Conditions · Carrollwood · Tampa Bay
Shoulder Pain
What hurts when you lift, what wakes you at night, and what your report actually says, sorted out by an examination that includes your neck.
Overhead. At night, when you roll onto that side. Reaching behind your back for a seat belt. Three different questions for the examination. A shoulder does not tell you which one you have by hurting; it tells you by when it hurts and what the arm can still do under load.
Shoulder Pain Overview
What the words on your report mean
Most of the language on a shoulder report names a structure, not a diagnosis.
Rotator cuff
Four small muscles and their tendons wrap around the ball of the shoulder and steer it in the socket: supraspinatus on top, infraspinatus behind, subscapularis in front. Partial-thickness means a change goes part of the way through the tendon; full-thickness means it reaches the other side. Those words describe depth, not how you are doing.
Also written as: rotator cuff tear, tendinopathy, tendinitis, tendinosis.
Impingement, bursitis, and the space above the tendon
A narrow gap sits between the top of your arm bone and the bony shelf above it, the acromion, the tip of your shoulder blade. The top cuff tendon runs through that gap alongside a thin fluid-filled cushion called a bursa. Impingement names those structures being pinched in the gap as the arm lifts; bursitis names the cushion being inflamed, which is why a report may mention bursal fluid.
Also written as: subacromial impingement, subacromial pain syndrome, subdeltoid bursitis.
The AC joint, and what a separated shoulder means
The AC joint, acromioclavicular on reports, is the small joint on top of your shoulder where the end of your collarbone meets that bony shelf. A separated shoulder refers to this joint and its ligaments, not the ball-and-socket joint most people picture.
Also written as: AC joint arthritis, acromioclavicular osteoarthritis.
The labrum, SLAP tears, and the biceps tendon
The socket is shallow, and a rim of cartilage called the labrum deepens it, with the long tendon of the biceps anchoring at the top of that rim. A SLAP tear, superior labrum anterior to posterior, is a tear at that anchor.
A finding is not a diagnosis
Before you read your report again, read this. In a pooled analysis of 30 studies covering 6,112 shoulders, imaging showed rotator cuff abnormalities, meaning changes in those tendons, in about 9.7% of shoulders in people aged 20 and younger and in 62% of shoulders in people aged 80 and older, and the review reported a similar increase across age groups whether or not the person had symptoms.1 Turn those numbers around and, in that review, about 38% of shoulders in the oldest group showed no such finding at all.
Both are true at once. A cuff finding on a report is not automatically the source of your pain, and your pain is not less real because the same words show up on other people’s reports. Whether it explains your symptoms is what the examination works out.
1. Teunis T, Lubberts B, Reilly BT, Ring D. A systematic review and pooled analysis of the prevalence of rotator cuff disease with increasing age. J Shoulder Elbow Surg. 2014;23(12):1913-1921. PubMed
Overhead, at night, or reaching behind your back
Four different things produce the same sentence, it hurts when I lift my arm: the cuff tendons, the space they pass through, the joint on top, and a nerve root in the neck.
When it hurts lifting overhead or out to the side
Pain that arrives partway through raising the arm out to the side and eases near the top is what reports call a painful arc, and it sends the examination to the cuff and the space above it. Pain that begins with the arm already high points more at the joint on top of the shoulder. Whether the arm is limited by pain or by strength is the next question.
When it wakes you at night
Night pain gets its own questions here: which side you were lying on, whether the arm was overhead or tucked, and whether any position gives relief. A shoulder that hurts pressed against a mattress behaves differently from one that hurts in every position.
When you cannot reach behind your back
Fastening a seat belt, a bra, or reaching a back pocket asks the shoulder to rotate inward and extend at once. When that is the motion that fails, the examination checks the front of the cuff, the subscapularis, and compares your own motion with the range the joint has when someone else moves the arm.
Shoulder pain that comes from the neck
An irritated nerve root in the neck, cervical radiculopathy on reports, can be felt at the shoulder, over the shoulder blade, or down the arm, sometimes with no neck pain at all. That is why a shoulder examination here tests the neck: motion, nerve tension, strength by muscle group, reflexes, and sensation. When the arm answers to the neck, the plan becomes a neck plan, built around neck pain, a pinched nerve, or a disc finding on a cervical report.
