Shoulder pain, rotator-cuff disease and adhesive capsulitis

01OverviewDefinition, clinical context and the essential points that orientate the chapter.

Begin with onset and mechanism. Ask whether pain is lateral, superior, deep or radiating; whether trauma caused immediate weakness; which movement hurts; whether the patient can sleep on that side, reach overhead, dress or reach behind the back; and whether neck movement, exertion or breathing changes it. Establish diabetes, thyroid disease, cancer, inflammatory symptoms, seizure, dislocation, injection, surgery and occupational or sporting load. Observe posture and scapular motion, examine neck and neurology, then assess active and passive range before resisted cuff tests.

Rotator-cuff-related shoulder pain includes tendinopathy, partial tears, many degenerative full-thickness tears and subacromial pain. Symptoms and imaging correlate incompletely because asymptomatic tears become common with age. Preserved passive range with a painful arc or pain on resisted abduction or external rotation supports the pattern. Weakness persisting when pain is controlled, a lag sign or acute loss after trauma increases concern for a substantial tear. Ultrasound and MRI assess cuff integrity when a result will change specialist management.

Adhesive capsulitis evolves through painful and stiff phases, with global passive loss and external rotation most restricted. Plain radiography excludes glenohumeral arthritis, fracture or tumour when needed; MRI is not required for a typical case. Education about the prolonged but usually improving course, safe analgesia and stage-appropriate mobility are central. Early glenohumeral steroid can reduce pain, particularly with exercise, while hydrodilatation, manipulation or arthroscopic release are specialist options for refractory disability.

Key points

Compare active with passive range: painful or weak active movement with relatively preserved passive movement supports rotator-cuff-related pain, while global active and passive restriction suggests capsulitis or arthritis.
Adhesive capsulitis classically causes disproportionate loss of passive external rotation, followed by abduction and internal rotation, with gradual painful onset.
No single cuff manoeuvre is definitive; use pain location, strength after analgesia, range, trauma and combinations of resisted abduction, external rotation and lag signs.
Do not request routine ultrasound or MRI at first presentation of atraumatic cuff pain; image when trauma, major weakness, stiffness, failed rehabilitation or surgery creates a specific question.
Provide explanation, temporary load modification and progressive cuff, scapular and range exercise, normally over at least six to twelve weeks before judging conservative care unsuccessful.
A targeted subacromial or glenohumeral corticosteroid injection can give short-term relief enabling exercise; exclude infection and avoid serial injections without durable gain.
Refer an acute traumatic suspected full-thickness tear promptly; refer persistent disabling cuff disease or frozen shoulder after an adequate supported pathway.
Shoulder pain may come from neck, heart, lung, diaphragm or malignancy; a normal shoulder examination or movement-independent pain should widen assessment.

02AetiologyUnderlying causes, associations and risk factors, with why each one matters.

Rotator-cuff overload

Age-related tendon change, repeated overhead load, altered scapular mechanics, smoking, diabetes and acute traction can produce tendinopathy, partial tear or full-thickness failure.

Capsular fibrosis

Adhesive capsulitis may be idiopathic or associated with diabetes, thyroid disease, prolonged immobility, trauma, stroke or surgery; synovitis progresses to capsular contracture.

Joint and regional sources

Glenohumeral or acromioclavicular osteoarthritis, instability, calcific deposit, bursal irritation and biceps disease produce overlapping pain but different movement patterns.

Referred pain

Cervical roots, brachial plexus, heart, diaphragm, lung and upper abdominal organs can refer pain without primary glenohumeral pathology.

03PathophysiologyThe causal sequence from the underlying abnormality to symptoms and harm.

1
Load-capacity mismatch
Rotator-cuff symptoms arise when tensile and compressive demand exceeds tendon capacity, with collagen disorganisation and pain that correlate imperfectly with tear size.
2
Dynamic humeral control
The cuff centres the humeral head while deltoid elevates the arm; weakness, pain inhibition or tear disrupts force coupling and active elevation.
3
Capsular contracture
In adhesive capsulitis, capsular inflammation and fibroblast activity shorten the rotator interval and glenohumeral capsule, restricting passive external rotation and later multiple planes.
4
Pain-related stiffness
Guarding and immobility add secondary loss of motion, but true capsulitis creates a consistent passive capsular restriction beyond voluntary guarding.

