Understanding Chronic Shoulder Pains

Understanding the complexities of chronic shoulder pain is essential for effective treatment. Explore various causes and therapies in this comprehensive guide.


Bursae are small fluid-filled sacs that are mostly used as cushions or sliding aids between protruding bones and muscle tendons pulling along them, or near joints. Bursae (technical term in the singular: bursa) tend to ignite in response to an unfamiliar mechanical stimulus, such as a “cracked” environment, as is the case with rotator cuff syndrome, for example. An overmovable shoulder joint is also one of the triggers. Secondly, diseases such as rheumatism (rheumatoid arthritis) and gout or infections in the case of injuries or bacterial diseases are possible. More on this below. The bursa on the roof of the shoulder (bursa subacromialis, connected to the bursa subdeltoidea) is more often inflamed, and secondly the bursa under the shoulder blade. The fourth lies under the so-called raven beak extension.


If the bursa under the roof of the shoulder is inflamed (subacromial bursitis), symptoms of subacromial impingement syndrome occur. Sometimes the pain can be felt locally in the front or side of the shoulder or in the upper third of the arm. They can disrupt sleep and active shoulder movements.

If the bursa under the shoulder blade becomes inflamed (subscapular or scapulothoracic bursitis), this is more likely to result in pain on the back of the shoulder blade or on the top of the back. Shoulder movements create a crack, overhead movements or push-ups are painful.

For diagnosis and therapy, see, Chronic shoulder pain: calcified shoulder, tendon tear.

Special features: A clinical test called the speed test can indicate, among other things, subacromial bursitis of the shoulder. The arm is raised to 90 degrees and turned outwards (palm facing up) against the resistance of the examiner. The test is positive for pain that can be felt even after suddenly letting go of resistance and gently jerking the arm.

For rheumatism see below. In the case of gout (more on this below), a suitable (purine-controlled) diet possibly with anti-inflammatory and uric acid-lowering drug can help. Bursitis can also recede below this. Unless there is a mechanical cause in the foreground – the doctor might address this surgically. An inflamed bursa can be removed as part of an operation on the rotator cuff of the shoulder.

Frozen Shoulder

Risk factors, accompanying circumstances

Even if you do not know exactly why “spontaneous” shoulder stiffness (primary form of the disease) sometimes occurs, some risk factors are known. These are, for example, disorders of the cervical spine, metabolic diseases such as diabetes (type 1 diabetes, type 2 diabetes) or functional disorders of the thyroid gland, strokes, autoimmune diseases, and rarely Parkinson’s disease. Primary frozen shoulder affects women somewhat more frequently than men, age group around 40 to 70 years. Both shoulders can become sick with a delay. Primary frozen shoulder is also called adhesive capsulitis. The name describes what is going on here: to put it simply, an inflammation with adhesions of the joint capsule and the surrounding tissue. The joint capsule is thickened and becomes very “tight” due to the newly formed connective tissue – at the expense of mobility.

A secondary stiff shoulder is possible in the context of a rotator cuff syndrome (see “Chronic shoulder pain – calcified shoulder, tendon tear“) or as a consequence of an injury, be it through a long immobilization, be it after a fracture on the shoulder that has not healed smoothly, or after an operation, also in connection with an accident. Secondary frozen shoulder can then develop as a complication of an acute infection of the shoulder joint or shoulder osteoarthritis.


The problem begins with increasing shoulder pain that can drag on for a few months. Some people cite a wrong movement with the shoulder or an actually harmless fall as the trigger. Often the whole thing comes out of nowhere. The pain mainly occurs at rest and thus also at night and is a sensitive disruption to the patient’s wellbeing. As the pain slowly subsides, the stiffness increases. This phase can also take longer, around four to twelve months. This applies in particular to the lifting and circling of the arm (active and passive) and thus all everyday movements of the arm at shoulder level, and even more above. Finally, after twelve to 36 months or later, the shoulder usually becomes more flexible again: really a game of patience.


