. There are four main types of rotator cuff problems:

• Tendonitis: Inflammation of the tendons (which connect your shoulder muscles to your upper arm bone, or humerus, which is shaped like a ball and fits into a socket in the shoulder blade) can be caused by poor posture.
• Bursitis: This is inflammation of the bursa (a fluid-filled space).
• Rotator cuff tear: A tear is the painful result of tendons of the rotator cuff pulling away from the arm bone.
• Impingement: This kind of pain occurs when you raise your arm. It's caused by the tip of your shoulder blade rubbing against the tendon and bursa located between the rotator cuff and the shoulder blade.

Rotator cuff problems cause pain, especially with activities like reaching or throwing. The deep, aching shoulder pain tends to worsen or flare up at night. It can easily wake you up from sleep or make it difficult to fall asleep.

Rotator cuff problems can be associated with a limited active range of motion. Since it's hard to voluntarily move your injured or inflamed muscle, your shoulder may feel stiff. But if someone does the work for you by lifting your arm (passive movement), your shoulder will likely move normally.

Research suggests that high blood pressure, as well as other heart disease risk factors, are associated with rotator cuff pain and inflammation.

Frozen Shoulder

Also called adhesive capsulitis, frozen shoulder is a common condition that leads to joint stiffness and pain, which can be constant and often occur suddenly. There is also a decrease in both active and passive range of motion.

While many shoulder conditions, including rotator cuff tendinitis, can be associated with frozen shoulder, the cause is often unknown. About 85% of people diagnosed with frozen shoulder have another medical condition, and these risk factors include:

• Diabetes
• Cancer
• Thyroid disease
• Heart disease
• Kidney stones
• Parkinson's disease

A previous shoulder injury or surgery also can contribute to frozen shoulder.

Calcific Tendonitis

Calcific tendonitis occurs when calcium crystals are deposited within a tendon, most commonly within the rotator cuff tendons. This condition typically causes progressive shoulder pain that is worse at night and with overhead motions, like putting on a sweatshirt.

Some people develop a chronic case of this form of tendonitis. Many others find that the symptoms resolve on their own with rest, physical therapy and pain management.

Fractured Humerus

A fracture in the humerus, or upper arm bone, can also cause pain on the outside of the shoulder. This type of fracture may occur when you fall on your shoulder onto an outstretched arm.

Front Shoulder Pain

Pain in the front of the shoulder is most commonly related to the biceps tendon—a tendon that attaches deep inside the shoulder. Conditions include:

• Biceps tendonitis
• Biceps tendon tears
• Superior labrum anterior-posterior (SLAP) tears
• Osteoarthritis

Bicep Tendonitis

Biceps tendon problems usually cause gradual pain at the front of the shoulder that can continue down over the biceps muscle. The pain often worsens after repetitive lifting, carrying heavy bags, or overhead activities. It can intensify at night.

Problems with the biceps tendon may also cause a clicking sound when the shoulder is rotated in an arc.

Biceps Tendon Rupture

A biceps tendon rupture may occur if the biceps muscle breaks free near the joint. The symptoms of a biceps tendon rupture include a sudden "pop," along with an acute worsening of pain, bruising, swelling, and often a lump just above the antecubital fossa (in front of your elbow).

SLAP Tears

A superior labrum anterior-posterior tear is a specific type of glenoid labrum (cartilage in the shoulder joint) tear. One common cause is a fall on an outstretched hand.

It's also a common tear in athletes (like baseball pitchers) who throw overhead and workers involved in repetitive overhead activities. Symptoms may include deep shoulder pain and a popping sound with movement.

Shoulder Osteoarthritis

With shoulder osteoarthritis, you can have deep shoulder pain or pain at the front of your shoulder, along with stiffness. There is generally a decrease in both active and passive range of motion.

Shoulder arthritis can sometimes be preceded by an injury to the arm, neck, or shoulder that occurred years prior. When severe, it may be treated with joint replacement surgery.

Pinched nerves are also associated with this type of wear and tear arthritis. This can lead to additional symptoms such as arm numbness.

Fractured Clavicle

A fractured clavicle may cause pain in the front of the shoulder. Your clavicle is also called your collarbone. When you break this bone, you may experience sharp pain in the front of your shoulder. There may also be a decrease in range of motion and an audible snapping sound when you try to move your arm.

