What causes shoulder pain when lifting my arms and how can I treat it?

Shoulder Pain with Arm Elevation and Extension

Your shoulder pain with lifting and extending your arms is most likely caused by rotator cuff tendinopathy or tear, especially if you are over 35-40 years old, and should be initially managed with conservative treatment including physical therapy focusing on rotator cuff strengthening and range of motion exercises, combined with NSAIDs or corticosteroid injections if needed. 1, 2, 3

Most Common Causes Based on Your Symptoms

Pain specifically during overhead lifting and arm extension strongly indicates rotator cuff pathology (tendinopathy or tear), which accounts for over two-thirds of all shoulder pain cases. 4 This is the predominant cause in patients over 35-40 years. 1, 3

Other important causes to consider:

• Impingement syndrome - pain when raising arm overhead, particularly between 60-120 degrees of abduction 5
• Adhesive capsulitis (frozen shoulder) - progressive loss of range of motion in all directions 5, 6
• Biceps tendinitis - anterior shoulder pain with overhead activities 3
• Acromioclavicular joint disease - superior shoulder pain, worse with cross-body adduction 3
• Cervical radiculopathy - if pain radiates down your arm with numbness, tingling, or weakness in specific patterns 2, 7

Critical Red Flags Requiring Urgent Evaluation

Seek immediate medical attention if you have: 8

• Fever, chills, or constitutional symptoms (suggests septic arthritis) 1
• Severe weakness or inability to lift arm at all (suggests massive rotator cuff tear) 1
• Numbness, tingling, or weakness radiating down the arm (suggests nerve compression) 2
• Recent significant trauma with deformity (suggests fracture or dislocation) 1

Initial Diagnostic Approach

Start with plain radiographs (X-rays) of the shoulder - this is the preferred initial imaging for any shoulder pain to rule out fractures, dislocations, and arthritis. 1 Get at minimum three views: anterior-posterior in internal and external rotation, plus an axillary or scapula-Y view. 1

If X-rays are normal and you're over 35 years old with suspected rotator cuff disease, the next step is either: 1, 3

• MRI without contrast - best for visualizing rotator cuff tears, labral pathology, and other soft tissue injuries 1
• Ultrasound - excellent for rotator cuff evaluation if local expertise is available, operator-dependent but can be done same-day 1, 4

If pain radiates down your arm with neurological symptoms, get MRI of the cervical spine without contrast to evaluate for nerve root compression from disc herniation or osteophytes. 2

Conservative Treatment (First-Line for Most Cases)

Most rotator cuff pathology and shoulder pain can be managed conservatively without surgery initially. 2, 3 Here's the treatment algorithm:

Physical Therapy (Most Important)

• Strengthening exercises focusing on rotator cuff muscles and scapular stabilizers 1, 3
• Range of motion exercises emphasizing external rotation and abduction to prevent frozen shoulder 1
• Avoid overhead pulleys - these encourage uncontrolled abduction and can worsen pain 1
• Address scapular dyskinesis if present 3

Pain Management

• NSAIDs (oral or topical) - first-line for pain and inflammation control 4, 6
• Corticosteroid injections (subacromial or intra-articular) - triamcinolone has significant effects on pain reduction 1, 4
• Ice, heat, and soft tissue massage - commonly used modalities though evidence is limited 1

Additional Modalities

• Functional electrical stimulation - improves shoulder lateral rotation and may reduce pain 1, 4
• Extracorporeal shock wave therapy - option for calcific tendinitis 4

When Surgery Is Needed

Consider surgical referral if: 8

• Failed appropriate course of conservative treatment (typically 3-6 months) 8
• Acute traumatic massive rotator cuff tear - may require expedited repair for optimal outcomes 1
• Unstable or significantly displaced fractures 1
• Persistent shoulder instability or recurrent dislocations 1

Surgical options include arthroscopic subacromial decompression, rotator cuff repair, or excision of distal clavicle depending on the specific pathology. 4

Common Pitfalls to Avoid

Don't assume absence of trauma means absence of serious pathology - osteoporotic fractures can occur with minimal trauma in elderly patients. 3

Don't delay imaging if red flags are present - septic arthritis, massive tears, and cervical radiculopathy require prompt diagnosis. 1, 2

Don't ignore radiation patterns - pain radiating down the arm in dermatomal distribution suggests cervical spine pathology, not primary shoulder disease. 2, 7

Protect the shoulder from further trauma during rehabilitation - staff education and proper positioning protocols reduce complications. 1