04Clinical features and red flagsSymptoms, examination findings, patterns of presentation and time-critical warnings.

Cuff-related pain

Lateral upper-arm pain with overhead activity, a painful arc and pain on resisted abduction or external rotation occurs while passive range remains preserved.

Full-thickness tear

True weakness, drop or lag signs and inability to elevate after trauma raise concern; pain inhibition can mimic weakness, so compare after analgesia.

Adhesive capsulitis

Gradual severe night pain progresses to global restriction of active and passive movement, with passive external rotation most clearly lost.

Acromioclavicular pain

Superior focal tenderness and pain on cross-body adduction or direct loading localises symptoms to the acromioclavicular joint.

Glenohumeral arthritis

Deep pain, crepitus and global passive restriction resemble capsulitis, but radiographs show joint-space narrowing, osteophytes and subchondral change.

Cervical referral

Pain below the elbow with neck provocation, sensory symptoms, reflex change or myotomal weakness suggests a cervical root or plexus source.

Systemic referral

Symptoms unrelated to shoulder movement with chest, respiratory, abdominal, constitutional or neurological signs require examination beyond the shoulder.

Red flags requiring action

Acute traumatic inability to raise the arm with true weakness, particularly in an older adult, can indicate a full-thickness cuff tear and needs expedited specialist imaging and referral.
Fever, marked warmth, rapid effusion, immunosuppression or severe pain through every passive movement raises septic arthritis and needs same-day hospital assessment.
A locked internally rotated arm after seizure or electrical injury suggests posterior dislocation even when an anteroposterior radiograph is inconclusive.
Progressive night pain, weight loss, a mass or previous cancer needs malignancy imaging; apical lung tumours can combine shoulder pain with hand weakness or Horner syndrome.
Shoulder discomfort with exertional chest pressure, breathlessness, diaphoresis, haemodynamic change or visceral symptoms requires urgent non-musculoskeletal assessment.

05InvestigationsWhat to request, why it matters and how to interpret it.

Investigation order

Read from the initial assessment onwards. Tests may run in parallel in urgent care; first-line, preferred, confirmatory, definitive and gold-standard labels appear only when the chapter explicitly states them.

01
First-line movement examinationFirst stepFirst line
Why
Localise glenohumeral, cuff, acromioclavicular, cervical or referred pain and identify trauma, infection or major weakness.
Interpretation and limitations
Preserved passive movement supports cuff or periarticular source; fixed passive external-rotation loss supports capsulitis or arthritis; no isolated provocative test is diagnostic.
02
Plain shoulder radiographs
Why
Assess trauma, marked stiffness, arthritis, calcification, tumour, unreduced dislocation or persistent atypical pain.
Interpretation and limitations
Use orthogonal views after trauma; normal films are expected in many cuff disorders and frozen shoulder, and degenerative acromial change does not prove causation.
03
Ultrasound for a cuff question
Why
Evaluate tendon discontinuity, bursal fluid or dynamic structures when examination and treatment course make the result actionable.
Interpretation and limitations
Operator skill matters and degenerative tears may be incidental; report size, retraction and symptom correlation.
04
MRI for surgical or complex disease
Why
Define cuff tear, muscle quality, labrum, marrow, occult fracture or tumour when specialist management depends on deeper anatomy.
Interpretation and limitations
MRI is not routine for uncomplicated cuff pain or capsulitis; fatty atrophy and retraction influence repairability while age-related changes need correlation.
05
Targeted blood or synovial tests
Why
Investigate infection, polymyalgia, inflammatory arthritis, endocrine association or malignancy rather than mechanical pain.
Interpretation and limitations
Use FBC, CRP or ESR, thyroid or diabetes assessment from context; aspirate a hot effusion for crystals and culture without delaying sepsis care.