Top-of-the-Shoulder Pain

The most common cause of pain in the top of the shoulder is an abnormality of the acromioclavicular joint (AC) joint. Problems of the AC joint include:

• AC arthritis
• AC separation
• Distal clavicle osteolysis

AC Arthritis

Arthritis can cause smooth cartilage to wear away, cartilage roughness, and bone spurs, which may limit mobility. Exposed bone and uneven cartilage surfaces may cause crepitus (a grinding sensation), especially when you reach overhead or across your chest.

AC Separation

AC separation, also called shoulder separation, can occur after a fall right onto your shoulder that injures the ligaments surrounding your AC joint. Depending on the severity of your ligament injury, a bump may form above your shoulder due to the separation of your scapula, or shoulder blade, from your collarbone.

Distal Clavicle Osteolysis

Distal clavicle osteolysis causes sharp or aching pain at the end of the collarbone. It most commonly affects weightlifters or others who repeatedly lift or carry heavy objects.

Poor Posture

Slouching or sitting with your head forward can cause pain at the top of the back side of your shoulder. This kind of pain may occur after sitting with poor posture for long periods in front of a computer or while looking at a phone.

Pain All Over the Shoulder

The tendons, ligaments, and muscles in your shoulder keep it stable. If these tissues become loose or torn, shoulder instability or dislocation may occur.

Shoulder Instability

As the name suggests, instability causes loosening of the joint. It can be caused by a traumatic injury (dislocation) or from overuse. Shoulders that feel unstable may feel as though they will pop out of the joint.

Multidirectional instability can result from chronically loose ligaments. This condition usually affects young, athletic individuals, making it feel as if their shoulder is not staying tightly in position (subluxation of the shoulder). The sensation is often described as a "dead arm" with excessive shoulder range of motion.

Shoulder Dislocation

A dislocation is an injury that occurs when the top of the arm bone becomes disconnected from the scapula. If someone has dislocated their shoulder, the normal ligaments that hold the shoulder in position may be damaged. The shoulder is then more likely to pop out of the joint again.

When to See a Healthcare Provider

It's time to seek medical attention if you have new, worsening, or severe shoulder pain. Other symptoms that require attention may include:

• An injury that causes joint deformity
• Inability to carry objects or use your arm
• Inability to raise your arm
• Shoulder pain that occurs at night or while resting
• Shoulder pain that persists beyond a few days
• Signs of an infection, including fever, skin redness, and warmth
• Swelling or significant bruising around your joint or arm
• Abdominal pain or another symptom you can't explain, which may be a sign of referred pain (or a problem that begins somewhere else in the body)

Diagnosis

Since there are many potential causes of shoulder pain, your healthcare provider will do a careful review of your symptoms, physical examination, and sometimes imaging tests to make a proper diagnosis.

Physical Examination

After reviewing your symptoms and medical history, your healthcare provider will perform a thorough exam of your shoulder. They will press on different areas of your shoulder to evaluate it for tenderness or deformity. They will also test your arm strength and your shoulder range of motion.

Your healthcare provider may also examine other areas of your body, like your neck or abdomen, to rule out non-shoulder-related causes of your pain.

Imaging

You might need one or more of the following:

• X-ray: A shoulder X-ray can visualize bone injuries or subtle problems, like bone spurs, that could suggest a diagnosis of osteoarthritis.
• Magnetic resonance imaging (MRI): This test provides detailed images of the tendons, ligaments, and muscles that surround the shoulder joint. For instance, an MRI can provide information about the location, size, and relative age of a rotator cuff tear.

Differential Diagnoses

While it seems logical that shoulder pain would stem from the shoulder, this is not always the case.

Pain in the general shoulder area, often difficult to pinpoint, can sometimes be related to a herniated disc in the neck or gallbladder disease. In rare cases, shoulder pain can be a symptom of bleeding from the liver or spleen.

If your healthcare provider has concerns about another cause that's outside your shoulder joint, they may focus on that diagnosis.

For example, an electrocardiogram (ECG) may be ordered for a suspected heart attack. An abdominal ultrasound may be ordered for suspected gallbladder disease.

