Shoulder Pain Over 60

Shoulders get in the way of a great deal. Sleeping on that side. Getting a coat or a bra on. Reaching for a seatbelt. Washing your hair. Getting something down from a high cupboard. Carrying shopping.

When a shoulder stops working properly it takes a surprisingly big bite out of your independence. That is usually what worries people most, more than the pain itself.

If you have had a scan, you may have been told you have a tear. I want to deal with that straight away, because it is probably the most misunderstood thing in this whole area. Section 4 explains why it is far less alarming than it sounds.

This guide is not saying your pain is in your head. Your pain is completely real.

One thing before you start. This guide assumes I have examined you. That matters here, because one particular cause of shoulder pain at your age is easy to mistake for an ordinary shoulder problem, and it needs treating quite differently. Section 5 covers it. If nobody has examined you yet, read sections 5 and 13 first.

Read it in chunks. There is no test at the end.

The short version

• Pain is an alarm. It protects you. It does not measure damage.
• There is a gate in your spinal cord. It controls how much of the warning signal reaches your brain.
• When pain lasts a long time, the alarm gets more sensitive. That is learned, so it can be unlearned. There is no age limit on that.
• A large share of pain free shoulders at your age show a tear on a scan. A tear on a report is not a sentence, and very often it is not the cause of the pain.
• Most people with a tear do well without surgery. Building strength works, and it works at your age.
• Hurt does not mean harm. Loading a shoulder slowly is safe.
• Aching and stiffness in both shoulders, worst first thing, coming on over days or weeks, is a different problem and needs your GP. See section 5.
• Shoulders are slow. Real change takes months, not weeks.

1. Pain is an alarm, not a damage meter

It feels obvious that pain comes from your shoulder. It does not, quite.

Your shoulder has danger sensors. They fire when tissue is stretched, squashed or irritated. They send warning signals to your spinal cord, and then to your brain. None of that is pain yet. It is just information.

Then your brain weighs that information against everything else it knows. What were you doing? What happened last time? What do you think this means? How stressed are you? Did you sleep?

Then it decides: how much danger am I in, and how much pain does this person need to feel to keep them safe?

Pain is the answer. Your brain produces it.

That is why damage and pain match up so badly:

• A paper cut really hurts. There is almost no damage.
• Soldiers get badly hurt and feel very little until they are safe.
• People who have lost an arm can still feel pain in it.

So how much pain you feel does not tell you how much damage there is. It tells you how protective your body is being right now.

2. The pain gate

In 1965, two researchers called Ronald Melzack and Patrick Wall came up with an idea that changed pain medicine. It is still one of the most useful pictures we have. Picture a gate in your spinal cord. Warning signals from your shoulder have to pass through it to reach your brain.

When the gate is open, lots get through and you feel more pain. When it is closed, fewer get through and you feel less. Your shoulder has not changed at all. Only the gate has.

What closes the gate

• Touch, rubbing, heat and hands-on treatment. Touch signals travel on bigger, faster nerves than danger signals, and they crowd them out. It is why you rub your elbow after you bang it.
• Moving and exercise. They release your body's own painkillers.
• Feeling safe and calm.
• A decent night's sleep.
• Company and conversation. Being lonely genuinely makes pain worse.
• Understanding what is going on. Reading this counts.

What opens the gate

• Stress and worry, especially about losing your independence.
• Broken sleep. Shoulders get caught in a loop here. The pain wakes you, and the broken sleep turns the pain up.
• Low mood, and feeling written off because of your age.
• Testing the shoulder over and over to see if it still hurts.
• Being afraid of reaching overhead or behind your back.
• Being told frightening things about your shoulder, especially the word tear.

Here is the key bit. Your brain does not just receive signals at that gate. It sends signals down and changes the settings. That is why the same bit of gardening is fine one week and floors you the next.

3. When the alarm gets too sensitive

When a pain system has been busy for months or years, it does not wear out. It gets better at its job.

Think of a car alarm. When it was fitted, it went off if someone tried to force the door. Years later it goes off when a cat walks past.

The alarm is not broken. It is not lying. It is just set far too sensitive for the actual level of threat.