The doctor will rule out specific causes. The precise documentation of the medical history, the careful physical examination and imaging procedures such as ultrasound and X-ray examinations serve this purpose. In the case of primary stiff shoulder, for example, the shoulder x-ray is normal; at most, there is occasionally a slight decrease in bone density. With regard to the risk factors in the form of other diseases, a diagnosis is recommended if there are corresponding indications; In-depth laboratory analyzes and diagnostic imaging procedures should therefore not be delayed.


In the painful phase, pain-relieving anti-inflammatory drugs or a simple pain reliever such as paracetamol, sometimes even an opioid, are possible. The doctor also often suggests a cortisone injection into the joint, combined with a local anesthetic. The stiffening can be significantly improved by conservative measures, in particular exercise treatment (physiotherapy) and manual therapy. The exercise therapy must take place daily for months, increasing in small steps according to improvement. If there is no progress or if there is too much movement deficit, an arthroscopy can help. Adhesions can be loosened and the shrunken joint capsule split and expanded. Arthroscopy is also of diagnostic importance, as the joint can be viewed from the inside and some tissue can be removed for a tissue examination.

In the post-treatment phase, physiotherapy is again very important. Initially, targeted pain relief may make it easier to practice. The shoulder exercises should “become flesh and blood” for those affected so that they can then do them daily themselves.

Shoulder Ostheoarthritis

Arthrosis = joint wear

Arthrosis is caused by cartilage and bone abrasion on the joint surfaces. The primary form is not based on any other diseases. However, inflammation, swelling and effusions often occur in active phases of the disease. The damage eventually reaches bone sections near the joint below the joint surface. As a result, the joint can deform and stiffen. If osteoarthritis is due to injuries or other diseases, it is a secondary form.

The smaller shoulder joint comes under pressure with all wear-prone lifting movements beyond the horizontal, for example during overhead sports or years of heavy physical work involving the shoulder. Therefore, arthrosis develops more often in this second joint of the shoulder. In addition to wear and tear due to chronic overload, genetic factors and injuries such as a split shoulder joint also play a role.

In the main joint of the shoulder, osteoarthritis (omarthrosis) can develop, for example, when tendons in the area of ​​the rotator cuff are torn, especially when the head of the humerus is in constant contact with the roof of the shoulder. Fractures of the upper arm – the head or the shaft of the humerus – can also lead to osteoarthritis. Then rheumatic diseases (rheumatoid arthritis) are among the classic triggers of secondary osteoarthritis, as are circulatory disorders of the bone (so-called osteonecrosis, see below).


If the shoulder joint is affected, a step may be visible there – for example as a result of an earlier blast injury with a torn ligament, as a result of which the joint parts have shifted against each other. The shoulder, often also the arm, hurts, especially when the arm is brought to the opposite side, for example when washing under the armpit or when moving overhead.

In the case of the main shoulder joint, the anterior part of the shoulder is painful. Patients also often complain that the shoulder has become stiffer: Movement deficits are particularly noticeable when lifting and turning the arm outwards. The pain subsides slowly, but this does not exclude nocturnal pain. In addition, there may be friction noises from the joint.


The information provided by the person concerned about current and previous complaints as well as the physical examination by the doctor usually point the way to the diagnosis. The clinical examination includes an adduction test – the doctor moves the arm of the affected side to the opposite side to check whether this movement is restricted due to pain and / or stiffness. The main diagnosis of joint wear is still x-rays. Supplementary examinations take place in the event of special questions.


Conservative treatment options include anti-inflammatory drugs that relieve pain, such as a non-steroidal anti-inflammatory drug (NSAID). If the pain is persistent, the doctor can inject cortisone into the joint in a cautious manner. Physical therapy measures support the treatment. For example, heat therapy and electrotherapy help against the muscle tension that often occurs in osteoarthritis. In the case of acute joint inflammation, for example, both procedures (unlike cold therapy) are not indicated. Physiotherapy is particularly important.

