In front

There are many different causes for pain that occurs in the front of the shoulder. The front rotator cuff, the biceps tendon, part of the joint capsule, the acromio-clavicular joint and various soft tissue structures such as bursae or tendons are located here. Alternatively, anterior shoulder pain can be a progressive pain, i.e. caused by damage to structures that are not directly located at the anterior shoulder.

On the one hand, anterior shoulder pain can be caused by inflammation or entrapment of the joint capsule. In addition, there are also bursa (bursa sacs) in the front part of the shoulder, which ensure that the muscles glide smoothly together. An inflammation of these bursa in the corresponding area can cause anterior shoulder pain.

Just as in the knee or hip joint, arthrosis (wear and tear) can occur in the shoulder. The arthrosis can affect the actual shoulder joint between the shoulder blade and the humerus (humero-glenoid joint) as well as smaller joints such as those between the collarbone and the shoulder blade (acromio-clavicular joint). In this case, the pain is projected onto the front of the shoulder.

Such a degenerative change is always a gradual process, whereby the pain initially only occurs in relation to the load. Degenerative changes in the soft tissues such as torn muscles or tendons can also be the cause. The biceps tendon is particularly often affected. Dislocation of the shoulder joint (dislocation) can also cause anterior shoulder pain, since the most common direction of dislocation is forwards and downwards.

Shoulder pain on the back side

In posterior shoulder pain, the pain is concentrated mainly in the posterior part of the shoulder joint. Here, too, the pain can be caused by more distant structures and can only be transmitted to the posterior shoulder joint.The cause is usually a vertebral blockage of the cervical spine, more rarely the thoracic spine. The pain, which often occurs immediately, radiates from the cervical spine into the posterior shoulder and is caused by an interlocking of the vertebral joints of two adjacent vertebral bodies.

This is often caused by jerky movements out of sleep or by an accident. The pain is not caused directly by the blockage but by a reactive tension of the muscles. In addition, considerable restrictions of movement occur.

A slipped disc of the cervical spine can also cause pain in the back shoulder. Furthermore, movement disorders of the shoulder blade are possible causes. This can be caused by inflammation of the tendon attachment at the shoulder blade (enthesiopathy), malformation of the shoulder blade or muscle tension.

Another cause can be a tear in the rear part of the rotator cuff (Musculus infraspinatus and Musculus teres minor). The pulling, stabbing pain is load-dependent (especially during external rotation), is located below the posterior acromion and can radiate into the upper arm. The tear is often the result of an impingement syndrome.

This impingement syndrome, which has existed for many years, increasingly causes wear and tear of the tendons of the muscles of the rotator cuff. The pre-damaged tendons can tear due to a sudden movement. The rupture of a non-damaged tendon due to an accident is far less common.

Finally, bench press can cause a wide variety of injuries, especially if the exercises are performed incorrectly. These range from a simple muscle ache to muscle rupture and can all cause pain in the rear shoulder. Normally, one expects that sleep and rest at night will also significantly reduce shoulder pain.

Often this is not the case, however, so the person concerned wakes up after a few hours of sleep with severe pain in the shoulder. A renewed falling asleep is not to be thought of. The pain, insomnia and exhaustion are a great burden of suffering for those affected.

This phenomenon is caused by the different conditions in the shoulder joint during the day and at night. During the day (in siting/standing), the arm hangs down from the shoulder like a weight with a few kilograms of mass, thus enlarging the joint space by simply “pulling it apart”. The expansion of the structures can only be a few millimeters, but it ensures that irritated and inflamed structures are relieved somewhat.

At night when lying down, the joint space contracts again and the structures lie closer together. So it is precisely this relaxation that causes soft tissues (tendons, bursae) to compress, which causes pain and wakes the person concerned up. In the short term, a kind of stretching device can help to prevent the pain at night.

This involves placing a sling around the wrist and another around the ankle joint, which are then connected with an expander rope. The pulling force on the arm simulates a hanging arm as during the day. Alternatively, the shoulder joint should be stretched at night when the patient is awakened by pain, which should make the pain disappear in the short term.

However, this type of first aid should only be used for a few weeks until the cause of the pain is clarified and treated. Night pain in the shoulder is not a diagnostically very meaningful symptom and can occur in the context of several shoulder diseases. Night pain can occur at night in both osteoarthritis and bottleneck syndrome, as well as in the calcified shoulder or in bursitis (inflammation of the bursa).

In order to make the correct diagnosis of shoulder pain, some information from the patient’s medical history is important (anamnesis), as it provides an initial indication of the causes. Known shoulder injuries, the movements during which the pain occurs, how long the pain persists, whether night-time pain occurs and risk factors for increased shoulder wear (e.g. caused by sport or work) must be asked for by the doctor treating the patient. A physical examination for shoulder pain can consist of a number of examination techniques and methods that allow the function of the shoulder joint muscles to be assessed.Typical clinical function tests are, for example, the Jobe test (side differences indicate a torn tendon, an irritated tendon or an inflammation of the bursa), the neck grip (both hands are placed in the neck), the apron grip (one grabs the back with both hands) and many more.

Palpation of trigger points (points whose touch causes pain) can provide further clues as to the causes of shoulder pain. The mobility of the individual joints in the shoulder joint must also be checked. To rule out the possibility that the cause of shoulder pain is a nerve entrapment, a neurological examination may be necessary.

Imaging procedures such as ultrasound (sonography), X-rays, magnetic resonance imaging (MRI, nuclear spin) or computed tomography (CT) provide further insight into the painful shoulder joint. In some cases, however, even the diagnostic procedures described so far do not lead to a clear diagnosis. For example, it may be necessary to perform a joint endoscopy (arthroscopy). This minimally invasive operation using the “keyhole technique” allows a direct view of the shoulder joint and, if necessary, treatment can also be carried out immediately as part of a arthroscopy, such as suturing a torn tendon or removing inflamed tissue.