And because your body learned it, your body can unlearn it. There is no age limit on that.

4. About that tear

This is the section worth reading twice.

Researchers scanned the shoulders of people who had no shoulder pain at all.

Tendon changes and tears turn up in a large share of these completely pain free people, and the number climbs steadily with age. By the seventies and eighties, a large share of pain free shoulders show a tear of some kind. Thickened tendons and bone spurs are even more common.

Two things follow, and both matter.

First, a tear on your scan is not automatically the cause of your pain. Plenty of people have a tear on one side and pain on the other. Plenty have tears on both sides and pain in neither. The tear is often part of the same process as grey hair: something that builds up with age in nearly everyone.

Second, most people with a tear do well without surgery. Building strength gives good results in the large majority of people whose tear came on gradually. The tear does not need repairing for the shoulder to work well and stop hurting. Other muscles take up the work.

Surgery has a place, particularly after a real injury in an otherwise healthy shoulder. But it is not the default, and it is not urgent for a tear that came on slowly.

There is more. A big UK trial called CSAW tested keyhole shoulder surgery. One group had the real operation. One had a pretend operation, where the surgeon did everything except shave the bone. One had no surgery. All three groups got better, and the real operation was no better than the pretend one. That is why national guidance moved away from that surgery as a routine answer, and towards exercise.

So if you have been told you have a tear: it is extremely common at your age, it is often not the source of the pain, and even when it is, the first answer is usually strength work rather than surgery.

5. The one to be sure about: both shoulders, and morning stiffness

There is a condition that specifically affects people over fifty, is commonest in the seventies, and is regularly mistaken for an ordinary shoulder problem. It is called polymyalgia rheumatica. It is treated in a completely different way, and it responds extremely well once it is spotted.

It causes aching and stiffness in the shoulders, very often the hips and thighs too, and it has a distinctive pattern:

• It affects both sides, not one.
• It came on relatively quickly, over days or a couple of weeks, rather than building over months.
• Morning stiffness is severe and lasts a long time. Usually more than forty five minutes, often much longer.
• Getting out of bed, turning over in bed, rising from a chair, and lifting your arms to wash or brush your hair are all hard, especially first thing.
• You may feel generally unwell with it. Tired, off your food, losing a little weight, sometimes slightly feverish.
• It tends to ease as the day goes on.

If that describes you, please see your GP rather than assuming it is your shoulders. A simple blood test usually shows inflammation, and a low dose of steroid often produces a dramatic improvement within days. Left untreated it is miserable and disabling for no good reason.

One more thing to know. A small number of people with this condition also get inflammation of the arteries around the temples, which can threaten sight if it is not treated quickly.

New headache, tenderness of the scalp or temples, aching in the jaw when chewing, or any change in your vision means contacting your GP the same day. If your vision is affected, go to A&E or an eye casualty department.

I will ask about this pattern when I examine you. If I think it fits, I will send you to your GP rather than treat you.

6. What turns your pain up and down

• Sleep. Poor sleep is one of the strongest signs of a bad pain day ahead, and shoulder pain is unusually good at wrecking sleep.
• Stress. Bereavement, caring for a partner, health worries.
• Mood. Low mood and pain feed each other. Depression is often missed in older adults, and it is very treatable.
• What you believe. Believing your shoulder is torn and finished is one of the strongest signs of a poor outcome. It is also something you can change.
• Activity. Shoulders dislike a sudden jump. A day of hedge cutting or ceiling painting after months of nothing.
• General health. Diabetes and thyroid problems are linked to more shoulder trouble.
• Being isolated. This genuinely matters.

7. Moving is safe, and load is treatment

Your shoulder is not fragile. It is the most mobile joint in your body, controlled by muscles and tendons that respond to being used.

Tendons are living tissue. They adapt to load at seventy as they do at thirty. More slowly, but they adapt. Rest them completely and they get weaker and cope with less, which is the opposite of what you want.

At your stage of life the balance of risk has shifted in favour of moving. A long rest costs a younger person some fitness. It costs you muscle, function and independence, and it costs them fast. A shoulder that has been guarded for six months is a much harder problem than a shoulder that hurts.

