Shoulder Pain

Shoulder pain is one of the leading musculoskeletal complaints worldwide. Many people experience it at some point in their lives, prompting visits to orthopedic specialists. The shoulder is a complex joint composed of bones (humerus, scapula and clavicle), muscles, tendons, ligaments, and bursae. This complexity allows for a wide range of motion, including rotation, lifting, and reaching, but also makes it vulnerable to injury.

Shoulder pain often leads to restricted range of motion. This can affect simple daily activities like dressing, grooming, or reaching for objects, reducing independence and productivity. Chronic shoulder pain can disrupt sleep, cause psychological distress, and limit participation in work, sports, and hobbies.

Impingement Syndrome – Rotator Cuff Tendinitis

Impingement syndrome is a common shoulder condition where the tendons of the rotator cuff become irritated and inflamed as they pass through a narrow space between the head of the humerus (the upper arm bone) and the acromion (part of the shoulder blade that forms the roof of the shoulder joint). This space is called the subacromial space. Because of repeated rubbing or friction in this confined space, the tendons can get pinched or “impinged,” leading to inflammation and pain. It can occur at any age but is most common in people aged 30 to 50 years. It may affect people with poor posture, muscle imbalances, or previous shoulder injuries. Its main symptoms are the following:

• Painwhen raising the arm above shoulder or head level.
• Discomfort or aching around the shoulder, sometimes extending to the upper arm.
• Weakness or difficulty lifting objects.
• Pain can get worse at night, especially when lying on the affected shoulder and it may affect your ability to fall (or stay) asleep.

Initial treatment is conservative (non surgical), including physical therapy, anti-inflammatory medications (NSAIDs) and biological agent injections. If the symptoms do not subside after 3 months, shoulder arthroscopy is recommended as a definitive solution to the problem.

Rotator Cuff Tendon Rupture

The rotator cuff is a group of four muscles and their tendons surrounding the shoulder joint. These tendons help stabilize the shoulder and enable a wide range of movements, especially lifting and rotating the arm. A rotator cuff tendon rupture means one or more of these tendons have torn, usually near where the tendon attaches to the bone (the humerus). The tendon most often affected is the supraspinatus tendon, which plays a key role in lifting the arm sideways away from the body. Shoulder pain is quite severe, even during sleep.

The rupture can be either traumatic or degenerative.

The traumatic rupture often occurs in younger to middle-aged adults (30-50 years) after a sudden injury or accident (like a fall or heavy lifting). The degenerative rupture is more common in older adults (over 50 years) and is caused by wear and tear of the tendon over time, sometimes due to poor blood supply or repetitive stress.

Its main symptoms are the following:

• Severe shoulder pain,which can be worse at night and disturb sleep.
• Restricted movement and weaknessin the shoulder, especially difficulty lifting the arm.
• Sometimes a popping or clicking sensation.
• Pain may worsen with overhead activities or lifting objects.

It is an extremely painful and limiting condition, and in the vast majority of cases, it needs to be treated surgically using minimally invasive techniques, such as arthroscopic tendon repair. The goal is to reattach the torn tendon to the bone to restore shoulder function. Post-surgery, physical therapy is crucial for rehabilitation to regain strength and mobility.

Shoulder Arthritis

Shoulder arthritis is a condition characterized by the wear and degeneration of the cartilage that covers the surfaces of the shoulder joint. This cartilage normally helps the bones glide smoothly against each other. When it breaks down, the bones can rub directly against one another, causing:

• Pain— often severe and persistent
• Stiffness— restricted movement of the shoulder
• Swelling and inflammation
• Loss of function— difficulty performing everyday tasks like reaching, lifting, or dressing

The most common causes of shoulder arthritis are:

• Osteoarthritis(most common): Age-related wear and tear
• Rheumatoid arthritis: An autoimmune inflammatory condition
• Post-traumatic arthritis: After fractures, dislocations, or injuries to the shoulder
• A vascular necrosis: Loss of blood supply leading to bone damage
• Rotator cuff tear arthropathy: Arthritis due to chronic rotator cuff tears

Its main symptoms are the following:

• Gradual onset of shoulder pain, often worsening with activity or at night
• Decreased range of motion and stiffness
• Grinding, clicking, or popping sensations in the joint
• Weakness or instability in some cases

In early stages, non-invasive treatments like hyaluronic acid and biological agent injections can reduce pain and slow down the disease progression. In advanced cases, when arthritis becomes severe and non-invasive treatments fail to relieve symptoms or restore function, shoulder arthroplasty (joint replacement surgery) is considered the most effective and safest option. Surgery can significantly reduce pain and improve shoulder function, but recovery involves rehabilitation and physical therapy.