06Differential diagnosisRealistic alternatives and the features that help distinguish them.

Glenohumeral osteoarthritis

Painful global active and passive restriction with crepitus resembles frozen shoulder, but radiographs show joint-space loss and osteophytes.

Cervical radiculopathy

Neck-provoked arm pain, paraesthesia, myotomal weakness and reflex change extend beyond the shoulder; passive glenohumeral movement may remain comfortable.

Calcific periarthritis

An acutely resorbing cuff deposit can cause abrupt severe atraumatic pain and near immobility; radiographs show calcification, but incidental deposits need correlation.

Polymyalgia rheumatica

Bilateral shoulder and hip-girdle aching with prolonged morning stiffness and raised markers in an older adult suggests systemic inflammation.

Visceral or malignant referral

Cardiac ischaemia, diaphragmatic irritation, apical lung disease and metastatic bone lesions can present as shoulder pain, especially when movement does not reproduce it.

07ManagementImmediate care, first-line treatment, alternatives and escalation.

01First-line assessmentUse movement to localise painFirst stepFirst lineAtraumatic or low-energy shoulder pain is present without deformity, systemic illness or neurovascular loss.

1Screen chest, lung, abdomen, neck, systemic symptoms and cancer risk, then compare active range, passive range, cuff strength, acromioclavicular tenderness and distal neurology.
2Classify a predominantly cuff-related, stiff glenohumeral, acromioclavicular, cervical or referred pattern without overclaiming a single special test.
3Use radiography for trauma, stiffness or atypical disease and reserve ultrasound or MRI for weakness, failed care or a specific specialist decision.
4EscalationGive return advice for fever, swelling, new weakness, deformity, chest symptoms or escalating unremitting pain.

02Preferred cuff rehabilitationRestore load capacityPreferredRotator-cuff-related pain is likely and no acute repairable tear or urgent lesion is suspected.

1Explain that tendon findings are common, then modify only provocative overhead or heavy load rather than resting the arm completely.
2Begin tolerable range, isometric or low-load cuff and scapular-control exercise, progressing resistance and functional reach over six to twelve weeks.
3Use topical or brief oral analgesia to enable sleep and exercise; consider one accurately placed subacromial steroid injection after infection exclusion.
4Reassess diagnosis, adherence, strength and cervical or glenohumeral alternatives if function fails to improve before specialist imaging.

03Adhesive-capsulitis pathwayMatch movement to disease phaseGradual pain and global active and passive restriction, especially external rotation, supports capsulitis after arthritis is excluded.

1Explain recovery commonly takes many months, screen diabetes and thyroid context, and use radiography when arthritis or another structural cause is plausible.
2During a painful phase, use gentle within-tolerance mobility and avoid forceful stretching; consider an intra-articular steroid to create a rehabilitation window.
3As pain settles, progress capsular range and strength; refer persistent major disability for hydrodilatation, manipulation or arthroscopic release discussion.
4Review glycaemic impact after injection and distinguish true capsular restriction from pain guarding, cuff weakness and cervical referral.

04Expedited referralPreserve repairable traumatic functionAcute trauma causes immediate inability to elevate, persistent true cuff weakness or imaging shows a substantial acute tear.

1Obtain trauma radiographs, control pain, document active and passive range, deltoid function and axillary sensation, and assess dislocation or fracture.
2Arrange expedited ultrasound or MRI and shoulder referral rather than requiring an extended routine exercise trial before defining the tear.
3Discuss age, baseline function, tear size, retraction, muscle quality and goals because not every tear needs repair, but delay can reduce repairability.

Key medicines and prescribing safety3 treatments · regimens, roles and cautions

Provides local relief facilitating sleep and therapeutic movement in cuff-related or joint pain.

Topical diclofenac gel

Apply the product-directed amount to the painful region, commonly 2–4 g of 1.16% gel three or four times daily for a short trial, without exceeding the product maximum.

