Shoulder Pain: Why it Hurts & When to Worry (Bursitis & Beyond)

The shoulder is the most mobile joint in the body. Because of its extensive range of motion, it’s susceptible to injury and pain. The shoulder can hurt after it has been injured or for no apparent reason. And though most shoulder problems are relatively short-lived, the pain is sometimes indicative of a more complex issue. Here’s a guide to what might be wrong and whether or not it’s a cause for concern.  

Shoulder Pain Sideview with Interior Anatomy

No Worries:

Slight pain with elevation and when playing overhead sports is common. The four tendons that make up the rotator cuff and the biceps tendon (the combined musculature that drives the shoulder motions) can be inflamed by activities such as throwing, shooting basketballs, and lifting weights overhead. The tendons are covered by a thin layer called a bursa, which swells when irritated. The resulting bursitis is filled with inflammatory components that irritate the nerve fibers, sending pain signals to the brain. Eliminating overhead activities and the occasional use of anti-inflammatories usually cures mild bursitis or tendonitis and solves the problem. 

Exercises to strengthen posture are also commonly used by our physical therapists to fix mild shoulder irritations. Slumping at your desk, reaching for your mouse, hunching over your keyboard, can all put extra strain on the shoulder, neck, or back, and may be the cause of your shoulder pain. 

What To Do:

Specific shoulder exercises start with posture correction. Stand with your shoulders at or behind your hips with your belly button tucked in and notice the difference. By squeezing your shoulder blades together repetitively during the day, with your stomach in and head up, you can correct your posture and relieve mild impingement pain. Perform all exercises for the shoulder with your hands below the level of the shoulder, then use free weights and resistance cords for internal and external strengthening exercises, including biceps curls and triceps pushes.

Shoulder anatomy - shoulder pain diagram

More Worry:

Pain that does not go away or pain that occurs with every activity indicates that the key tissues are irritated enough that they are sending pain signals even without motion. This degree of inflammation precedes more structural injuries—such as tears of the tissue or early arthritis. Treated early, full rotator cuff tears and eventual arthritis can be prevented. The treatments are often injections of growth factors from platelets, amniotic fluid, and lubrication with hyaluronic acid. Physical therapy focuses on shoulder mechanics, muscle strengthening, and sport-specific training to help fix the activity that might be causing the injury. Often we see throwers with slight errors in their throwing mechanics or golfers with swing abnormalities that bring on the problems. Correction of the throw or swing fixes the pain. 

We avoid injections of cortisone, as there is clear evidence that it weakens the tissues of the shoulder if used too frequently. Pain can also be generated by shoulder instability, where the shoulder is moving abnormally across the face of the glenoid. While this can be genetic in origin, it is most commonly due to an injury to the labrum or gasket of the joint.

What To Do:

Persistent pain requires a full examination, X-rays, and an MRI. While an ultrasound exam can also add information, nothing gives a more complete picture than an exam with X-ray and MRI imaging. Once a definitive diagnosis is made, targeted therapy can begin. It is sad for us to see small injuries extend into more massive ones due to the lack of an accurate diagnosis. For inflammations and even small tears, injections of biologic therapies, combined with shoulder specific exercises, may be curative. For tears of the labrum and the rotator cuff, a careful decision must be made to select which should be repaired and how the repair is performed.

Real Worry:

Pain at night or pain not improving with therapy after four weeks are red flags. Pain radiating down the arm or up to the neck or to the back is also worrisome, and may indicate injuries not just of the shoulder but sometimes of the neck. It can originate in the discs in the neck or in the nerves at the front of the shoulder called the brachial plexus. These injuries need to be worked up with careful physical exams, X-rays, and MRIs. Instability of the shoulder, with the shoulder popping in or out of the joint, is another area best treated with early repair of the torn ligaments.

A full tear of the rotator cuff will often present with night pain since when you roll over, you push the arm up into the socket through the rotator cuff tear. Torn rotator cuffs fall into two major groups: acute tears and degenerative ones. Acute tears in healthy tissue, when small, may be cured with injections and time. Larger ones, however, are almost always surgically repaired. Degenerative tears that have been present for a long time—and are often associated with some degree of arthritis—fall into a more nuanced decision tree. Some should clearly be repaired. In others, though, the failure rate of repair is high enough that non-operative treatment is the best course. After repair, the patient needs to be ready for a painful three-month rehabilitation course, with full recovery obtained after a year of exercises.

What To Do:

Diagnose and treat early. Fortunately, most of the torn tissue problems in the shoulder can be repaired under a local block with an arthroscope as an outpatient procedure. Only the most severe arthritis cases require bionic (artificial) replacement. Biologic treatments using anabolic stimulation of the tissues with injections, exercise, physical therapy, and activity coaching are becoming more effective, more targeted, and more widespread. The key is to treat them early before full tearing of tissues leads to disability.
 


Article originally published June 25, 2015. Updated & republished September 20, 2020 by Kevin R. Stone, MD with scientific and content updates. 


If you're experiencing shoulder pain, learn more about your injury with our shoulder self-diagnosis tool or download our Saving My Shoulder Guide to learn our clinic's cutting-edge approach to shoulder treatment. 

Medically authored by
Kevin R. Stone, MD
Orthopaedic surgeon, clinician, scientist, inventor, and founder of multiple companies. Dr. Stone was trained at Harvard University in internal medicine and orthopaedic surgery and at Stanford University in general surgery.
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