Shoulder pain is one of the most common complaints in orthopedic clinics, and it appears at every age, not only in athletes. Pain that gets worse when lifting the arm to the side or above the head, wakes you from sleep when you lie on the painful side and makes it hard to get dressed or reach behind your back usually comes from the rotator cuff, a group of four muscles and tendons that wraps around the head of the upper arm bone and stabilises the joint. Another common cause, mainly after the age of forty, is a frozen shoulder, in which the joint itself stiffens and loses its range of motion. It is worth seeing an orthopedist when the pain lasts more than a few weeks despite rest, when there is weakness in lifting the arm, when movement is severely limited or when the pain began after a fall or an injury.
How the shoulder is built and why it is vulnerable
The shoulder is the most mobile joint in the body: the head of the upper arm bone rests on a shallow socket in the shoulder blade, and to allow movement in every direction it is held mainly by soft tissues rather than by bone. The rotator cuff is the main stabiliser. Its tendons pass through a narrow space beneath the tip of the shoulder blade, and every time the arm is raised they are squeezed a little. Over years of use, and especially in work with the arms raised, the tendons tire, thicken and sometimes tear.
This structure explains why shoulder pain tends to appear gradually, without a clear event, and why it gets worse in certain movements and at night, when the weight of the body on the painful side increases the irritation in the narrow space.
Common causes of shoulder pain
- Impingement syndrome: the rotator cuff tendon and the bursa, a small fluid cushion above it, are squeezed and irritated in the narrow space. This is the most common cause, and it shows up as pain when lifting the arm to the side, mainly between shoulder height and head height.
- Tendinitis or calcification in the tendon: the tendon thickens, and sometimes a calcium deposit settles in it and causes sharp pain, at times sudden and very severe.
- A rotator cuff tear: partial or complete, usually in the upper tendon. In younger people it is usually caused by an injury or a fall, and in older people it develops gradually. The typical symptom is weakness, difficulty lifting the arm or holding it raised.
- Frozen shoulder: the capsule that surrounds the joint thickens and contracts. In the first stage pain dominates, and later a severe restriction of movement in every direction joins it, even when someone else moves the arm. It is more common in women, after the age of forty and in people living with diabetes or a thyroid problem.
- Wear in the acromioclavicular joint, the small joint between the collarbone and the shoulder blade, which hurts on direct pressure and when crossing the arm over the chest.
- Pain referred from the neck: pressure on a nerve root in the neck can show up as pain in the shoulder and arm, sometimes with tingling in the fingers.
What you can do at home in the first weeks
Shoulder pain that began gradually, without an injury and without clear weakness, justifies a few weeks of self-care:
- Temporarily reduce activity with the arm above shoulder height and carrying heavy objects in the painful arm, without immobilising the shoulder completely.
- Keep moving the shoulder gently within the pain-free range, to prevent stiffening.
- Cold on the painful area after activity, and gentle heat before exercises.
- Over-the-counter painkillers and anti-inflammatories for a short period, following the instructions on the pack and after consulting a pharmacist if you have other medical conditions.
- Sleep on the healthy side, with a small pillow supporting the painful arm.
- Adjust the workspace: screen and keyboard height, breaks from repetitive movements with the arm raised.
When the pain improves after two or three weeks, gradually add strengthening exercises for the rotator cuff and the shoulder blade muscles. When there is no improvement, it is worth being examined rather than continuing to guess.
When to see an orthopedist
It is worth booking a visit with a private orthopedist in Modi’in in these situations:
- Shoulder pain that lasts more than three to four weeks despite reduced activity and painkillers.
- Clear weakness: difficulty lifting the arm to the side or holding it raised, especially after a fall or a strong pull.
- A marked restriction in the range of motion, for example difficulty reaching your back, your head or your back pocket.
- Pain that wakes you from sleep night after night.
- Pain that began after a fall, an injury or an accident, especially with swelling, a change in the shape of the shoulder or an inability to move the arm at all.
- Tingling or weakness in the hand and fingers alongside the shoulder pain.
- Shoulder pain in someone living with diabetes, in whom frozen shoulder is common and progresses faster.
