Common Causes of Shoulder Pain

Shoulder pain can come from several different structures, including the rotator cuff tendons, biceps tendon, labrum, cartilage, joint capsule, bursae and the joints surrounding the shoulder.

The location of the pain can sometimes provide clues, but symptoms from different shoulder conditions frequently overlap.

Pain along the outside or front of the shoulder is commonly associated with rotator cuff problems, bursitis, biceps tendon conditions and shoulder impingement.

Pain accompanied by significant stiffness and loss of motion may occur with frozen shoulder or arthritis.

Pain following an injury may be associated with a rotator cuff tear, labral injury, fracture, dislocation or other structural problem.

Some pain that seems to originate from the shoulder may actually come from the neck or surrounding nerves.

Because many shoulder conditions produce similar symptoms, determining the source of the pain is important before deciding on treatment.

Rotator Cuff Tendonitis and Tendinopathy

The rotator cuff consists of four muscles and their tendons that help stabilize and move the shoulder.

Rotator cuff tendinopathy can develop gradually from repetitive activity, sports, lifting, age-related tendon changes or a combination of factors.

Patients may experience pain when reaching overhead, lifting objects, exercising or sleeping on the affected shoulder. Pain is often felt along the outside of the upper arm rather than directly over the injured tendon.

Many rotator cuff tendon problems can initially be treated without surgery.

Treatment may include activity modification, rehabilitation and strengthening, medications and selected image-guided procedures. For certain chronic tendon conditions, PRP or shockwave therapy may also be considered.

Rotator Cuff Tears

A rotator cuff tear does not automatically mean that surgery is required.

Rotator cuff tears vary considerably. Some are small partial tears, while others involve a complete tear of one or more tendons.

Age, activity level, how the injury occurred, degree of weakness, size and location of the tear, tendon quality and the patient's goals can all influence treatment.

Many patients—particularly those with chronic or partial-thickness tears—may initially be managed nonsurgically.

However, significant traumatic tears, substantial weakness or certain larger tears may warrant evaluation by an orthopedic surgeon.

The important point is that an MRI showing a rotator cuff tear should be interpreted together with the patient's symptoms and physical examination rather than automatically leading to surgery.

Shoulder Impingement and Bursitis

Shoulder impingement is a term commonly used to describe pain that occurs when structures around the rotator cuff become irritated during shoulder movement.

The subacromial bursa, which helps reduce friction around the rotator cuff, can also become inflamed or irritated.

Patients frequently experience pain when raising the arm, reaching overhead, exercising or lying on the affected side.

While bursitis may be part of the problem, persistent shoulder pain is not always caused by an isolated inflamed bursa. Rotator cuff tendinopathy, partial tendon tears, shoulder mechanics and other conditions may contribute to the symptoms.

Treatment should therefore focus on identifying and addressing the underlying problem rather than simply assuming every painful shoulder needs a cortisone injection.

Frozen Shoulder

Frozen shoulder can cause substantial pain and progressive loss of shoulder motion.

Patients often notice increasing difficulty reaching overhead, reaching behind the back, getting dressed or sleeping comfortably.

Unlike many rotator cuff conditions, frozen shoulder typically causes significant restriction in both active and passive shoulder movement.

Treatment may include rehabilitation, medications and image-guided procedures depending on the stage and severity of the condition.

For selected patients, an ultrasound-guided shoulder hydrodilatation may be considered as part of the treatment plan.

Shoulder Arthritis

Arthritis can affect different joints around the shoulder.

The glenohumeral joint, where the upper arm bone meets the shoulder socket, can develop osteoarthritis and other forms of joint degeneration.

Patients may experience pain, stiffness, grinding, reduced motion and difficulty reaching or lifting.

The AC joint, located at the top of the shoulder where the collarbone meets the acromion, can also become arthritic and painful.

Not every patient with shoulder arthritis requires shoulder replacement.

Depending on the severity of the arthritis and symptoms, nonsurgical treatment may include activity modification, rehabilitation, medications and image-guided injections.

For appropriately selected patients, regenerative treatments such as PRP may also be discussed.

Biceps Tendon Pain

The long head of the biceps tendon travels through the front of the shoulder and can be an important source of shoulder pain.

Biceps tendinopathy may cause pain in the front of the shoulder, particularly with lifting, pulling, reaching or repetitive activity.

Biceps tendon problems can occur independently but are also frequently associated with rotator cuff or labral abnormalities.

Diagnostic musculoskeletal ultrasound can be particularly useful because the biceps tendon can be visualized dynamically as the shoulder moves.

Treatment depends on the underlying problem and may include rehabilitation, activity modification and selected image-guided procedures.

Labral Tears

The labrum is a ring of cartilage surrounding the shoulder socket that contributes to shoulder stability.

Labral injuries can occur after falls, dislocations, sports injuries or repetitive overhead activity. Some labral abnormalities also develop gradually with age.

Patients may experience deep shoulder pain, clicking, catching, instability or pain during throwing and overhead movements.

Finding a labral tear on an MRI does not automatically establish that the tear is responsible for the patient's pain or that surgery is required.

Symptoms, examination findings, age, activity level and the type of labral injury all need to be considered when determining treatment.

Is Your Shoulder Pain Actually Coming From Your Neck?

Not all pain felt around the shoulder originates from the shoulder itself.

Problems involving the cervical spine and nerves can produce pain that travels into the shoulder, shoulder blade, arm or hand.

Numbness, tingling, burning pain or symptoms that extend below the elbow may increase suspicion for a nerve-related source, although symptoms can vary considerably.

Shoulder and neck problems can also occur at the same time.

A careful examination can help determine whether symptoms are primarily coming from the shoulder, the cervical spine or another structure.

This distinction is important because injecting or treating the shoulder is unlikely to solve pain that is actually originating from the neck.

