Pain, shoulder - Treating shoulder pain

There are several types of treatment for shoulder pain, depending on the cause of your shoulder pain and your symptoms.

Some treatment options, such as heat or ice packs and painkillers, may help to reduce pain and treat minor injuries at home. 

You should see you GP if your pain is either the result of an injury, it's particularly bad, or there is no sign of improvement after a couple of weeks.

Your GP may refer you for specialist treatment with an orthopaedic surgeon (a specialist in conditions that affect the bones and muscles) or a rheumatologist (a specialist in conditions that affect the muscles and joints) if you have:

• a frozen shoulder
• a rotator cuff disorder
• an acromioclavicular joint disorder
• a rotator cuff tear
• shoulder instability and you are under 30 years old

Treatment options

The main treatment options for shoulder pain include:

• avoiding activities that make your symptoms worse
• using ice packs
• painkillers
• anti-inflammatories
• physiotherapy 
• arthrographic distension (hydrodilatation)
• surgery (in some cases)

These are described in more detail below, and you can also see a summary of the pros and cons of these treatments, which allows you to easily compare your options.

As well as pain, you may also have reduced strength or movement in your shoulder. In this case, a combination of different treatments may be used.

Read more about treating frozen shoulder.

Avoiding activities

Depending on what is causing your shoulder pain, your GP may recommend that you avoid certain activities or movements that could make your symptoms worse.

For example, in the early, painful stage of frozen shoulder, you may be advised to avoid activities that involve lifting your arms above your head and stretching vigorously. However, you should continue using your shoulder for other activities, because keeping it still could make your symptoms worse.

If you have shoulder instability, you may be advised to avoid any movements that are likely to make the instability worse, such as overarm throwing or bench pressing.

If you have sprained your acromioclavicular joint (the joint at the top of your shoulder), you may be advised to avoid activities that involve moving your arm across your body (such as a golf swing or weightlifting). You should keep the shoulder mobile with light tasks if possible, but avoid heavy lifting and contact sports for 8 to 12 weeks. You may also be given a sling (a supportive bandage) to wear to support your arm for up to a week after your injury. Osteoarthritis is the most common cause of acromioclavicular joint disorders.

Ice packs

If you injure your shoulder – for example, while playing sport – you can apply an ice pack to the affected area to reduce pain and inflammation.

You should apply the ice pack for 10-30 minutes. A bag of frozen peas, or similar, will also work well. Wrap the ice pack in a damp towel to avoid it directly touching your skin and causing ice burn.

Painkillers

If your pain is mild, taking painkillers such as paracetamol or codeine may be enough to control it. Always follow the dosage instructions on the packet to ensure the medicine is suitable and that you do not take too much.

If your shoulder pain is more severe, your GP may recommend or prescribe a non-steroidal anti-inflammatory drug (NSAID), such as ibuprofen, diclofenac or naproxen.

As well as easing the pain, NSAIDs can also help reduce swelling in your shoulder capsule. They are most effective when taken regularly, rather than when your symptoms are most painful.

Corticosteroid tablets

Corticosteroids are medicines that contain steroids, which are a type of hormone. Hormones are powerful chemicals that have a wide range of effects on the body, including reducing pain and swelling.

You may be prescribed corticosteroid tablets for frozen shoulder. Some evidence suggests that these may provide short-term pain relief for a few weeks. However, it is not clear whether corticosteroid tablets are any better than other treatment options, such as corticosteroid injections.

Corticosteroid tablets can also cause a number of side effects. 

Read more about the side effects of corticosteroids.

Corticosteroid injections

If your shoulder pain is very severe, oral painkillers may not be enough to control the pain.

Corticosteroid injections in and around your shoulder joint may help to relieve the pain and increase your range of movement for several weeks at a time. However, the injections cannot cure your condition completely, and your symptoms may gradually return.

Some experts believe that the use of corticosteroid injections should be delayed for as long as possible, and there is little evidence to suggest that this is an effective treatment. However, they may help to reduce pain, thereby allowing you to do your physiotherapy and rehabilitation more effectively.

Cautions

After having a corticosteroid injection, you may experience side effects at the site of the injection, including:

• temporary pain
• lightening of your skin
• thinning of your skin 

Having too many corticosteroid injections can damage your shoulder. Therefore, you may only be able to have this treatment up to three times in the same shoulder in one year.

Read about corticosteroids for more information.

Hyaluronate injections

Hyaluronate is another medicine that can be injected into your shoulder to treat shoulder pain. One review of a number of studies found that hyaluronate was effective at reducing pain.

However, the National Institute for Health and Care Excellence (NICE) does not recommend hyaluronate to treat osteoarthritis (a condition that affects the joints). It found that hyaluronate only helped a little and that corticosteroid injections were a better treatment choice. Therefore, hyaluronate may not be used for this condition.