A shoulder that has come out of its socket, an inability to move the arm after a fall, or shoulder pain accompanied by chest pain, shortness of breath and sweating are emergencies that need an immediate visit to the emergency room.
What the orthopedist checks
The visit begins with a conversation: how the pain began, which movements make it worse, whether it wakes you at night, what your work and physical activity involve, and whether there are other medical conditions. The doctor then checks the active and passive range of motion, feels for tender points and performs a series of manual tests that isolate each of the rotator cuff tendons and check for weakness or impingement. The physical examination usually makes it possible to distinguish between impingement, a tear and a frozen shoulder even before imaging.
As needed, the doctor refers you for imaging. An X-ray shows the bones, calcifications in the tendon and wear in the joint. Ultrasound or MRI shows the tendons themselves, the bursa and the size of the tear when there is one. When the pain is suspected to come from the neck, the work-up is directed there. The doctor chooses the test according to the findings, and not every painful shoulder needs an MRI.
How shoulder pain is treated
Most shoulder problems are treated without surgery. The foundation is focused physiotherapy: releasing the capsule and gradually strengthening the rotator cuff and the muscles that stabilise the shoulder blade, together with correcting movement patterns. This process usually takes several months and requires persistence with home exercises.
When the pain is severe and prevents exercising, the doctor may suggest a steroid injection into the bursa or the joint, which reduces inflammation and allows rehabilitation to progress. For calcification in the tendon there are also methods for breaking up the deposit. In a frozen shoulder, treatment is aimed mainly at the pain in the first stage and at restoring range in the later stages, and its natural course is long, sometimes a year or more.
Surgery comes up for discussion when there is a complete tear in an active person, mainly after an injury, when there is weakness that does not improve, or when full conservative treatment over several months has not helped. Most operations today are performed arthroscopically through small incisions, followed by structured rehabilitation. The decision is made after a full work-up and a conversation about the benefits, the risks and the length of recovery.
Why the work-up should not be put off
A rotator cuff tear that is not treated tends to enlarge over time, and the tendon retracts and degenerates, which makes a late repair harder. A shoulder that is not moved because of pain stiffens, and a restriction of movement that takes months to release joins the pain. A timely work-up makes it possible to choose the right treatment while it is still simple, and to return to restful sleep and full function sooner.
At EliteMed in the Ayala 360 complex in Modi’in you can book a visit with an orthopedic specialist without a referral, and the consultation can be held in English. If another joint is troubling you as well, read our article on knee pain that will not settle. The information here is general and does not replace an examination and advice from a doctor.
Frequently asked questions
Why does shoulder pain get worse at night?
Lying on the painful side, the weight of the body increases the irritation of the tendon and the bursa in the narrow space beneath the shoulder blade, and at rest there are no distractions from the pain. Persistent night pain is typical of rotator cuff problems and of a frozen shoulder, and when it lasts for weeks it justifies an examination.
How do I know whether I have a rotator cuff tear?
The suspicious sign is weakness: difficulty lifting the arm to the side or holding it raised, sometimes with pain at night, especially after a fall or a strong pull. The diagnosis is made by physical examination and by imaging such as ultrasound or MRI, which show the tendon and the size of the tear.
Does every rotator cuff tear need surgery?
No. Partial tears and many of the tears in older people are treated successfully with physiotherapy, adjustment of activity and sometimes an injection. Surgery is considered mainly for a complete tear after an injury in an active person, for weakness that does not improve or when prolonged conservative treatment has not helped.
What is a frozen shoulder and how long does it last?
A frozen shoulder is a thickening and contraction of the capsule that surrounds the joint, which causes pain and then a severe restriction of movement in every direction. Its natural course is long and sometimes lasts one to two years, but proper treatment of the pain and the range of motion shortens it and improves function along the way.
Should I rest the painful shoulder completely?
Immobilising the shoulder is not recommended. Reducing activity with the arm above shoulder height and carrying heavy objects is right in the first weeks, but it is important to keep moving the shoulder gently within the pain-free range to prevent the joint from stiffening. When the pain does not improve, see a doctor.