Shoulder pain
Exam Tips
- In OSCEs, always open with red-flag screening: trauma + weakness/inability to raise arm, hot red joint with fever, deformity after trauma, mass/swelling, systemic cancer symptoms.
- Pattern recognition is high yield: painful active arc with near-full passive movement suggests rotator cuff disorder; loss of both active and passive external rotation suggests frozen shoulder/glenohumeral pathology.
- Do not overcall a painful arc alone; combine with history and resisted tests because specificity/sensitivity are limited.
- Examine neck and perform focused neuro exam if indicated; reproduced pain on cervical movement supports referred cervical source.
- Mention key comorbidity links in viva answers: diabetes and thyroid disease increase frozen shoulder risk and may predict a tougher course.
- Use safe prescribing language: lowest effective NSAID dose, shortest duration, check GI/renal/cardiovascular contraindications, and provide clear safety-net advice.
Definition
Shoulder pain is a symptom complex arising from intrinsic shoulder pathology (for example rotator cuff disease, adhesive capsulitis, acromioclavicular or glenohumeral joint disease) or from referred extra-shoulder causes such as cervical radiculopathy, cardiopulmonary disease, or malignancy. In UK primary care it is a common musculoskeletal presentation, and accurate clinical pattern recognition with red-flag screening is central to safe diagnosis and management.
Pathophysiology
Mechanisms vary by cause: rotator cuff disorders involve tendon overload/degeneration and subacromial pain generation during elevation; adhesive capsulitis involves capsular inflammation then fibrosis causing global restriction (especially external rotation); acromioclavicular disease is typically degenerative/inflammatory focal joint pain; glenohumeral osteoarthritis causes cartilage loss and mechanical pain/stiffness. Referred pain occurs via shared segmental innervation (for example cervical spine, diaphragm, cardiac and pulmonary pathology), so shoulder pain may occur without primary shoulder tissue injury. See Figure from core anatomy text (rotator cuff tendons beneath acromion) and Figure from MSK examination chapter (painful arc and shoulder movement planes).
Risk Factors
- Age 35-75 years for rotator cuff-related pain; 40-60 years for frozen shoulder
- Repetitive overhead activity, heavy lifting, and overhead sport/occupation
- Previous shoulder trauma, dislocation, or traction injury
- Diabetes mellitus (strongly associated with frozen shoulder, often more severe/prolonged)
- Thyroid dysfunction, cardiovascular disease, stroke/hemiparesis
- Female sex and prior frozen shoulder in the contralateral shoulder
- Known malignancy history (for secondary/metastatic causes)
- Inflammatory rheumatological disease risk
Clinical Features
Symptoms
- Site-specific pain (often lateral/superior shoulder in rotator cuff disorders)
- Pain worse on arm elevation or overhead activity; difficulty with tasks like lifting a kettle
- Night pain and disturbed sleep
- Stiffness (prominent in adhesive capsulitis and glenohumeral pathology)
- Instability symptoms or prior episodes of shoulder 'coming out'
- Post-traumatic pain/weakness or sudden inability to actively raise arm (acute cuff tear red flag)
- Systemic features: fever, weight loss, night sweats, respiratory symptoms (red flags)
- Associated neck/upper-limb pain or neurological symptoms suggesting referred/cervical source
Signs
- Painful active movement with relatively preserved passive range in rotator cuff disease
- Global restriction of active and passive range (especially passive external rotation) in frozen shoulder
- Painful arc on abduction (commonly 70-120 degrees; useful but not highly sensitive/specific)
- Pain on abduction with thumb-down position, worse against resistance
- Positive cross-arm adduction test with local acromioclavicular joint pain
- Drop-arm weakness after trauma suggesting significant rotator cuff tear
- Shoulder deformity/loss of rotation after trauma suggesting dislocation
- Red, hot, very painful joint with systemic illness suggesting septic arthritis
Investigations
Management
Lifestyle Modifications
- Explain diagnosis, expected course, and safety-net red flags (fever, deformity, rapidly progressive weakness, systemic symptoms)
- Relative rest from provocative overhead loading, then graded return to activity
- Structured physiotherapy/home exercise programme targeting range of motion, scapular control, and rotator cuff strengthening
- Work/sport modification and ergonomic advice
- Use patient information leaflets (for example UK arthritis/shoulder education resources)
Pharmacological Treatment
Simple analgesic
- Paracetamol 1 g orally every 4-6 hours when required (maximum 4 g/24 hours)
First-line analgesic in many patients; reduce maximum dose in low body weight, frailty, or hepatic impairment; counsel to avoid duplicate paracetamol-containing products.
