Shoulder pain

What your diagnosis means

Shoulder pain has a way of creeping into everyday life. Reaching into the top cupboard, putting on a coat, doing up a bra, lying on that side at night. When you finally see someone about it, you'll often come away with a label: a rotator cuff problem, impingement, bursitis or a frozen shoulder.

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In my 25 years as an Osteopath, I've noticed that many people leave their appointment with the word but not the meaning. So let me explain what the most common shoulder diagnoses describe.

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A quick tour of the shoulder

The shoulder is a ball-and-socket joint. The ball is the top of your upper arm bone (the humerus) and the socket is a shallow dish on your shoulder blade. Because the socket is shallow, the shoulder is very mobile, and it relies on muscles and tendons to keep the ball centred. The best known of these is the rotator cuff: a group of four muscles whose tendons wrap around the front, top and back of the joint. Above them sits a bony ledge called the acromion, and between the two lies a small fluid-filled cushion called the subacromial bursa. Most shoulder labels refer to one of these parts.

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Rotator cuff tendinopathy

'Tendinopathy' is a general term for a tendon that is painful, irritated or not working as well as usual. A diagnosis of rotator cuff tendinopathy describes changes in one or more of the rotator cuff tendons, often the one across the top of the shoulder (supraspinatus). You may have heard the older word 'tendonitis', and many practitioners now use the umbrella term 'rotator cuff related shoulder pain' instead.

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The label is commonly linked to a change in load, such as a sudden spell of gardening or decorating, or to gradual age-related changes in the tendon. People given this diagnosis often describe discomfort lifting the arm out to the side, reaching behind their back or lying on that shoulder.

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Rotator cuff tear

A rotator cuff tear is a label that describes a split or hole in one of the rotator cuff tendons. Tears tend to be described in two ways. A traumatic tear follows an injury, such as a fall onto an outstretched arm, and may come with a sudden loss of movement or strength. A non-traumatic, or degenerative, tear is one that develops gradually as tendons change with age.

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Impingement and subacromial pain

For many years, 'impingement' was one of the most common shoulder labels. The idea behind the name is that the rotator cuff tendons and the bursa are being squeezed in the space between the ball of the shoulder and the acromion as you lift your arm. You may also see 'subacromial pain syndrome', an umbrella term describing pain around this part of the shoulder.

As understanding has developed, many clinicians now group impingement, subacromial pain and rotator cuff tendinopathy together as 'rotator cuff related shoulder pain'. So if you've been given more than one of these names over the years, you may well have been told much the same thing in different words.

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Bursitis

A bursa is a small, fluid-filled sac that cushions a joint and helps tissues glide over one another. Bursitis is the label for a bursa that has become irritated and swollen (inflamed). In the shoulder it usually refers to the subacromial bursa, and it's often mentioned alongside rotator cuff problems. Some people are given it after an ultrasound scan, others after an examination.

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Frozen shoulder

Frozen shoulder, also called adhesive capsulitis, describes the tissue around the shoulder joint (the capsule) becoming inflamed, then thickening and tightening. The hallmark is stiffness: the shoulder becomes difficult to move in several directions, not just when lifting the arm. It isn't fully clear why it happens and it can take up to 18 months to settle.

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These labels describe what a scan or examination shows. They don't explain why pain persists and for many people the nervous system is an important part of the picture.

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Where arthritis fits

Arthritis can affect the shoulder too, either in the main ball-and-socket joint or in the small joint on top of the shoulder where the collarbone meets the shoulder blade (the acromioclavicular, or AC, joint). Many people with a stiff, achy shoulder assume it must be arthritis, when the label they've actually been given is one of the musculoskeletal ones above. If you'd like to know more about this, read my page on arthritis.