Physiotherapy

Physiotherapy uses a number of different physical methods to promote healing. If you are referred to a physiotherapist, they should explain to you what treatment they will use and how it will work.

Possible treatments include:

• specific shoulder exercises – for example, if you have shoulder instability, you may be given exercises to strengthen your shoulder
• massage – where the physiotherapist uses their hands to manipulate your shoulder

Read more about some of the different techniques used in physiotherapy.

Shoulder exercises

If you have shoulder pain, it's important to keep your shoulder joint mobile with light and gentle movement. Not using your shoulder can cause your muscles to waste away and may make any stiffness worse. Therefore, if possible, you should continue using your shoulder as normal.

If your shoulder is very stiff, exercise may be painful. Your GP or physiotherapist can give you exercises to do without further damaging your shoulder.

You may be given exercises to do on your own, or you may complete the exercises with supervision from your GP or physiotherapist. You may also have manual therapy, where the healthcare professional moves your arm for you. Manual therapy uses special techniques to move the joints and soft tissues in your shoulder.

One review of a number of studies found that long-term physiotherapy was as effective as surgery for impingement syndrome (any type of damage to the tendons in the rotator cuff).

Arthrographic distension (hydrodilatation)

Arthrographic distension or hydrodilatation may sometimes be recommended to treat frozen shoulder. A special fluid, which shows up clearly on X-rays, is injected into your shoulder joint at the beginning of the procedure. Under continuous X-ray guidance, a mixture of saline, corticosteroid and local anaesthetic is then injected into the shoulder joint. This procedure usually only takes about 15 minutes, is done under local anaesthetic, and you can go home the same day. Physiotherapy may be recommended afterwards to help you regain a good range of movement in your shoulder.

Surgery for frozen shoulder

If other treatments for frozen shoulder have not worked, you may be referred for surgery. There are two possible surgical procedures explained in more detail below.

Manipulation

Manipulation involves having your shoulder moved while you are under general anaesthetic. During the procedure, your shoulder will be gently moved and stretched while you are asleep.

Afterwards, you will usually need to have physiotherapy to help maintain mobility in your shoulder. Manipulation may be used if you are finding the pain and disability from your shoulder difficult to cope with.

Arthroscopic capsular release

An alternative procedure to manipulation is arthroscopic capsular release, which is a type of keyhole surgery. The surgeon will carry out the procedure after making an incision that is less than 1cm (0.4in) long. A special probe opens up your contracted shoulder capsule and any bands of scar tissue are removed. This should greatly improve your symptoms.

As with manipulation, you will need physiotherapy after the surgery to help you regain a full range of movement in your shoulder joint.

Surgery for a rotator cuff tear

Surgery may be used to treat rotator cuff tears if the tear is large or if other treatment options have not worked after three to six months. It's possible that having surgery earlier will lead to a quicker recovery, although there is currently not enough research into whether early surgery is beneficial.

During the procedure, a small amount may be shaved off the bones in your shoulder. Damaged tendons and bursae (fluid-filled sacs found over joints and between tendons and bones) may also be removed. This creates more space within the joint to allow your rotator cuff to move freely.

The operation can be performed as:

• open surgery – a large incision is made in your shoulder
• mini-open surgery – a small incision is made in your shoulder 
• arthroscopic surgery – a type of keyhole surgery that uses a camera to look inside your shoulder joint

Evidence suggests that people return to work about a month earlier if they have mini-open surgery rather than open surgery.

As with frozen shoulder surgery, you will need physiotherapy after your operation to help you regain a full range of movement in your shoulder joint.

Surgery for shoulder instability

If your shoulder dislocates (the ball comes out of the socket) regularly or severely, you may need surgery to prevent it happening again and to prevent surrounding tissues and nerves from becoming damaged. Depending on the type of instability you have, surgery may involve: 

• tightening stretched ligaments or reattaching them if they have torn (ligaments are tough bands of connective tissue that link two bones together at a joint)
• tightening the shoulder capsule by tightening it with stitches

Surgery for shoulder instability can either be done using keyhole or open surgery. After the operation, your shoulder will need to be immobilised (prevented from moving) using a special sling for several weeks. You will also need physiotherapy to improve your strength. Full recovery may take several months.

Joint replacement (arthroplasty) for osteoarthritis of the shoulder

Joint replacement therapy, also known as an arthroplasty, is the most common treatment for osteoarthritis of the shoulder. During an arthroplasty, your surgeon will remove your affected joint and replace it with an artificial joint (prosthesis) made of special plastics and metal. An artificial joint can last for up to 20 years. However, it may eventually need to be replaced.