NSAID
- Ibuprofen 400 mg orally three times daily with food (typical prescription dose; use lowest effective dose for shortest duration)
- Naproxen 250-500 mg orally twice daily (alternative oral NSAID)
Avoid/caution in CKD, heart failure, ischaemic heart disease, uncontrolled hypertension, active peptic ulcer disease, anticoagulant use, pregnancy (especially from 20 weeks; avoid in 3rd trimester), and NSAID-exacerbated asthma. Consider gastroprotection (for example omeprazole 20 mg once daily) in GI-risk patients.
Weak opioid (short-course rescue only)
- Codeine phosphate 30-60 mg orally every 4 hours when required (maximum 240 mg/24 hours)
Use briefly if first-line analgesia inadequate; warn about constipation, sedation, nausea, dependence risk; avoid in breastfeeding and in people with significant respiratory depression.
Corticosteroid injection (selected intrinsic shoulder disorders)
- Triamcinolone acetonide 40 mg subacromial or intra-articular injection (single injection, often with local anaesthetic, by appropriately trained clinician)
Can provide short-term pain relief in rotator cuff-related pain or frozen shoulder; avoid if septic arthritis is possible; use caution in diabetes (transient hyperglycaemia) and around anticoagulation.
Surgical / Interventional
- Urgent orthopaedic referral for traumatic acute rotator cuff tear (early repair improves outcomes)
- Emergency reduction pathway for unreduced dislocation
- Arthroscopic/open procedures for refractory structural pathology (for example rotator cuff repair)
- Manipulation under anaesthesia or arthroscopic capsular release for persistent severe frozen shoulder after failed conservative care
- Shoulder arthroplasty for end-stage glenohumeral osteoarthritis in selected patients
Complications
- Persistent pain and functional disability
- Sleep disturbance and reduced quality of life
- Chronic stiffness/adhesive capsulitis progression
- Recurrent instability after dislocation
- Delayed diagnosis of serious causes (septic arthritis, malignancy, acute full-thickness cuff tear)
- Medication-related adverse effects (NSAID GI/renal/cardiovascular harm; opioid adverse effects)
Prognosis
Prognosis is heterogeneous and depends on aetiology, comorbidity, baseline disability, and timeliness of accurate diagnosis. While some cases settle with conservative care, recurrence and chronicity are common; approximately 40-50% of people still report pain at 6-12 months after first primary-care consultation. Outcomes are generally worse with longer symptom duration, multisite pain, older age, and delayed treatment of time-critical pathology (for example traumatic cuff tear).
Sources & References
✅NICE Guidelines(1)
- Shoulder pain[overview]
📖Textbook References(4)
- David Randall PhD MRCP (Editor), John Booth PhD MRCP (Editor), K - Kumar and Clark's Clinical Medicine (2025, American Elsevier Publishing Co.) - libgen.li.pdf(pp. 730)[context]
- David Randall PhD MRCP (Editor), John Booth PhD MRCP (Editor), K - Kumar and Clark's Clinical Medicine (2025, American Elsevier Publishing Co.) - libgen.li.pdf(pp. 993)[context]
- David Randall PhD MRCP (Editor), John Booth PhD MRCP (Editor), K - Kumar and Clark's Clinical Medicine (2025, American Elsevier Publishing Co.) - libgen.li.pdf(pp. 1102)[context]
- [Williams, Bailey and Love's Short Practice of Surgery] Norman Williams, Christopher Bulstrode, P Ronan O'Connell - Bailey & Love's Short Practice of Surgery 26E (2013, CRC Press) - libgen.li.pdf(pp. 1107)[context]