If these measures are unsuccessful, an intervention is possible in which the worn part of the joint is removed and, if necessary, replaced with a tendon transplant. This is possible, for example, on the shoulder joint – arthroscopically, i.e. as part of a joint endoscopy, or as an open, minimally invasive operation. Any damage to the rotator cuff can also be treated (see acromioplasty here “Chronic shoulder pain: calcified shoulder, tendon tear“).

A heavily damaged, arthritic main shoulder joint with constant pain can be replaced by an artificial joint (prosthesis). There are different types of prostheses for different degrees of severity of joint damage.

Example of secondary osteoarthritis

Circulatory disorders with tissue damage to the shoulder joint (osteonecrosis): If tissue is not supplied with sufficient blood, it will be permanently damaged. The lack of blood circulation can result from an injury (traumatic) or for other reasons (atraumatic, illness-related). In addition to the more frequently affected hip and knee joints, circulatory disorders can also occur in the shoulder, especially in the area of ​​the head of the humerus, i.e. the main shoulder joint.

The damaged bone is less able to withstand mechanical loads and collapses as the damage progresses. Since the area is usually close to the joint, damage to the sensitive articular cartilage is inevitable. The result is secondary osteoarthritis. The root causes are not known. Risk factors include, for example, working under compressed air conditions, excessive alcohol consumption, pronounced lipid metabolism disorders, certain blood diseases and connective tissue diseases such as lupus erythematosus (an autoimmune disease in which the immune system attacks the body, including the blood vessels, resulting in circulatory disorders). Drugs such as cortisone are also risk factors.


Those affected develop shoulder pain at rest, for example at night, and increasingly during the day, depending on the intensity of the shoulder work. Audible joint noises and blockages can occur. As the disease progresses, the shoulder’s range of motion decreases. Further complaints are possible depending on the (joint) responsible circumstances.


It is based in particular on carefully collected medical history, physical examination and imaging tests. In addition to X-rays, these are usually magnetic resonance imaging, rarely scintigraphy. Tissue removal (biopsy) is also rarely performed to rule out other bone diseases. Doctors know four stages of the disease.


As usual, the treatment depends on the diagnosis and the stage of the disease. It is also important to get a grip on risk factors. As long as x-rays show a normally contoured shoulder joint in addition to the first pathological changes (stages one and two), conservative measures are paramount, especially physiotherapy. In stages three (damage to the bone near the joint) and four (osteoarthritis), surgical techniques are available. They range from interventions that can initially preserve the joint and relieve pain to joint replacements. A joint-preserving procedure is, for example, drilling into the diseased bone (core decompression), which takes pressure off the bone, improves blood circulation and helps relieve pain (in stage four this does not make sense).


What is rheumatism?

Rheumatism is a collective term for numerous chronic inflammatory diseases with a focus on the joints. Sometimes gout and so-called pseudo gout are also included. However, both are metabolic joint diseases. Urate (in gout) or calcium pyrophosphate crystals (in pseudogout) precipitate in the joint, in the surrounding soft tissue and in other tissues. Therefore, these diseases are also called crystal arthropathies (i.e. joint problems caused by crystal deposits). They occur less often on the shoulder joint, but more often on bursae (see above, section “Bursitis”). You can also read the natural measures for rheumatism here.

Rheumatoid arthritis

The most important rheumatic disease is rheumatoid arthritis (chronic rheumatoid arthritis). The disease is caused by chronic inflammation of the synovial membrane. It happens as a result of an immunological disorder. The inflammation can spread to the adjacent bone areas and damage the affected joints at an early stage. With timely therapy, this development can be stopped or mitigated. In the early phase, the small joints on the hands and feet – the metatarsophalangeal and middle joints of the fingers and toes – are mainly affected. Often larger joints such as knees or shoulder joints (the latter is called rheumatoid omarthritis) are also affected. Here too, pronounced bursitis can occur. In addition, other organs sometimes become ill, for example blood vessels, lungs, heart, eyes.