Sorting all of this apart is not one test. In a 2012 systematic review with meta-analysis of shoulder examination tests, the authors concluded that any single shoulder examination test used alone to make a definitive diagnosis cannot be unequivocally recommended, that combinations of tests give better accuracy but marginally so, and that their findings seem to support a comprehensive clinical examination including both the history and the physical examination.2 For pain in the space under the bony tip of the shoulder blade, the Neer test was positive in 72% of shoulders that had the condition, so it was negative in about 28 of every 100 that did, and it was negative in 60% of shoulders that did not have it, so about 40 of every 100 without it still tested positive. That is the reason a shoulder gets a full examination here.
2. Hegedus EJ, Goode AP, Cook CE, Michener L, Myer CA, Myer DM, Wright AA. Which physical examination tests provide clinicians with the most value when examining the shoulder? Update of a systematic review with meta-analysis of individual tests. Br J Sports Med. 2012;46(14):964-978. PubMed
Frozen shoulder, and what the research did and did not find
Adhesive capsulitis is the shoulder that loses range in every direction because the capsule, the sleeve of tissue around the joint, has thickened and tightened. There is a long-repeated story about what happens next, and researchers went looking for the evidence behind it. In a systematic review of seven studies, each of which included a comparison group that received no treatment, low-quality evidence showed some, but not complete, improvement in range of motion at one to four years of follow-up, which means motion in those untreated groups had not come back to normal by the end of that window.3 The reviewers found no evidence supporting the long-repeated idea that a frozen shoulder progresses through recovery phases to full resolution in people receiving no treatment, and they reported moderate-quality evidence from three randomized trials that most of the improvement that did occur happened early rather than late.
So a stiff shoulder gets measured here rather than predicted: range recorded in each direction, re-examined at set intervals, and referred rather than given a longer plan when it is not progressing.
3. Wong CK, Levine WN, Deo K, Kesting RS, Mercer EA, Schram GA, Strang BL. Natural history of frozen shoulder: fact or fiction? A systematic review. Physiotherapy. 2017;103(1):40-47. PubMed
Symptoms, and the warning signs we screen for
A shoulder announces itself by task rather than by location: the arm that stops partway up, the sleep that ends at two in the morning on that side, the reach behind the back that used to be automatic.
Common, and examined here
- Pain lifting the arm overhead or out to the side
- Pain that wakes you when you roll onto that side
- Trouble reaching behind your back
- Shoulder or shoulder blade pain after a car accident
- Clicking, catching, or grinding with movement
- A report naming the cuff, bursa, labrum, or AC joint
Emergency, not an appointment
Call 911 for shoulder or arm pain that comes with chest pressure or tightness, shortness of breath, a cold sweat, nausea, or jaw pain. Shoulder and arm pain can be how a heart attack shows up, more often on the left side. Call 911 as well for sudden drooping or weakness on one side of the face, trouble speaking, sudden weakness in an arm and leg on the same side, or pain that starts abruptly with trouble breathing or coughing up blood.
Go to the emergency department now for:
- A shoulder that is hot, red, and swollen, or one you cannot move, with fever or chills
- A deformed or out-of-place shoulder after a fall or a crash, or an arm locked in one position
- Losing the ability to lift or use the arm at all right after an injury
- A hand or forearm that goes numb, cold, pale, or dusky, or an arm that swells quickly
How we approach a shoulder
The examination comes first: history, the shoulder tested through its own motion and through motion someone else provides, resistance testing by muscle group, the AC joint and biceps tendon checked directly, and the neck examined in the same visit. Bring any report; it gets read with you, not at you. That visit is the Pain Source Exam.
When conservative care fits, it is built from those findings: a chiropractic adjustment where the examination finds restricted motion, hands-on soft-tissue work, dry needling for trigger points in the muscles around the joint, and loaded movement you can do at home. Ultrasound is used here as a screening look and as visual confirmation during the visit, including seeing the needle reach the spot on the screen. Care is monitored, and the plan changes if you do not.
Some shoulders get examined and then sent elsewhere, and we say so in the room: weakness on strength testing rather than pain limiting the effort, an arm that drops when held out to the side, a suspected fracture, a shoulder that has come out of the joint more than once, and arm findings progressing visit to visit.
Hurt in a car accident? Florida’s PIP law requires care to begin within 14 days; start at our auto accident page. For the other joints, and for what a visit costs, see the joint pain page.
What the research shows
The two studies below, a randomized trial and a research review that pooled such trials, rest on a comparison that is rare in surgery research: decompression surgery, which removes bone and soft tissue to widen the space under the bony shelf at the tip of the shoulder blade, tested against a placebo version of itself.