Some soreness while you build back up is expected. It does not mean damage. A good rule: pain that rises while you move and settles back to normal within about a day is fine. Pain still up the next day means you did a bit too much, not that you did harm.

Building up strength is the best treatment we have for most shoulder pain, and it works in older adults. Two things catch people out:

• Most people load far too lightly. A small band for months, and then they wonder why nothing changes. A tendon needs a real stimulus.
• Tendons are slow. Give any programme twelve weeks before you judge it.

The NHS advice for adults over 65 is strength, balance and flexibility work on at least two days a week, plus 150 minutes of moderate activity. Shoulder work counts towards that, and so does the carrying strength that comes with it.

8. Pacing, and the boom and bust trap

A good day comes. You seize it. Then you pay for three days. Over months the trend quietly goes down.

• Work out what you could manage on almost any day, including a bad one. If you can do twelve repetitions on a good day and four on a bad one, start at four.
• Do that amount every day, good and bad.
• Once it feels easy, add about a tenth more each week.
• Break overhead jobs into chunks. Take breaks before you need them, not after. Annoyingly slow for a few weeks. Over a few months it is the fastest route there is.

9. Flare-ups

Flare-ups are normal, and they do not mean you have torn something new.

• Keep moving, gently. Do less rather than stopping. A shoulder completely rested during a flare-up gets stiff fast, and stiffness is much harder to undo than soreness.
• Drop back to your baseline for a few days, then build again.
• Use whatever settles it: heat, gentle movement, changing position often, medication as advised.
• For night pain, try lying on the good side with a pillow supporting the sore arm in front of you. Some people do better propped up in a recliner for a few nights.
• Remind yourself that this has settled before and will settle again.
• Get in touch if it is not settling as it normally does, or if anything in section 13 applies.

10. Falls, and why your shoulder is part of that

This may look like a detour. It is not.

A shoulder that is weak, painful and avoided is a shoulder that cannot save you. Reaching for a handrail. Pushing up from a chair. Breaking a fall. Steadying yourself on a door frame. All of these need shoulder and arm strength.

And a fall onto an outstretched arm, or onto the shoulder itself, is one of the commonest ways people your age break a bone.

So there are two reasons to build the strength back rather than accept the limitation. The obvious one is your shoulder. The less obvious one is the rest of you.

Worth mentioning to me or your GP:

• Any fall in the last year, even one that did not hurt you.
• Any near miss, or any unsteadiness.
• Whether you have broken a bone from a minor fall since you were fifty. That is a reason to ask about a bone density scan.

11. A word about painkillers

I am not your prescriber, and this is not prescribing advice. But one thing is worth knowing. Anti-inflammatory tablets like ibuprofen and naproxen carry noticeably higher risks after sixty. Stomach bleeding, kidney problems and raised blood pressure. They interact with several medicines commonly taken later in life.

Anti-inflammatory gels rubbed into the skin carry much less risk than tablets, and they often suit a shoulder well, because it is close to the surface.

If you are taking painkillers regularly rather than now and then, talk to your GP or pharmacist. A pharmacist medicines review is free and genuinely useful.

12. What treatment does, and what it does not

Hands-on treatment works through everything above. It closes the gate. It calms the sensitivity. It relaxes muscles that have tightened to protect you. It gives you a spell where moving feels easier and safer. That is a real effect and it is worth having.

What it does not do is repair a tendon or put anything back in place. Nothing in your shoulder is out.

Think of a session as a window. A stretch of time where you can move more freely, and use that freedom to load the shoulder and build up what it can handle. The loading is what changes things in the long run.

I will adapt what I do to you. Technique, positioning and force all change depending on your bone strength, your joints, your medicines and your other health conditions. I will always ask.

Please tell me if you have osteoporosis, take blood thinners or long term steroids, have had shoulder surgery or a joint replacement, or have had a fracture. All of those change what is right for you.

