Shoulder pain: What helps?

Photo of an athlete holding his shoulder in discomfort (PantherMedia / martinan) Shoulder pain is typically felt on the outer side of the shoulder and is more noticeable when you lift your arm. It can be relieved with anti-inflammatory painkillers, steroid injections and physical therapy.

Shoulder pain usually arises under the “roof” of the shoulder, known as the acromion. The medical term for this kind of pain is “subacromial pain” (subacromial = under the acromion).

This pain can be caused by

It’s often not possible to find out exactly what’s causing shoulder pain. That’s partly because there’s no clear link between the symptoms people have and things that can be seen in x-ray, ultrasound or MRI images. For instance, a lot of people don’t have shoulder pain even though these images show that there are tears in the rotator cuff (a group of muscles and tendons that surround the shoulder joint) or calcium deposits in the shoulder tendons.

What can I do myself?

If you have shoulder pain, it’s a good idea to avoid activities that make the pain worse. These may include things like working on something above your head, lifting and carrying heavy objects, or doing sports that put a lot of strain on the shoulder. It’s also best to avoid sleeping on the affected side of the body.

Although you should go easy on the shoulder, it’s still important to continue moving it. Not moving the shoulder at all can make the muscles weaker and also cause it to become stiff. To gently mobilize the shoulder, you could do the following simple exercise, for example:

  • Place the hand on the “pain-free” side of your body on a table or chair for support,
  • lean forward a little and let the other arm hang down,
  • then gently swing the whole arm in small circular motions, or back and forth.

You can do this exercise two to three times a day for one to two minutes at a time.

Anti-inflammatory (inflammation-reducing) painkillers like ibuprofen can relieve shoulder pain somewhat. But they shouldn’t be taken for longer than two weeks. An alternative to tablets, with fewer side effects, is treatment with creams and gels containing diclofenac. These are applied to the shoulder two to three times a day. They are also suitable for people who can’t take tablets because their kidneys or liver don’t work properly or because they have a stomach ulcer.

When should you see a doctor?

Shoulder pain usually isn’t caused by anything serious, but it’s still a good idea to seek medical advice if:

  • the shoulder joint feels unstable or was recently dislocated
  • the shoulder is red, warm or swollen
  • the shoulder is injured following an accident
  • numbness or signs of paralysis occur
  • the pain is very bad
  • the arm is very weak or you can't move it properly

What helps relieve severe pain?

If the pain is very bad, the doctor can inject steroids into the shoulder. This can reduce the pain and make it easier to move the shoulder. But it’s important not to have too many steroid injections because they can weaken the tendons and cartilage. In the two days after having the injection, you should avoid activities that put strain on the shoulder.

Steroid injections can irritate the skin where the needle is inserted and – if you have several injections – make the skin turn lighter. Serious complications such as an infection of the joint are rare, though.

Can physical therapy help?

Having weak shoulder muscles, ligaments and tendons can increase the likelihood of shoulder pain: The shoulder is a very movable joint that is mainly kept stable by the muscles. If the shoulder muscles are weak, the head of the upper arm bone (humerus bone) may “fall” out of the socket. This can be painful if it pushes against the surrounding soft tissue. Physical therapy can help to strengthen and stabilize the shoulder.

Physical therapy is a suitable treatment for shoulder pain under the acromion (subacromial pain). Research has shown that it can relieve the pain and improve the function of the shoulder.

The physical therapy exercises should aim to

  • improve the range of movement (mobility) of the shoulder,
  • strengthen the muscles in the shoulder blade and rotator cuff, and
  • improve your overall posture.

The physiotherapist should also tell you how you can move the shoulder more gently. Research has shown that the treatment should last 8 to 16 weeks. The exercises that are recommended will depend on the symptoms and circumstances. It’s important to do the exercises at home or at work, too.

Why is surgery often not recommended?

If the shoulder pain is thought to be caused by impingement, surgery can be done to widen the space under the acromion (the subacromial space). This is meant to get rid of the cause of pain. The surgery involves trimming off parts of the acromion and removing the bursa during an arthroscopy (keyhole) procedure. The medical term for this type of surgery is “subacromial decompression.” But it usually doesn’t help and, like all operations, it is associated with risks.

Two good-quality studies looked into the pros and cons of subacromial decompression. In these studies, some people had this surgery and others only thought they had had the surgery (placebo). After comparing the outcomes, the researchers concluded that there were no differences between decompression surgery and placebo surgery. In other words: Subacromial decompression surgery didn’t lead to a clear improvement in symptoms (see illustration: Shoulder pain with and without surgery).

Illustration: Shoulder pain with and without surgeryShoulder pain with and without surgery

 

Surgery might help if the acromion is hooked (a “type III acromion”) rather than flat. The tip of the shoulder blade curves down more than usual here, which can make the space under the acromion even narrower (see illustration: Normal and hooked acromion). But only a small number of people in the studies had a hooked acromion. Because of this, it’s not clear whether surgery would help in people who have a hooked acromion.

Illustration: Normal and hooked acromion (side view of the right shoulder)Normal and hooked acromion (side view of the right shoulder)

 

If a doctor recommends having shoulder arthroscopy surgery, it’s a good idea to discuss the pros and cons of this treatment with each other. She or he should then also inform you that you can get a second medical opinion from a different doctor.

Many experts only recommend considering surgery if the person has already had thorough treatment with physical therapy or steroids and it didn’t lead to an improvement.

Surgery can lead to complications such as wound healing problems, thrombosis and – in very rare cases – nerve damage. Overall, complications occur in about 1 out of 100 operations. And about 1 out of 100 people have a frozen shoulder after the operation. The risk of this is greater in women and people who have diabetes.

When can shock wave therapy help?

Some people who have shoulder pain have calcium deposits in their shoulder tendons (calcific tendinitis of the shoulder). You can see them in x-ray images. These deposits often go away on their own after a while.

One treatment for calcium deposits is known as shock wave therapy. The medical term for this treatment is “extracorporeal shock wave therapy” or ESWT for short. It only makes sense to treat shoulder pain with shock waves if it’s clear that there are actually calcium deposits in the shoulder tendons.

Shock wave therapy involves passing high pressure sound waves through the skin from outside the body, targeting the calcium deposits in order to break them up. Studies have found that high-energy shock waves are particularly helpful. In one large study they relieved the symptoms in 70% of those affected.

Because shock wave therapy can be very painful, people are often given painkillers and/or an anesthetic beforehand. But the treatment can still be painful. Shock wave therapy can lead to bruising and reddening of the skin.

If you live in Germany, it's important to know that the costs of shock wave therapy are currently not covered by German statutory health insurers. You have to pay for this kind of treatment yourself. The costs can add up to several hundred euros, depending on the exact method used, the number of sessions and how long they last.

What other treatments are there – and can they help?

Many other treatments are available for subacromial shoulder pain, but they haven’t been proven to work. They include the following:

  • Acupuncture
  • Hyaluronic acid injections
  • Injections of platelet-rich plasma (PRP) made from your own blood
  • Interferential current therapy
  • (Kinesiology) Taping
  • Light therapy
  • Low-level laser therapy
  • (Pulsed) Electromagnetic field therapy
  • Massages
  • Microwave diathermy
  • Transcutaneous electrical nerve stimulation (TENS)
  • Trigger point therapy
  • Ultrasound waves

The costs of most of these approaches aren’t covered by German statutory health insurers, so you have to pay for them yourself.