Shoulder Fractures or Dislocations

Fractures or dislocations of the shoulder are fractures of the humeral head. Like clavicle fractures, they are extremely painful injuries and are usually treated surgically. They are caused by falls and require immediate treatment in order to quickly restore the upper limb function.

The dislocation of the humeral head causes intense shoulder pain and requires prompt treatment. In cases of shoulder instability, especially in younger patients, surgical management with shoulder arthroscopy is required.

Calcific Tendonitis

Calcific tendonitis is a condition characterized by the buildup of calcium deposits inside a tendon. Tendons are the strong, fibrous tissues that connect muscles to bones. When calcium crystals accumulate in a tendon, they can cause inflammation, irritation, and pain. The most commonly affected tendon is the rotator cuff tendon in the shoulder. The exact cause of calcium deposits in tendons is not fully understood. It is thought to result from a combination of factors like tendon wear and tear, decreased blood supply, or cellular changes that lead to calcium crystal formation. It often affects adults between 30 and 50 years of age and it can occur without any specific injury. In calcific tendonitis, the pain in the shoulder can be intense enough to disrupt sleep and often worsens with movement, especially overhead or lifting activities. If the pain in the shoulder persists then an immediate evaluation by an orthopedic shoulder surgeon is required. The treatment approach is determined based on the severity of the symptoms. Early diagnosis and treatment improve outcomes and reduce the risk of chronic shoulder problems.

Frozen Shoulder (Adhesive Capsulitis)

Frozen shoulder is a condition where the shoulder joint becomes stiff and painful due to inflammation and thickening of the joint capsule—the tissue surrounding the shoulder joint. Over time, adhesions (bands of scar-like tissue) form inside the joint, causing intense shoulder pain and significant restriction of movement. It can occur after shoulder injury or surgery due to prolonged immobility. Diabetes, thyroid disorders, and cardiovascular disease increase risk. It is most common between ages 40-60 and slightly more frequent in women. Initially, it is treated with physiotherapy and the administration of anti-inflammatory drugs (NSAIDs) and corticosteroid injections. If shoulder movement remains limited and conservative treatment fails, then shoulder arthroscopy is required in order to release the tight joint capsule and adhesions, restoring mobility.

The first step in diagnosing shoulder pain is taking the patient’s medical history and conducting a clinical examination by a specialized Orthopedic Surgeon.

During the examination, the doctor checks for structural problems in order to rule out issues that may be related to the spine or neck. Then, the range of motion is assessed to determine the exact condition and imaging tests are performed.

The imaging tests are the following:

• X-ray: It is primarily used to visualize bones. X-rays can reveal bone fractures, dislocations, arthritis changes (like bone spurs or joint space narrowing), and calcifications around the shoulder.
• MRI (Magnetic Resonance Imaging): It provides detailed images of soft tissues in and around the shoulder. MRI is excellent for detecting injuries to rotator cuff tendons, labrum tears, cartilage damage, bursitis, and inflammation. It can also identify tumors or infections.
• CT Scan (Computed Tomography): It provides cross-sectional images of bone and some soft tissues. CT scans offer better detail than X-rays for complex bone fractures, bone alignment and joint structures. They are useful for evaluating complex anatomy or pre-surgical planning.
• Electromyography (EMG): It tests the electrical activity of muscles and nerves. EMG helps diagnose nerve compression or injury, muscle diseases, and problems with nerve-muscle communication, which can cause shoulder weakness or numbness. Fine needles are inserted into muscles to record electrical signals during rest and contraction. It is often used when nerve damage is suspected, such as in cases of a pinched nerve or brachial plexus injury.
• Shoulder Arthroscopy: it is a minimally invasive surgical technique used to diagnose and treat shoulder problems. A tiny camera (arthroscope) is inserted through small incisions to visualize the inside of the shoulder joint on a monitor. It allows the surgeon to see structures like cartilage, ligaments, and tendons directly, and to perform treatments such as removing damaged tissue, repairing tears, or smoothing bone spurs. It is less invasive than open surgery and has quicker recovery time.

Early diagnosis and treatment are crucial to reduce pain and prevent the worsening of symptoms. The doctor will recommend the most appropriate and effective treatment after a detailed clinical evaluation and thorough examination of the patient.

Depending on the extent of the symptoms, the appropriate treatment option is recommended. In most cases, conservative (non surgical) treatment is the first line of care before considering surgery.

What Does Conservative (Non Surgical) Treatment Include?