On the one hand, rheumatism causes a typical morning stiffness of the joints, which often lasts for hours and as such is present for at least six weeks. In addition, pain, a feeling of swelling and swelling of the soft tissues occur. The symptoms appear on both sides of the body in a similar form (symmetrical pattern) and also last longer than six weeks. On the other hand, flu-like general symptoms such as fatigue, tiredness and moderate fever are possible. If the treatment does not work, persistent joint pain, stiffness and deformation will develop in the diseased joints. Nerves can be stressed. So-called rheumatoid nodules – rubber-like nodules – are also possible under the skin, especially in places of increased stress such as near joints. The shoulder can be swollen from an inflamed bursa or an effusion. With rheumatism, complaints from other (internal) organs are also possible, with gout kidney damage and high blood pressure.


Results from the symptom pattern, the physical examination results, x-ray, sonography and blood values, an examination of the fluid (puncture) from a swollen joint or bursa. However, there is no relevant diagnostic “evidence”. The experience of the specialist (rheumatologist) is often required.

Polymyalgia rheumatica

The term “Polymyalgia rheumatica” stands for inflammatory muscular rheumatism. Sometimes joint structures and bursa on the one hand and blood vessels on the other hand become inflamed. The disease occurs mainly after the age of 50 and affects women much more often than men. In addition to the muscle pain, especially in the shoulder and pelvic area, painful inflammation can occur in the shoulder joints, on the bursae and the connections between the sternum and collarbones. The wrists can also be involved. A vicious circle of inflammation, reduced mobility and relieving posture can lead to a frozen shoulder. A smaller proportion of patients with polymyalgia rheumatica also develop what is known as giant cell arteritis (also known as cranial arteritis or Horton’s temporal arteritis, inflammation of the temporal arteries). Serious complication of this vascular inflammation is loss of vision in one or both eyes as a result of circulatory disorders in the optic nerve.


The pain affects the shoulder and / or pelvic area. They radiate into the upper arms and thighs and occur especially at night and in the morning. During the day, after the initial morning stiffness, they become somewhat more bearable. General symptoms such as tiredness, weight loss, sweating, malaise and fever are also suspected of being rheumatic. With simultaneous giant cell arteritis, those affected often have throbbing temporal headaches and pain when chewing. An inflamed temporal artery can be seen as a thickened, touch-sensitive vascular cord on the side of the temple. Eye complaints (visual disturbances) are another key symptom and at the same time alarm signs.

Diagnosis and therapy

The symptoms and blood tests give the doctor strong indications. If giant cell arteritis is suspected, the doctor will arrange an ultrasound examination (color Doppler sonography of the temporal arteries). The tissue sample (biopsy) from the vessel, which was previously considered necessary, can be dispensed with if sufficient diagnostic features are available, because the tissue examination is partially normal. Color duplex sonography (color Doppler) always precedes a biopsy!

In some people with giant cell arteritis, other body vessels are also affected, such as the main artery and the arm and leg arteries. If there is any suspicion, the doctor will also examine these vessels with the color Doppler. Cortisone improves the symptoms relatively quickly, which is another clue to the diagnosis. Otherwise, the doctor will carefully review them and rule out other diseases. For giant cell arteritis, treatment should begin immediately with a sufficiently high dose of cortisone and a drug to improve blood flow. In polymyalgia rheumatica, the dose of cortisone is slightly lower. Sometimes the doctor also uses other immunosuppressive agents and so-called biologicals for giant cell arteritis. The therapy lasts for at least two years for both clinical pictures.

Bacterial inflammation of the shoulder joint

Possible triggers for this generally rare disease are pus, mostly germs called staphylococci. The germs get into the joint either through a pretreatment measure such as joint replacement, joint endoscopy, joint puncture, or from another source of infection in the body via the blood (vascular septic omarthritis), or through an injury near the joint or an infected bursa. Illnesses that lead to an immunodeficiency, wounds near the joints and certain medications (e.g. cytostatics against cancer or so-called biologicals) can also promote joint infections. Osteoarthritis can develop as a long-term consequence of bacterial joint inflammation.


