The shoulder is the most mobile joint in the human body, and it pays for that freedom with fragility. It is not held together by its bones, which barely fit into one another, but by its tendons and muscles. So they are the first to suffer.
In the vast majority of cases, shoulder pain comes from the tendons of the rotator cuff, from the capsule that surrounds the joint, or from the cartilage. Far more rarely, it does not come from the shoulder at all, and I come back to that further down.
This page is here to point you in the right direction. It does not replace an examination, but it will help you put a name on what you feel and work out whether your situation needs a prompt consultation or can wait.
This is the leading cause in adults. Rotator cuff pain sits on the tip of the shoulder and the outer side of the arm, appears when you lift the arm and gets in the way of anything overhead. It is often worse at night when you sleep on the affected side. The tendon is inflamed but intact.
A deposit of crystals has formed inside the tendon. The picture is very distinctive: sudden, extremely intense pain, often at night, which makes any movement impossible for a few days, in someone who had almost nothing before. The detail is on the calcific tendinitis of the shoulder page.
Here the shoulder is no longer just painful, it is weak. The sign that counts is loss of strength: an arm that drops, a hand that can no longer be lifted away from the back, difficulty carrying. See the rotator cuff tear page.
The hallmark of frozen shoulder is stiffness, not just pain. The shoulder gradually locks up in every direction, including when the doctor moves it for you. It often follows a minor injury or appears for no obvious reason. See the frozen shoulder page.
It affects the cartilage and shows up as a deep, mechanical pain that increases with use, along with grinding and a gradual loss of range of motion. It builds up over years.
In young, active patients it is apprehension that dominates: the feeling that the shoulder is about to slip out in certain positions, with the arm raised and turned backwards. See the shoulder dislocation page.
The pain is very localised, right on top of the shoulder, and flares when you bring the arm across your body or sleep on it. It is easy to tell apart from the others because the patient points to the painful spot with one finger.
This is a very common description, and it is rather reassuring once you know how to read it.
Pain that starts at the shoulder and runs down the outer side of the arm as far as the elbow, but no further, is typical of a rotator cuff tendon problem. This is what we call referred pain, and it does not mean the arm itself is diseased.
What changes the reasoning is pain that travels beyond the elbow, into the forearm or the fingers, especially with pins and needles, numbness or loss of grip strength. At that point the trail leads not to the shoulder but to the neck, with a nerve root pinched at the level of the cervical spine.
One simple test already helps: if turning your head or tilting your neck reproduces the pain, it probably comes from the neck. If raising the arm sets it off, it comes from the shoulder.
Mechanically, no. The same conditions affect both sides, with a slight predominance on the dominant side, the one you use most.
There is one important exception, and it explains the worry you often read about: left shoulder pain together with chest tightness, breathlessness, sweating or feeling faint may signal a heart attack and is a medical emergency. Call your local emergency services immediately. That is not shoulder pain, it is pain felt in the shoulder.
Outside that specific situation, isolated left shoulder pain that gets worse when you lift the arm and wakes you at night is ordinary shoulder pain.
This is the symptom that brings the most patients to the consultation, because it is the one that wears you down. A shoulder that wakes you is a shoulder worth getting an opinion on.
Night pain points to a tendon problem, a calcification or a frozen shoulder. Lying down narrows the space under the acromion and increases pressure on the tendon, which is why the pain is worse in bed than standing up.
While you wait for your appointment, sleep propped up in a semi-seated position on pillows, with a cushion under the elbow on the painful side, and avoid sleeping on that side.
This is the most characteristic sign of impingement under the acromion. The pain typically appears between sixty and one hundred and twenty degrees of elevation and disappears once the arm is fully raised. This is known as a painful arc.
If on the other hand the arm will not go up at all, two situations have to be told apart: a shoulder that will not lift because it is locked, including when someone moves it for you, points to a frozen shoulder; a shoulder that will not lift although it stays supple when moved for you points to a tendon tear.
This is rare, but worth knowing. Several organs refer their pain to the shoulder.