Treatment

The treatment of shoulder pain depends entirely on the cause of the problem. And while one treatment protocol may be useful for one issue, it may not be helpful (and can even be harmful) for another.

It's vital that you seek expert medical advice before embarking on a treatment program. Not all treatments listed here are appropriate for every condition. But, some may help relieve shoulder pain given your situation.

Rest

The first treatment for many common types of shoulder pain is to rest the joint and allow the inflammation or irritation to subside. In some cases, the shoulder may be immobilized.

Use caution when resting the joint; prolonged rest can lead to joint stiffness.

Improve Posture

If you spend long periods of time sitting in front of a computer or bending over your phone, try to be aware of your posture. Sit straight in your chair and make sure your head is aligned with your screen. Stretch your shoulders. Try to correct your posture whenever you notice you are slouching. 

Ice and Heat Application

Ice packs are most often used to reduce swelling and pain from an acute shoulder injury. They can also be used to treat shoulder overuse injuries (for example, rotator cuff tendinitis or bursitis).

In these cases, the ice is applied right after the overhead activity to minimize the onset of inflammation. Heat pads are also used to treat chronic shoulder conditions, but generally, before the overhead activity is performed. Heat can relax the muscles, ease stiffness, and reduce pain.

Before applying ice or heat, talk with your healthcare provider or physical therapist. Developing a specific plan for the timing and duration of each treatment is important so that you heal properly.

Physical Therapy

Physical therapy plays an important role in shoulder pain treatment. Your physical therapist may use different modalities to increase your strength, restore mobility, and help you return to your pre-injury level of activity.

Stretching

Stretching exercises can help relieve pain while you are at home. Try placing one arm across your chest and pulling it gently with your opposite arm to stretch the back of your shoulder. Hold for 30 seconds, then switch arms. 

Ask your healthcare provider about other stretches you can do at home to relieve specific types of shoulder pain. These exercises also may follow surgery, if needed to repair your shoulder. 

Medications

The two most common medications used to ease shoulder pain and swelling are nonsteroidal anti-inflammatories (NSAIDs) and steroid injections.

NSAIDs

Some NSAIDs are available over the counter (for example, ibuprofen), and others are prescribed, like Voltaren (diclofenac). These are commonly used to treat shoulder problems like arthritis, bursitis, and tendonitis.

It's important to use them only for a short time and only under the guidance of your healthcare provider. NSAIDs present some risks, so notify your healthcare provider if you are pregnant or have any health problems like:

• High blood pressure
• Asthma
• Kidney disease
• Liver disease
• Stomach ulcers

Steroid Injection

With a steroid injection, your healthcare provider will give you a shot of cortisone—a powerful steroid medication that reduces inflammation—into your shoulder. An injection can help reduce pain and help you engage in physical therapy sessions more easily.

Surgery

In some cases, and probably as a last resort, surgery may be needed if conservative measures are not working or if your shoulder injury is severe from the start. Shoulder surgery requires the services of an orthopedic surgeon and may involve one of several techniques, such as Latarjet surgery.

Prevention

Shoulder pain can sometimes be prevented by making a few changes at home. They include reducing the risk of trips and falls by making sure floors are uncluttered and rugs are safe.

You can also try to:

• Stay healthy by exercising, including your shoulder muscles.
• Make sure you're getting enough calcium and vitamin D for bone health.
• Improve balance and flexibility (with yoga, for example).
• Stretch before doing an activity (even household chores).
• Avoid lifting over your head by changing kitchen storage or closets.

Sometimes, your shoulder can hurt because of repetitive use. For example, if your job requires the same motion (whether lifting things or sitting at your computer), consider how to prevent injury by taking frequent breaks and using good posture.

Summary

Pinpointing the cause of shoulder pain can be a huge challenge because there are so many possibilities to consider. It helps to narrow down the region of the pain and where it feels worst: outside of the shoulder, at the front or top region, or all over.

The process of elimination can be aided by an X-ray or MRI before a healthcare provider or physical therapist devises a treatment plan. It may include rest, hot and cold packs, medication, physical therapy, and maybe a steroid injection depending on how serious the shoulder condition is.