The painful shoulder is immobile, the skin over it reddened and overheated, the shoulder area swollen. The affected person spares the joint (relieving posture), which can also be extremely painful when touched. Fever and a feeling of illness indicate a pronounced infection (see also above, section “Bursitis”).


The diagnosis of a joint infection results from the medical history, the physical examination findings, from blood analyzes, by cultivating pathogens from the synovial fluid (puncture) and tissue parts of the joint and, if necessary, by imaging procedures. In addition to an ultrasound examination, this sometimes includes magnetic resonance imaging. It can be useful to identify the extent of the inflammation.


The joint must be surgically relieved (debridement) and rinsed, otherwise there is a risk of complete stiffening. If necessary, the inflamed synovium is removed (synovialectomy). Joint bodies or a loosened implant are also removed. Other surgical measures may be necessary depending on the findings.

Targeted antibiotic treatment is carried out through the bloodstream. The joint is immobilized, supported in the relief position on a rail, and cooled. Initially, as soon as possible, only one passive exercise treatment is announced, i.e. by the physiotherapist. Later the patient is allowed to practice actively himself.

Shoulder paralysis: Neuralgic shoulder amyotrophy

First shoulder pain, then paralysis – there are many names for this, such as arm plexus or plexus neuritis, idiopathic plexus neuropathy, shoulder neuritis or Parsonage-Turner syndrome (PTS for short). After a long period of time, the disease often disappears.

The arm plexus forms the plexus of nerves for the arm, shoulder and parts of the chest. Partially misdirected immune reactions are said to be at play if a shoulder suddenly hurts badly and muscles in particular subsequently fail. Possible triggers: a viral infection, vaccination, pregnancy, surgery or heavy strain on the arm. There are also hereditary forms. Repeated occurrence in a family suggests this. In general, young adults are more likely to be affected, men more often than women, but the disease, especially in hereditary forms, can also occur in childhood.


There is sudden, tearing pain in the side of the shoulder and arm on one side of the body, which is not dependent on movement. For some people, the hand or neck also hurts. Parasitic sensations such as tingling or numbness are less common. A short time later, sometimes within 24 hours, muscle weakness or paralysis occurs in the shoulder and upper arm area, while the pain subsides. The disturbances are more common on the right. In pronounced cases, both shoulders can be paralyzed. The diaphragm (possibly with shortness of breath), the larynx area (with hoarseness) or the legs (with muscle paralysis, possibly also sensory disorders) are rarely affected. After about two years, the changes have almost completely regressed in the majority of patients.


A neurologist is usually responsible. It excludes other neurological diseases, for example a herniated disc in the cervical spine, so-called mono- or polyneuritis or polyradiculitis. These are inflammatory diseases of peripheral nerves or of nerve roots on the spinal cord, for which in turn there are numerous possible causes – from diabetes to borreliosis (neuroborreliosis). Therefore, different specialists are required in individual cases. The doctor asks the patient in advance for information about his personal medical history and he gives him a thorough clinical-neurological examination. He also checks the electrical muscle activity (electromyography) as well as the nerve conduction speed (electroneurography) and above all, if necessary, the blood and the cerebrospinal fluid (CSF puncture). More rarely, X-rays or magnetic resonance imaging (MRI) can be expected to provide further information for this clinical picture.


Nerve pain can be quite persistent. What is needed is a specialist such as a neurologist or pain therapist. As with many shoulder problems, physiotherapy is very important here too. It should start as soon as the patient tolerates it as the pain subsides. Before that, the shoulder can be carefully and passively moved by the physiotherapist. The point is to avoid shortening and shrinking as much as possible. Because the exercise treatment can improve shoulder mobility, but not shorten the duration of the illness.

Chronic Shoulder Pains

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