One note on progress. A better question than your pain score is: what can I do now that I could not do three months ago? Can you wash your own hair? Get a coat on unaided? Fasten a bra? Reach the top shelf? Carry a shopping bag? Sleep on that side? Function usually improves before pain does. Shoulders are slow, and real change takes months rather than weeks. That is normal, not a sign it is not working.

13. When to get urgent help

Almost all shoulder pain is not an emergency. The problems below are less common, but they need attention.

Call 999

• Shoulder or arm pain with chest tightness or pressure, breathlessness, sweating, feeling sick, or light headedness. Or pain that comes on with effort and eases with rest. Heart problems can be felt in the left shoulder, arm or jaw, and can happen with no chest pain at all, especially in women, people with diabetes, and people over seventy. Do not wait to see if it settles.
• Sudden severe pain at the tip of the shoulder with tummy pain, especially after a fall.

Contact your GP, NHS 111 or A&E today

• A red, hot, swollen shoulder with fever or feeling generally unwell. Infection in a joint is uncommon but urgent. It is more likely with diabetes, rheumatoid arthritis, or a weakened immune system.
• Not being able to lift or move the arm after a fall, an obviously deformed shoulder, or severe pain straight after a fall. A break in the upper arm bone is one of the commonest fractures at your age, and it needs checking rather than waiting out.
• New headache with scalp or temple tenderness, jaw ache when chewing, or any change in vision, especially alongside aching in both shoulders. See section 5. If vision is affected, go to A&E or eye casualty.
• New or worsening weakness, numbness or pins and needles in the arm or hand, or a hand losing grip.
• Shoulder pain with weight loss you cannot explain, fever, night sweats, or a past history of any cancer.
• A new lump or swelling around the shoulder, in the armpit, or above the collarbone.
• Shoulder pain with a cough that will not settle, coughing blood, or breathlessness.

Worth mentioning at a normal appointment

• Aching and stiffness in both shoulders, worst first thing and lasting more than forty five minutes, that came on over days or weeks. See section 5.
• Any fall in the last year.
• Any bone broken from a minor fall since you were fifty.

Everything else, including a bad flare-up, can wait for a normal appointment.

14. If you want to read or watch more

Start here

• Tame the Beast. A five minute animation by Professor Lorimer Moseley. tamethebeast.org
• Flippin' Pain. A UK campaign about long lasting pain. flippinpain.co.uk
• NHS advice on shoulder pain. nhs.uk/symptoms/shoulder-pain
• NHS activity guidelines for older adults. nhs.uk/live-well/exercise/physical-activity-guidelines-older-adults

Practical help

• The Pain Toolkit, by Pete Moore. paintoolkit.org
• Recovery Strategies, by Greg Lehman. A free illustrated workbook. greglehman.ca/recovery-strategies-pain-guidebook
• Versus Arthritis, on polymyalgia rheumatica and shoulder pain. versusarthritis.org
• Age UK, on staying steady, and strength and balance exercises. ageuk.org.uk

Books

• Explain Pain, by David Butler and Lorimer Moseley.
• The Explain Pain Handbook: Protectometer, by the same authors.

The research behind this guide

• Melzack R, Wall PD. Pain mechanisms: a new theory. Science, 1965. The original pain gate paper.
• Teunis T et al. Prevalence of rotator cuff disease with increasing age. Journal of Shoulder and Elbow Surgery, 2014. The scan findings in section 4.
• Beard DJ et al. Arthroscopic subacromial decompression for subacromial shoulder pain (CSAW). The Lancet, 2018.
• Vandvik PO et al. Subacromial decompression surgery for adults with shoulder pain. BMJ, 2019.
• Kuhn JE et al. Effectiveness of physical therapy in treating atraumatic full thickness rotator cuff tears. Journal of Shoulder and Elbow Surgery, 2013.
• Dasgupta B et al. Provisional classification criteria for polymyalgia rheumatica. Annals of the Rheumatic Diseases, 2012.
• NICE Clinical Knowledge Summaries: Polymyalgia rheumatica, and Shoulder pain.

Bring any of this to your next appointment. Especially the parts that did not sit right, or that felt uncomfortably familiar.

This guide is general information. It does not replace the advice I give you in clinic.