Shoulder Pain in Your 30s, 40s and 50s

Shoulders are wearing, because they get in the way of so much. Sleeping on that side. Reaching for a seatbelt. Getting a coat on. Lifting anything overhead. Picking up a child.

By the time most people get to me they have been given several different explanations, some of which contradict each other.

This guide is not saying your pain is in your head. Your pain is completely real. What follows is what we now know about how pain works, in plain words.

One thing before you start. This guide assumes I have examined you and ruled out the serious causes. That check is what makes the reassurance here worth trusting. If nobody has examined you yet, read section 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.
• Scans of pain free shoulders are full of tears, thickening and bone spurs. These findings are very common and often not the cause.
• Hurt does not mean harm. Loading a shoulder slowly is safe, and it is one of the best treatments there is.
• Shoulder pain does not always come from the shoulder. The neck is a common source.
• Shoulders are slow. Real change takes months, not weeks. That is normal.

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 and rugby players 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.
• Understanding what is going on. Reading this counts.

What opens the gate

• Stress and worry, especially worrying about what the pain means.
• Broken sleep. Shoulders get caught in a loop here. The pain wakes you, and the broken sleep then turns the pain up.
• Low mood, and feeling that nobody has listened.
• Testing the shoulder over and over to see if it still hurts.
• Being afraid of a movement, usually 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 decorating 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. The sensors fire more easily. The spinal cord turns the signal up. The brain decides there is danger more quickly.

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.

That is what long lasting shoulder pain usually is. And because your body learned it, your body can unlearn it. That is hopeful, because you can change how sensitive you are. You cannot change the shape of a tendon.

4. What scans actually show

Researchers scanned the shoulders of people with no shoulder pain at all. Tendon changes and tears turn up in a large number of these pain free people, and the number climbs steadily with age. Even in the middle of your age band, a fair share of completely pain free shoulders show a tear of some kind. Thickened tendons and bone spurs are even more common.

These findings are the shoulder version of grey hair. They are so common in people with no symptoms that finding one on your scan does not, by itself, mean it is causing your pain. Plenty of people have a tear on one side and pain on the other.

There is a second reason this matters. In 2018 a big UK trial called CSAW tested keyhole shoulder surgery. One group had the real operation. One group had a pretend operation, where the surgeon did everything except shave the bone. One group had no surgery.

All three groups got better. The real operation was no better than the pretend one. That result, and others like it, is why national guidance moved away from this surgery as a routine answer, and towards exercise instead.

Words like tear, degeneration, impingement and fraying sound frightening. Frightening words raise threat. Threat opens the gate. People told their shoulder is torn move it less and guard more, which makes sense, and they hurt more.

5. Sometimes the shoulder is not the problem

This one surprises people. Pain over the shoulder, the shoulder blade and the outer upper arm is very often coming from the neck, not the shoulder joint.

The nerves that supply your shoulder come from your neck, and your brain is not always precise about where it puts the alarm.

Two rough clues, and they are only clues:

• If the pain changes when you move your neck, and your shoulder itself moves freely, the neck is more likely involved.
• If particular shoulder movements bring it on, and neck movement does nothing, the shoulder is more likely the source.

Very often it is both. That is why a proper check looks at your neck, upper back and ribs, not just the sore shoulder. It also means treating only the sore spot often does not work.

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. Deadlines, family worries, money. It all feeds in.
• Mood. Low mood and pain feed each other, both ways.
• What you believe. What you think is happening in your shoulder changes how much it hurts.
• Activity. Shoulders really dislike a sudden jump. A weekend painting a ceiling after months of nothing. Going back to the gym at the weight you used to lift.
• General health. Smoking and being unfit add to the load. Diabetes and thyroid problems are linked to more shoulder trouble.
• Work. Feeling unsupported or stuck makes pain worse.

Most of that list is something you can influence. That is more than can be said for the shape of a tendon.

7. Moving is safe, and load is treatment

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

Tendons are living tissue. They adapt to load. Rest them completely and they get weaker and cope with less, which is the opposite of what you want.

Resting and avoiding make shoulder pain worse. Muscles get weaker, the range you use shrinks, and your nervous system gets more protective. Avoiding a movement teaches the alarm that the movement really was dangerous.

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.

For most shoulder pain, building up strength is the best treatment we have. In trials it does about as well as surgery. What matters most is that the exercise is heavy enough to count, and that you keep doing it. The exact exercises matter far less.

Two things catch people out.

Most people load far too lightly. They use a small resistance band for months and wonder why nothing changes. A tendon needs a real stimulus to adapt. Tendons are slow. Give any programme twelve weeks before you judge it.

