Shoulder Pain — Common Causes and When to See an Orthopedic Surgeon
Author: Dr. Alexandru Grecu — Senior Orthopedic and Trauma Surgeon
Published: March 24, 2026 · Reviewed: 2 mai 2026
The Shoulder — The Most Mobile Joint, The Most Vulnerable
The shoulder allows for a wide range of motion, but its stability is provided by muscles and tendons, not solid bone structures. That makes it prone to a variety of conditions. And because many of them cause the same pain on the outer side of the shoulder, the first step is not treatment but triage: which structure is involved, and why.
Common Causes — A Map by Age and Mechanism
Age does not make the diagnosis, but it narrows the list. Together with the mechanism — whether there was an accident or gradual overload — it guides the assessment better than anything else.
Under 40. Instability and overload dominate. A shoulder that "pops out of place" after a dislocation, or a feeling of insecurity in certain positions, occurs in young people and in athletes who throw or work overhead. Overload tendinopathy comes from volume increased too quickly: the gym, swimming, plastering, painting. The pain is tied to the movement and to effort, not to rest.
Between 40 and 60. There are three main suspects here. Rotator cuff disease, from irritation to a partial tear — pain on lifting, night pain, sometimes weakness. → Read about rotator cuff tears. Adhesive capsulitis, which blocks the shoulder progressively and is more frequent in people with diabetes and after immobilisation. → Read about adhesive capsulitis. And calcific tendinitis, with calcium deposits in the tendon, causing intense painful episodes, sometimes at night, in a shoulder that was normal until then.
Over 60. Degenerative cuff tears become frequent, and glenohumeral osteoarthritis enters the discussion: deep pain, grinding on rotation, slowly increasing stiffness. The two can overlap, and in advanced stages shoulder arthroplasty is discussed, including the reverse design, conceived for a shoulder without a functioning cuff.
Subacromial impingement syndrome crosses the age groups: pain in a particular sector of lifting the arm to the side, when the tendon is compressed under the acromion. It is a clinical picture, not a final diagnosis — cuff disease often lies beneath it.
The acromioclavicular joint, at the top of the shoulder, deserves a separate mention: the pain is pinpointed with a finger, appears when the arm crosses the midline, and follows old collarbone injuries.
Pain That Does Not Come from the Shoulder
The shoulder is an area where the pain of other organs is projected. The clue to the origin is simple: on examination, the shoulder moves freely and painlessly even though the patient reports pain.
The cervical spine. Irritation of the nerves in the neck causes pain that starts at the nape and runs down the arm, often with numbness or tingling in the fingers. It changes with the position of the neck, not with movement of the shoulder.
The heart. Pain of cardiac origin can be felt in the left shoulder and arm. It does not depend on shoulder movement, appears on exertion and comes with chest pressure, sweating, nausea or shortness of breath. This is an emergency: do not wait for an orthopaedic appointment, call the emergency number.
The gallbladder. Biliary disease typically causes pain in the right shoulder and between the shoulder blades, linked to fatty meals, with nausea.
The diaphragm. Irritation of the diaphragm is felt at the top of the shoulder. It appears after abdominal surgery, in lung disease or, more rarely, after abdominal trauma — a situation that calls for immediate assessment if it comes with abdominal pain, pallor or shortness of breath.
How Is Shoulder Pain Evaluated?
What I ask at the consultation. How it started: suddenly, after a specific movement, or gradually. Where exactly it hurts, pointed out with a finger. Which movement reproduces the pain. Whether it wakes you at night and whether you can sleep on that shoulder. Whether the arm has become weak or only hurts. Which movements are no longer possible — combing your hair, the seatbelt, the hand behind the back. What work you do and what sport you play. Whether you have diabetes or thyroid disease. What you have already tried and with what result.
The clinical examination. It is compared with the healthy shoulder. Active and passive motion are measured, and the difference between them is the key to triage: preserved passive motion with limited active motion points to the cuff; motion limited both ways points to capsulitis. Strength is tested tendon by tendon, the painful points are palpated, the impingement manoeuvres are performed, and the neck is checked.
Imaging, in order. The X-ray first: it shows the bone, osteoarthritis, calcifications and the position of the humeral head. Ultrasound second: it shows the tendons in motion and the fluid in the bursa; it is quick and repeatable. MRI last, when surgery is discussed or when lesions are suspected that ultrasound cannot show — labrum, tendon retraction, muscle degeneration. The order is dictated by the clinical examination. An MRI obtained before the examination usually produces more confusion than clarity, because in a shoulder over 50 there are almost always changes that do not necessarily explain the pain.