The neck, by far the most frequent, with pain that runs beyond the elbow and pins and needles in the fingers.
The heart, for the left shoulder and left arm, in a setting of chest tightness and breathlessness.
The gallbladder and the diaphragm, for the right shoulder, with pain often linked to meals.
The top of the lung, rarely, with stubborn shoulder pain that does not vary with movement, in a smoker, sometimes with the hand affected too.
What all these situations have in common is easy to remember: shoulder pain that changes neither with position nor with movement is probably not shoulder pain, and it deserves a general medical examination.
Call your local emergency services immediately if left shoulder pain comes with chest tightness, breathlessness, sweating or feeling faint. Do not wait, and do not drive yourself.
Seek medical care promptly in case of an injury with a visible deformity or a complete inability to move the arm, fever with a hot and swollen shoulder, sudden loss of strength after a fall or an effort, or pins and needles and weakness in the hand.
Book an appointment without urgency, but without waiting too long, if the pain has lasted more than four to six weeks despite rest and painkillers, if it wakes you at night, if it stops you working or playing your sport, or if you feel your strength fading.
One remark that matters: with a tendon problem, time works against you. A torn tendon never heals back on its own and the muscle gradually deteriorates. Coming in early often means avoiding surgery, not bringing it forward.
The clinical examination remains the most important step. A series of simple tests, tendon by tendon, shows which one is affected before any imaging at all. A precise history of how the pain started, which movements set it off and how it affects your nights already gives three quarters of the diagnosis.
The X-ray shows the bone, the space under the acromion and any calcifications. It is done as a matter of course.
Ultrasound is quick and is often enough to confirm a tendon problem.
MRI and CT arthrography are kept for situations where a surgical decision is on the table, because they alone show how far the tendon has retracted and the quality of the muscle.
Do not immobilise your shoulder. Prolonged rest is the surest way to build stiffness, and a stiff shoulder is harder to treat than a painful one. Carry on with everyday movements, simply avoiding whatever triggers the pain.
For a few days, avoid repeated overhead movements, carrying loads and sleeping on the affected side.
Ice relieves inflammatory and night pain, twenty minutes several times a day, never directly on the skin. Heat loosens muscular and neck pain.
Paracetamol, known as acetaminophen in the United States, is the first painkiller to try. Anti-inflammatories can help during a flare but should not be taken long term without medical advice.
And write down what triggers the pain, the time of day and the movements you can no longer make. Those three pieces of information are worth more than a scan brought along to the consultation.
Pain running down the outer side of the arm as far as the elbow is typical of a rotator cuff tendon problem, and it is referred pain. If it travels beyond the elbow with pins and needles in the fingers, it is more likely coming from the neck.
Lying down narrows the space under the acromion and increases pressure on the tendon. Shoulder pain at night points to tendinitis, a calcification or a frozen shoulder. Sleep propped up in a semi-seated position, with a cushion under the elbow, and avoid the painful side.
Pain that appears between sixty and one hundred and twenty degrees of elevation and then disappears with the arm fully raised is called a painful arc and signals impingement under the acromion. If the arm will not lift at all, a locked shoulder has to be told apart from a supple shoulder with no strength.
No, except in one specific case. Left shoulder pain with chest tightness, breathlessness, sweating or feeling faint is a medical emergency: call your local emergency services immediately. Outside that setting, pain that varies with movement and wakes you at night is ordinary shoulder pain.
Simple tendinitis often settles within a few weeks with relative rest and physiotherapy. Beyond four to six weeks of persistent pain despite treatment, or if it wakes you at night, you should see a doctor.
Ice for inflammatory and night pain, twenty minutes several times a day and never directly on the skin. Heat for muscular pain and neck tension. If in doubt, try ice first.
No. Prolonged immobility builds stiffness, and a stiff shoulder is harder to treat than a painful one. Carry on with everyday movements, simply avoiding whatever triggers the pain.
An X-ray is done as a matter of course, and ultrasound is often enough to confirm a tendon problem. MRI and CT arthrography are kept for situations where a surgical decision is on the table. The clinical examination remains the most important step.
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