Do You Need an MRI for Shoulder Pain?

Not every patient with shoulder pain needs an MRI.

Depending on the symptoms and examination, evaluation may include X-rays and diagnostic musculoskeletal ultrasound.

Ultrasound allows the physician to evaluate many shoulder structures in real time, including the rotator cuff and biceps tendons. It can also be used dynamically while the patient moves the shoulder.

MRI may be appropriate when more detailed evaluation is necessary, when certain labral or structural injuries are suspected, or when the diagnosis remains uncertain.

The objective is to obtain imaging when it is likely to provide useful information that affects treatment rather than ordering an MRI for every painful shoulder.

How We Diagnose Shoulder Pain

Shoulder treatment begins with determining what structure is actually causing the symptoms.

An evaluation typically includes a review of how the pain began, the activities that aggravate it, previous injuries and treatments, and a physical examination assessing shoulder motion, strength and specific structures.

When appropriate, our physicians can use digital X-ray and diagnostic musculoskeletal ultrasound as part of the evaluation.

Ultrasound is particularly useful in the shoulder because many tendons and soft tissues can be examined dynamically while the patient moves.

If an MRI or surgical consultation is necessary, we can recommend that as well.

Can Shoulder Pain Be Treated Without Surgery?

Many common shoulder conditions can be managed nonsurgically.

Depending on the diagnosis, treatment may include activity modification, rehabilitation and strengthening, medications, image-guided injections, tendon procedures, shockwave therapy, PRP or other nonsurgical treatments.

The appropriate treatment for shoulder arthritis may be very different from treatment for frozen shoulder, rotator cuff tendinopathy or a labral injury.

That is why our approach begins with the diagnosis rather than selecting an injection before determining the cause of the pain.

PRP for Shoulder Pain and Rotator Cuff Problems

Platelet-rich plasma (PRP) is prepared from a patient's own blood and contains concentrated platelets and associated signaling proteins.

PRP may be considered for certain chronic tendon injuries and other selected shoulder conditions.

One potential application is rotator cuff tendinopathy and selected partial-thickness rotator cuff tears.

However, not every rotator cuff tear is an appropriate PRP case.

A large traumatic tear with substantial weakness, for example, should not simply be injected without considering whether surgical repair is more appropriate.

At Carolina Nonsurgical Orthopedics, regenerative treatment begins by identifying the condition and determining whether the patient is an appropriate candidate.

Learn more about our dedicated rotator cuff tear treatment.

Shockwave Therapy for Shoulder Tendon Problems

Shockwave therapy is a noninvasive treatment that may be considered for certain chronic tendon conditions.

One particularly important shoulder application is calcific tendinopathy, in which calcium deposits develop within a rotator cuff tendon.

Depending on the size, location and symptoms associated with the calcium deposit, treatment options may include rehabilitation, shockwave therapy or an ultrasound-guided procedure to address the calcification.

Learn more about our approach to calcific tendonitis treatment.

Why Image Guidance Matters for Shoulder Procedures

The shoulder contains several joints, tendons, bursae and other potential treatment targets within a relatively small area.

An injection described simply as a “shoulder shot” could therefore be placed into very different structures depending on the diagnosis.

Musculoskeletal ultrasound allows the physician to visualize the anatomy and guide the needle toward the intended target in real time.

This can be useful for procedures involving the shoulder joint, AC joint, biceps tendon, rotator cuff, bursae and other structures.

At Carolina Nonsurgical Orthopedics, image guidance is an important component of many of the shoulder procedures we perform.

When Should You See a Shoulder Pain Specialist?

Consider an orthopedic evaluation when shoulder pain:

• Persists despite rest or activity modification

• Interferes with exercise, sports or work

• Makes it difficult to reach overhead

• Causes significant pain at night

• Makes sleeping on the affected shoulder difficult

• Is associated with weakness

• Causes progressive loss of motion

• Began after an injury

• Continues despite previous treatment

• Prevents you from performing normal daily activities

More urgent evaluation may be appropriate following a significant injury associated with deformity, inability to move the arm, severe weakness or concern for a fracture or dislocation.

When Is Shoulder Surgery Necessary?

Focusing on nonsurgical orthopedics does not mean that every shoulder problem should be treated without surgery.

Certain fractures, recurrent instability, significant traumatic rotator cuff tears and other structural injuries may require surgical treatment.

Patients with severe shoulder arthritis and substantial loss of function despite appropriate nonsurgical care may eventually benefit from shoulder replacement.

Our objective is not to prevent surgery when surgery is clearly the better treatment.

It is to determine whether a reasonable nonsurgical option exists before an operation is pursued.

Staying Active With Shoulder Pain

Shoulder pain can interfere with weight training, golf, tennis, pickleball, swimming and many other activities.

Complete avoidance of shoulder movement is not always the best long-term strategy.

Depending on the diagnosis, temporary modification of aggravating activities combined with appropriate strengthening and rehabilitation may allow patients to maintain fitness while the shoulder improves.

The goal is not simply to tell active patients to stop doing everything that hurts.

It is to determine the cause of the problem and develop a treatment plan designed to help them return to the activities that are important to them.

Shoulder Pain Treatment in Raleigh & Cary, NC

Shoulder pain does not automatically mean you need surgery.

At Carolina Nonsurgical Orthopedics, our physicians evaluate rotator cuff injuries, arthritis, frozen shoulder, tendon problems, sports injuries and other causes of shoulder pain.

Treatment may include rehabilitation recommendations, image-guided procedures, PRP, shockwave therapy and other nonsurgical options when appropriate.

If shoulder pain is interfering with exercise, work, sports, sleep or everyday activities, schedule an orthopedic evaluation at our Raleigh or Cary, NC location.