What You Can Do Until the Consultation
A few measures are reasonable and do no harm. Temporarily avoid movements above the head and lifting weights with the arm outstretched — those are the movements that compress the tendon. Do not immobilise the shoulder completely: total rest favours stiffness, and in a shoulder prone to capsulitis that is exactly what we do not want. Move the arm daily, within ranges that do not hurt.
Ice helps in pain of sudden onset, after exertion or during an episode of calcific tendinitis, applied briefly and through cloth. Heat helps more in a stiff, chronically painful shoulder, before exercise. There is no single rule; use what eases your pain.
Sleep can be improved with a pillow under the arm and by lying on the healthy side or on your back. Anti-inflammatory medication is used short-term, if you have no contraindications — it reduces pain, it does not treat the cause.
About physiotherapy, I state exactly what the evidence shows. The Cochrane review of physiotherapy interventions for shoulder pain finds limited and uneven evidence, with a possible benefit of exercise in rotator cuff disorders. For frozen shoulder, the Cochrane review of manual therapy and exercise shows that these may help, but the certainty of the evidence is low and superiority over other treatments is not established. The practical conclusion is cautious: properly guided exercise makes sense and is worth trying, but no result can be promised, and the programme has to match the cause — a blocked shoulder and a weak shoulder are not trained in the same way.
When to See an Orthopaedic Surgeon
- Pain persisting beyond 2-3 weeks
- You cannot lift your arm above your head
- Night pain that wakes you
- Progressive stiffness, increasing from week to week
- Sudden pain with inability to move, after a fall or a pull
- Weakness when lifting the arm, not only pain
Signs that call for emergency assessment rather than an appointment: deformity of the shoulder after trauma, with no movement possible; left shoulder pain with chest pain, cold sweats or shortness of breath; fever with a red, hot, very painful shoulder; numbness or paralysis of the arm of sudden onset.
Frequently Asked Questions
How long can I wait with a painful shoulder?
Pain that appears after unusual effort and lessens day by day can be watched at home for a few weeks. If it persists, wakes you at night or limits lifting the arm, waiting no longer helps: the causes are treated differently, and the right treatment starts once we know what it is.
Why does my shoulder hurt more at night?
At night the distraction goes and so does the support: the arm hangs, the capsule tightens, and an inflamed tendon becomes more sensitive lying down. Night pain is a useful sign — it is common in rotator cuff disease and in capsulitis.
Which imaging comes first?
Usually the X-ray, because it shows bone, osteoarthritis and calcifications. Ultrasound follows for the tendons and for fluid. MRI is used when surgery is discussed or when lesions are suspected that ultrasound cannot show. The order is set by the clinical examination, not the other way round.
Can shoulder pain come from elsewhere?
Yes. The cervical spine, the heart, the gallbladder and irritation of the diaphragm can all be felt in the shoulder. The clue is that the shoulder moves freely and painlessly on examination even though the patient reports pain. Sudden left shoulder pain with chest pain, sweating or shortness of breath needs emergency assessment.
For context, see the dedicated page on shoulder arthroplasty, and if you want to go deeper, read aboutrotator cuff tears and aboutadhesive capsulitis (frozen shoulder).
Have questions or need a consultation?
Scientific References
Mitchell C, Adebajo A, Hay E et al. — Shoulder pain: diagnosis and management in primary care. BMJ. 2005;331(7525):1124-8.
For the triage of shoulder pain: a synthesis of the causes by age group and mechanism, of the clinical examination and of the order of investigations.
Green S, Buchbinder R, Hetrick S — Physiotherapy interventions for shoulder pain. Cochrane Database Syst Rev. 2003;(2):CD004258.
For physiotherapy in shoulder pain: the evidence is limited and uneven, with a possible benefit of exercise in rotator cuff disorders.
Page MJ, Green S, Kramer S et al. — Manual therapy and exercise for adhesive capsulitis (frozen shoulder). Cochrane Database Syst Rev. 2014;(8):CD011275.
For frozen shoulder: manual therapy and exercise may help, but the certainty of the evidence is low and superiority over other treatments is not established.