8. Pacing, and the boom and bust trap

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

Pacing is the way out:

• 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 big overhead jobs into chunks. Take breaks before you need them, not after.

It feels annoyingly slow for a few weeks. Over a few months it is the fastest route there is.

9. Flare-ups

Flare-ups are normal. They do not mean you have torn something new.

A flare-up is a sensitive system reacting, usually to a pile-up: a hard week, two bad nights, a stressful conversation, a burst of overhead work.

Your plan:

• Keep moving, gently. Do less rather than stopping. A shoulder that is 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 more upright for a few nights.
• Remind yourself, on purpose, 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. A word on the stiff shoulder

There is a condition called frozen shoulder that behaves quite differently from everything else in this guide. It is worth knowing it exists, because the plan for it is different. The giveaway is losing movement in every direction, including when someone else moves your arm for you. If you cannot rotate your arm outwards with your elbow tucked in at your side, this is not a simple sore tendon.

It usually runs in phases. A painful phase, where pain dominates and nights are often bad. A stiff phase, where the pain settles a bit but movement is very restricted. Then a thawing phase, where movement comes back.

The whole thing commonly takes one to three years. That is much longer than people expect, and it is better to know that in advance than discover it month by month.

The important points. It is most common between about forty and sixty, so it sits squarely in your age band. It is more common if you have diabetes or a thyroid condition. Most people get most of their movement back. Pushing hard into stretches during the painful phase usually makes things worse.

If I think this is what you have, I will tell you straight, and we will talk through the options. Those may include seeing your GP about pain relief or a steroid injection, and a referral for physiotherapy. It is not something I would ask you to simply work through using section 7.

11. 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.

The best way to think about a session is 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.

That is why hands-on treatment alone rarely fixes long lasting shoulder pain. The best results come from hands-on care, a strength programme, and understanding what is going on. Each does a different job.

One note on progress. Pain scores bounce around and can be disheartening. A better question is: what can I do now that I could not do three months ago? Can you reach the top shelf? Fasten a bra? Get a coat on? Lift a child? Sleep on that side? Function usually improves before pain does, and pain follows function. Shoulders are slow. Real change takes months, not weeks. That is normal, not a sign it is not working.

12. Getting back to what you actually do

The goal is almost never just less pain. It is usually a specific thing you have stopped doing. Tell me what that is, because the plan should be built backwards from it.

Common ones worth naming:

• Overhead pressing, pull ups or bench press. Almost always achievable again. The route is a graded return, not permanent avoidance.
• Swimming, especially front crawl. Often easier to rebuild than people expect, sometimes by changing stroke for a while rather than stopping.
• Racket and throwing sports. These need a real build up phase. The common mistake is going back at your old volume after a long gap.
• Lifting and carrying children. This is a load like any other, and you cannot pace it. Which is exactly why the shoulder needs to be stronger than the task.
• Overhead work. Modified duties for two weeks beat six weeks off.

13. When to get urgent help

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

Call 999

• Shoulder or arm pain with chest tightness or pressure, breathlessness, sweating, feeling sick, or light headedness. Heart problems can be felt in the left shoulder, arm or jaw, and can happen with no chest pain at all, especially in women and people with diabetes. Pain that comes on with effort and eases with rest is a particular worry. Do not wait to see if it settles.
• Sudden severe pain at the tip of the shoulder with tummy pain, especially after an injury. Problems under the diaphragm, including internal bleeding, can be felt at the shoulder tip.

Contact your GP or NHS 111 today

• A red, hot, swollen shoulder with fever or feeling generally unwell.
• Sudden inability to lift or rotate the arm at all after a fall, an obviously deformed shoulder, or a suspected dislocation.
• 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 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.

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. The best possible starting point. tamethebeast.org
• Flippin' Pain. A UK campaign about long lasting pain. flippinpain.co.uk
• Retrain Pain. Free, very short illustrated lessons. retrainpain.org
• NHS advice on shoulder pain. nhs.uk/symptoms/shoulder-pain

Practical help

• The Pain Toolkit, by Pete Moore. Very good on pacing and boom and bust. paintoolkit.org
• Recovery Strategies, by Greg Lehman. A free illustrated workbook, one idea per page. greglehman.ca/recovery-strategies-pain-guidebook

Books

• Explain Pain, by David Butler and Lorimer Moseley.
• The Explain Pain Handbook: Protectometer, by the same authors.
• Painful Yarns, by Lorimer Moseley. The same ideas as short, funny stories.

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.
• Lewis J. Rotator cuff related shoulder pain: assessment, management and uncertainties. Musculoskeletal Science and Practice.
• NICE Clinical Knowledge Summaries: 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.