Activity Modification: This means changing or reducing activities that worsen shoulder pain or strain. For example:

• Avoiding repetitive overhead motions (like throwing or lifting heavy objects above the head)
• Adjusting sports techniques (e.g., altering a tennis serve or golf swing)
• Modifying work tasks (e.g., reducing lifting or changing posture at a workstation)
  The goal is to prevent further injury and allow the shoulder to heal without completely stopping movement. 

Rest: Giving the shoulder time to heal by avoiding activities that cause pain is crucial. However, complete immobilization isn’t usually recommended for long periods, as some movement is important to prevent stiffness and muscle weakness. Rest could mean:

• Taking frequent breaks during repetitive tasks
• Using a sling temporarily if needed
• Avoiding sleeping positions that aggravate pain

Medication: Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) like ibuprofen or naproxen are commonly prescribed or recommended over-the-counter to reduce:

• Inflammation in the shoulder tissues
• Pain and swelling
• It’s important to use these as directed, since long-term or excessive use can cause side effects like stomach irritation or kidney issues.

Physical Therapy (Physiotherapy): Physical therapy is often central to conservative management because it:

• Helps strengthen shoulder muscles to provide better joint support
• Improves flexibility and range of motion
• Corrects biomechanical issues and posture that may contribute to pain
  A physical therapist will tailor exercises based on the injury type, severity, and individual patient needs. This might include:
• Stretching exercises to relieve tight muscles
• Strengthening exercises for rotator cuff and scapular muscles
• Manual therapy techniques such as massage or joint mobilization
• Education on posture and movement techniques

Injections: When pain is severe or persistent, injections can be used as adjunct treatment. These may include:

• Corticosteroid injections to rapidly reduce inflammation and pain
• Sometimes local anesthetics for temporary pain relief

Injections can allow patients to participate more effectively in physical therapy by decreasing pain. However, they are generally not a long-term solution and should be used judiciously.

If these conservative treatments fail to improve symptoms over a reasonable timeframe (often several weeks to months), and the patient still experiences pain, limited function, or impaired daily activities, surgical options may be considered. Surgery aims to directly repair damaged tissues or correct mechanical issues that can’t be resolved with conservative care alone.

What does surgical treatment include?

Surgical treatment is performed through shoulder arthroscopy, a modern and minimally invasive procedure that offers excellent functional as well as aesthetic results. In cases of arthritis or another serious condition, shoulder arthroplasty (joint replacement) is also a highly effective solution, providing excellent outcomes and pain relief. Each case requires personalized evaluation by the orthopedic surgeon in order to select the appropriate procedure.

The advancement of shoulder surgery has revolutionized the way shoulder conditions are treated today. Dr. Panagiotis Pantos is a specialized Orthopedic Surgeon and the Director of the Orthopedic Clinic, Upper Limb Surgery Department, at the Athens Medical Group (AMG) (in Marousi) as well as the Scientific Director and Head of the Upper Limb and Sports Injuries Departments at “Osteon” Orthopedic & Spine Clinic. He treats the full range of shoulder joint conditions—either conservatively or surgically—using the most modern techniques and innovations in the field.

His many years of experience and specialization ensure reliable and safe results. Each patient is treated individually, supported by advanced facilities and state-of-the-art equipment provided by the Athens Medical Group (AMG).

Can shoulder pain be a sign of a serious condition?

Yes, persistent shoulder pain can be a warning sign of more serious underlying issues like arthritis or tendonitis. However, it is essential to visit a specialist who will assess the situation and provide you with a detailed treatment plan.

How can I prevent shoulder pain?

Preventing shoulder pain involves maintaining good physical condition, avoiding excessive and strenuous movements or techniques, and keeping proper posture during daily activities like desk work, driving, or computer use. Give your shoulder enough time to rest and relax after potentially strenuous activities. Consult your doctor about a personalized program to strengthen the muscles surrounding the shoulder and maintain their flexibility.

Is it a good idea to exercise my shoulder when it hurts?

Gentle stretching and strengthening exercises are commonly recommended for shoulder pain because they can improve blood flow, maintain or restore mobility, strengthen the muscles and help relieve pain, but they should be performed carefully. If exercises cause more pain or discomfort, you should consult a specialist immediately. If in doubt, it’s a good idea to consult your doctor before starting any shoulder exercise program. He/she will help you choose exercises that are safe and appropriate for your condition. In any case, it’s important to listen to your body and not persist with exercises that cause additional pain or discomfort.

Can physical therapy help with shoulder pain?

Yes, physical therapy is often very effective, especially when shoulder pain is due to musculoskeletal or neurological problems.