In the trial, 313 adults across 32 UK hospitals had shoulder pain from that space for at least 3 months. All had intact rotator cuff tendons; full-thickness tears, the kind that go all the way through, were excluded. All had already completed a non-operative program that included exercise therapy and at least one steroid injection. They were assigned to decompression surgery, to arthroscopy alone, where the camera goes in but no bone or soft tissue is removed, or to no treatment. At 6 months, the trial’s primary measuring point, shoulder scores did not differ between the two surgical groups, and while both surgical groups did score a small benefit over no treatment, the trial authors judged those differences not clinically important.4 Because every participant had finished that non-operative program first, the trial did not test conservative care head-to-head against surgery as a first step; it reports what happened after such a program had already run. The authors read their result as raising questions about the value of this operation for these patients, and directed it where it belongs, into the decision a patient and surgeon make together.
A Cochrane review, the kind that gathers every randomized trial of a treatment and grades how certain the combined evidence is, then pooled 8 trials of this surgery for rotator cuff disease, 1,062 participants in all, every one of them with subacromial impingement, the pinching described earlier on this page, and none with a full-thickness tear. Resting on the two placebo-controlled trials, 506 participants between them and the comparisons least prone to bias, high-certainty evidence showed the surgery provided no clinically important improvement over placebo surgery, an arthroscopy where nothing is removed, in pain, shoulder function, or quality of life up to one year, and moderate-certainty evidence showed probably no clinically important benefit in how participants rated their own success.5 The reviewers concluded that the data do not support this one operation for this one condition, which is not a statement about shoulder surgery in general, about repairing a torn cuff, or about any other procedure.
Neither study examined your shoulder, and that is where the Pain Source Exam starts: working out where your pain actually comes from, so any conversation about treatment begins with findings.
4. Beard DJ, Rees JL, Cook JA, Rombach I, Cooper C, Merritt N, et al; CSAW Study Group. Arthroscopic subacromial decompression for subacromial shoulder pain (CSAW): a multicentre, pragmatic, parallel group, placebo-controlled, three-group, randomised surgical trial. Lancet. 2018;391(10118):329-338. PubMed
5. Karjalainen TV, Jain NB, Page CM, Lähdeoja TA, Johnston RV, Salamh P, et al. Subacromial decompression surgery for rotator cuff disease. Cochrane Database of Systematic Reviews. 2019;1(1):CD005619. PubMed
Common questions about shoulder pain
Why does my shoulder hurt when I lift my arm over my head?
Raising the arm loads the cuff tendons and moves them through the narrow space under the bony shelf above them, so pain that arrives partway up and eases near the top points at that area.
Why does my shoulder wake me up when I roll onto that side?
Night pain that no position changes, alongside unexplained weight loss or fever, is a reason for medical workup rather than a course of care, and we say so.
Is my shoulder pain actually coming from my neck?
Sometimes, and the examination is what tells. The nerves that run the shoulder and arm leave the spine in the neck, so an irritated nerve root can be felt at the shoulder or shoulder blade with no neck pain at all. Strength, reflexes, sensation, and neck position sort the two apart.
My report says rotator cuff tear. Does that mean I need surgery?
That decision belongs with a surgeon, and a line on a report does not make it. Partial-thickness and full-thickness describe how deep the change goes, not what you should do next. What moves the conversation is the examination: what the arm does under resistance, whether strength is dropping, and whether the finding matches when and where you actually hurt.
Is this frozen shoulder, and how long am I looking at?
A shoulder that has lost range in every direction, including when someone else moves your arm, is the pattern that points there. We do not put a date on it. In a review of studies whose comparison groups received no treatment, low-quality evidence showed some, but not complete, improvement, and motion had not come back to normal at one to four years of follow-up.
Do I need an MRI or an ultrasound before I come in?
No. The examination decides whether imaging is needed. If you already have an MRI, X-ray, or ultrasound report, bring it, because reading it with you is part of the visit. The ultrasound used here is a screening look and a way to see what we are doing while we do it.
Can a chiropractor treat a shoulder, or should I see an orthopedist?
Often it starts here. A chiropractic physician examines the shoulder and neck, treats the joint and the muscles around it when the findings fit, and refers when they do not. Weakness on testing, a suspected fracture, a shoulder that keeps coming out of the joint, or one that is not progressing goes for an orthopedic opinion.
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This page is general health information and is not medical advice for any individual. The studies summarized describe groups, not any one person’s outcome, and whether any finding on your imaging explains your symptoms can only be determined by examination. Talk to Dr. Bobby Koser, DC, about your own situation, and seek emergency care immediately for the warning signs listed above.
Bring the arm, and the report.
A complete examination with Dr. Bobby Koser, DC, your shoulder and neck both examined, and your findings explained the same day.