Shoulder Pain

Shoulder pain most often arises from the rotator cuff and surrounding subacromial structures, presenting as pain on overhead reaching, difficulty lying on the affected side and weakness on resisted movement. Imaging is misleading here in a specific and important way: rotator cuff tears are found on MRI in a large proportion of entirely asymptomatic people over 60, so a scan finding does not establish the cause of pain. Diagnosis is clinical, based on the pattern of restricted and painful movement. Frozen shoulder, or adhesive capsulitis, is the important alternative pattern, distinguished by loss of passive external rotation — the shoulder will not move even when someone else moves it — and it is disproportionately common in people with diabetes. Referred pain from the neck, and less commonly from the diaphragm or heart, must be considered when shoulder movement itself is painless. Management evidence has shifted decisively toward exercise. Progressive loading programmes for rotator cuff pain match or beat injection and surgery over medium-term follow-up, and the landmark CSAW trial found subacromial decompression no better than placebo arthroscopy. Corticosteroid injection provides short-term relief but shows no advantage beyond a few months and may impair tendon quality with repetition. Supplement evidence is limited: collagen and curcumin have small tendinopathy datasets, and vitamin D deficiency associates with poorer cuff healing.

• •Pain on reaching overhead or behind the back
• •Difficulty lying on the affected side
• •Weakness lifting or rotating the arm
• •Painful arc of movement
• •Stiffness with global loss of movement in frozen shoulder
• •Night pain

• •Rotator cuff tendinopathy
• •Subacromial bursitis
• •Cuff tears
• •Adhesive capsulitis
• •Glenohumeral or AC joint arthritis
• •Instability
• •Referred cervical pain

Rotator cuff tendinopathy from cumulative overload or sudden unaccustomed activity, subacromial bursitis, degenerative or traumatic cuff tears, adhesive capsulitis particularly in diabetes, glenohumeral or acromioclavicular osteoarthritis, instability in younger people, and referred pain from the cervical spine.