Avoid broken skin, NSAID hypersensitivity and excess combined NSAIDs; systemic harms remain possible. In pregnancy use only when clearly necessary and avoid during the third trimester.

Short-term systemic relief when topical treatment is unsuitable or insufficient and rehabilitation is limited.

Naproxen with omeprazole when indicated

Use naproxen 250–500 mg orally twice daily with food for the shortest course; add omeprazole 20 mg orally once daily while taking it when gastroprotection is indicated.

Assess ulcer, anticoagulants, eGFR, heart failure, hypertension and cardiovascular disease; avoid severe kidney impairment and apply pregnancy restrictions from 20 weeks.

Provides short-term relief enabling rehabilitation in selected cuff pain or capsulitis; site choice follows diagnosis.

Triamcinolone acetonide shoulder injection

Use 20–40 mg once into the anatomically selected subacromial bursa or glenohumeral joint under a trained local protocol; repeat only after documented benefit and reassessment.

Exclude joint, bursal and skin infection and use asepsis; warn about transient hyperglycaemia, post-injection flare, skin atrophy and rare infection, and avoid harmful repeated exposure.

08ComplicationsImportant consequences, why they occur and why they matter clinically.

Persistent weakness

A substantial cuff tear may retract, accumulate fatty muscle change and become less repairable, especially after trauma with immediate functional loss.

Chronic capsular restriction

Adhesive capsulitis often improves but can leave pain, reduced external rotation and disability for years, particularly in diabetes.

Deconditioning and compensation

Avoidance weakens cuff and scapular muscles and overloads neck, opposite shoulder and distal arm, perpetuating pain despite healing.

Treatment-related harm

Repeated corticosteroid injections can impair tendon, elevate glucose and introduce infection; forceful stretching or manipulation can worsen pain, fracture or instability.

09Monitoring and follow-upTreatment response, safety checks and longer-term review.

Record active elevation, passive external rotation, sleep, dressing or work task and review the same outcomes after six to twelve weeks.
Progress cuff and scapular loading only when technique and next-day response are acceptable; persistent true weakness warrants imaging or referral.
After injection, give infection advice, review glucose in diabetes and verify analgesia was used to advance movement.
In frozen shoulder, follow pain and passive external rotation over months, moving from pain-limited mobility toward stronger stretching as irritability falls.
Reassess neck, neurology, chest and systemic features when pain radiates, becomes movement-independent or fails the expected pattern.
After traumatic tear or surgery, follow specialist protection and rehabilitation timing because premature resistance and prolonged immobilisation both harm outcome.

10Special situationsVariants, exceptions and circumstances that change the usual approach.

Passive range is pivotal

Cuff weakness limits active elevation while the examiner moves farther; capsular or arthritic disease restricts passive motion itself.

External rotation exposes capsulitis

Loss of passive external rotation with the elbow by the side is particularly useful and should be compared with the opposite shoulder.

Tears may be incidental

Degenerative full-thickness tears become common with age; imaging must link to side, onset, weakness, muscle quality and functional loss.

Injection target matters

Subacromial injection addresses cuff or bursal pain, while glenohumeral injection better matches adhesive capsulitis; neither should be vague.

Diabetes alters trajectory

Frozen shoulder is more frequent, persistent and sometimes bilateral in diabetes, while steroid injection can transiently worsen glucose.

11Common pitfallsFrequent interpretation and management errors.

01
Do not diagnose frozen shoulder from painful active movement without passive external-rotation restriction and exclusion of arthritis.
02
Do not rely on one impingement or cuff test; sensitisation, guarding and several structures can make isolated manoeuvres positive.
03
Do not order MRI for every atraumatic episode or present an age-related tear as proof surgery is required.
04
Do not delay referral of an acute traumatic tear with major weakness by requiring months of routine physiotherapy.
05
Do not perform repeated steroid injections without a defined target, infection exclusion, glucose advice and previous functional gain.
06
Do not ignore chest, lung, cervical, neurological or malignant causes when movement does not reproduce symptoms.