Shoulder Pain

The shoulder trades stability for range. A large ball sits against a shallow socket, held in place less by bone than by a cuff of four tendons, a capsule, and the muscles around them. That design lets you reach overhead and behind your back, and it is why the tissues that do the steering are the ones that most often hurt. Shoulder pain is the third most common musculoskeletal reason people see a primary-care clinician, and most of it is not dangerous.

What can hurt in a shoulder

Subacromial pain is the most frequent source. The rotator cuff tendons and a thin cushion called the bursa pass through a narrow space under a bony roof, the acromion. Pain here is often felt on the outside of the upper arm, worse when reaching up or lying on that side. Older labels – rotator cuff tendinopathy, impingement, bursitis, partial tear – overlap so much that a 2026 review in JAMA Internal Medicine suggests the plainer term, subacromial pain, for all of them.

Frozen shoulder (adhesive capsulitis) is different: the joint capsule itself becomes inflamed, thickened, and tight. Pain comes first, often worst at night, and then stiffness that limits movement in every direction, even when someone else moves the arm for you. It is more common in people with diabetes and in middle age. Osteoarthritis of the shoulder joint wears the cartilage surfaces and tends to cause a deep, grinding ache with stiffness. Instability – a shoulder that has dislocated or feels as if it might – follows injury or very loose joints and matters more in younger people.

Finally, some shoulder pain does not start in the shoulder. Referred pain from an irritated nerve root in the neck, and more rarely from the heart, the diaphragm, the top of a lung, or the gallbladder, can be felt around the shoulder. A clinician asks about neck movement, tingling, breathlessness, and chest symptoms for exactly this reason; our neck pain page explains the nerve-root pattern.

Why it hurts

Tendons are living tissue that adapts to load. When the load changes faster than the tendon can – a new sport, a season of overhead work, a fall, or simply years of use – the tendon and the bursa beside it become sensitive and sore. Pain then changes how you move: the arm is held close, the shoulder blade stops gliding, and the tissues are asked to work in a position they tolerate badly. That loop, more than any single structural flaw, is what most shoulder treatment tries to interrupt.

Persistent shoulder pain also changes the system receiving the signal. Broken sleep, worry about damage, and repeated flare-ups can raise sensitivity so the shoulder hurts with less provocation. That is a normal property of the pain system, not a sign that the pain is imagined. You are not imagining your pain. It is a reason to treat sleep, confidence, and movement together with the tendon.

Cortisone shot or exercise: fast versus durable

Both options sit in current guidelines, and both are reasonable. What the evidence can now describe is the shape of each. In the SIX-Shoulder Study, a pragmatic one-year trial run in Dutch general practice, 183 people with a new episode of shoulder pain were randomly assigned to a single corticosteroid injection or to twelve sessions of physiotherapist-led exercise. At six weeks the injection group had improved more. At six, nine, and twelve months the exercise group was doing better on pain and function, though the confidence intervals were wide and the authors call the result an indication rather than a verdict. Side effects were reported more often with exercise (mostly temporary soreness) than with injection.

The larger UK GRASP trial, 708 people with rotator cuff disorders, looked at the same question from another angle. A progressive exercise programme was not better over a year than a single best-practice advice session with a physiotherapist, and adding a subacromial corticosteroid injection brought no long-term benefit. Read together, the two trials say something honest: an injection buys speed, structured exercise or good advice tends to hold, and the evidence cannot yet say which person should start with which. That is a conversation for you and your clinician, weighing how much the next few weeks matter against the longer run. The site’s comparing your options page describes the same trade-off across other treatments.

The rest of the ladder

For most non-traumatic shoulder pain, first-line care is the same whatever the label: an explanation of what is going on, reassurance that the natural history is usually favourable, keeping the arm moving within tolerable limits, and adjusting the activity that keeps setting it off. Short-term pain relief with over-the-counter medicines may be discussed with a clinician or pharmacist; our medications for pain page describes the classes without prescribing. Frozen shoulder is managed somewhat differently – a corticosteroid injection into the joint may be used for the painful early phase, with movement work afterwards – and a 2017 systematic review found the old idea that it reliably resolves on its own in three phases is not well supported, so it deserves a plan rather than waiting it out.

Surgery has a narrower place than it once had. The Cochrane review of subacromial decompression and the UK CSAW trial, which compared the operation with placebo surgery, found no meaningful benefit over sham surgery for subacromial pain at one year – high-certainty evidence that has moved the operation to the margins. Surgery remains a real conversation for traumatic full-thickness tears, recurrent instability, advanced osteoarthritis, and selected frozen shoulders that have not responded. The interventional procedures page covers how injections and operations are selected.

What a scan can – and cannot – settle

The American College of Radiology does not recommend early imaging for non-traumatic shoulder pain unless there are suspicious features. The reason is in the data: when researchers scanned both shoulders of 664 people in one Japanese village, about one in five had a full-thickness rotator cuff tear, and two-thirds of those tears caused no symptoms at all. Tears were present in a quarter of people in their seventies and more than a third in their eighties. A tear on an MRI of a painful shoulder over sixty may be the cause, a bystander, or a finding that was there years before the pain.

Imaging earns its place after significant trauma, when a dislocation or fracture is suspected, when a frozen shoulder or arthritis diagnosis is unclear, when surgery is being planned, or when fever, weight loss, or a cancer history raise concern. An X-ray shows bone and arthritis; ultrasound and MRI show tendons and the bursa. Your clinician can decide whether a scan would answer a question that matters to the plan now.

When shoulder pain needs urgent care

Seek emergency care if shoulder pain comes with chest pressure, breathlessness, sweating, or nausea – especially pain in the left shoulder or arm that starts with exertion – because the heart can refer pain here. Go urgently after a fall or accident if you cannot move the arm, the shoulder has changed shape or is badly swollen, or there is numbness or a cold, pale hand, which can mean a fracture, dislocation, or a blood-vessel or nerve injury.

Prompt assessment also matters for a hot, red, swollen shoulder with fever or feeling unwell (possible infection), for severe pain in both shoulders that arrived over days in someone over fifty (possible inflammatory disease), for steadily worsening pain at night with weight loss or a cancer history, and for pins and needles or weakness that do not settle. None of these is a diagnosis on its own; they are reasons for a clinician to look at the whole picture quickly rather than wait.

What’s coming

The open question is not whether exercise or injection works but for whom. Programmes such as the UK’s PANDA-S project are building prognostic tools to predict which shoulders settle quickly and which need more help from the start. Better matching, rather than a new operation, is the likeliest advance. The precision pain medicine page follows that work across conditions.

When to see a specialist

See a clinician sooner for the warning signs above, for pain after injury, for a shoulder that is getting steadily stiffer, or for pain that is not improving after a few weeks of sensible self-care. When shoulder pain remains limiting after a well-run course of first-line care, a physiotherapist, a musculoskeletal or sports physician, or a pain physician can revisit the diagnosis, separate shoulder-origin pain from neck or referred pain, and help you choose between speed and durability with your own life in view. An orthopaedic surgeon becomes the right call when a tear after trauma, instability, or advanced arthritis is on the table.