Shoulder pain: causes, diagnosis and treatment in Australian general practice

What shoulder pain is

The shoulder is the most mobile joint in the body, which is what allows the arm to reach overhead, behind the back, and across the body — but that mobility comes at the cost of stability. Pain in the shoulder can arise from the joint itself, from the rotator cuff tendons that surround it, from the bursa (a fluid-filled cushion), from the acromioclavicular (AC) joint at the top, from the biceps tendon, or from structures further away that refer pain into the shoulder — the neck, heart, lungs, gallbladder or diaphragm.

Shoulder pain is one of the most common reasons people see their GP for a musculoskeletal problem. Around 70% of adults experience it at some point in their lives, and it is the second-most-common musculoskeletal presentation in Australian general practice after low back pain.

This article explains how shoulder pain is assessed, what the common causes are, what treatment looks like, and when to seek medical help. It draws on Australian general-practice guidance from the RACGP, Therapeutic Guidelines (eTG), the Australian Medicines Handbook, and consumer resources such as HealthDirect and Better Health Channel.

Common causes

Rotator cuff problems

The rotator cuff is a group of four small muscles and their tendons (supraspinatus, infraspinatus, teres minor, and subscapularis) that wrap around the top of the upper arm bone and stabilise the shoulder during movement. Problems with the rotator cuff — collectively called rotator-cuff-related shoulder pain — account for around 70% of shoulder presentations to GPs.

This umbrella term covers tendinopathy (a wear-and-load problem in the tendon), bursitis (irritation of the cushioning bursa), partial-thickness tears, and full-thickness tears. The pain is typically felt in the lateral upper arm and is worse with overhead activity, reaching, and sleeping on the affected side. The shoulder is often most painful between 60 and 120 degrees of lifting the arm out to the side — known as the “painful arc”.

The old term “impingement” — the idea that the rotator cuff is being mechanically pinched under the bony arch above it — is now considered too simplistic. The pain comes from a mix of tendon load, nerve sensitisation, and movement patterns rather than purely mechanical impingement.

Frozen shoulder (adhesive capsulitis)

Frozen shoulder accounts for around 5% of shoulder presentations. The capsule that surrounds the shoulder joint becomes inflamed and contracted, leading to a global loss of movement — especially when someone else tries to rotate the arm outward. It moves through three phases over 18 to 36 months: a painful phase (2 to 9 months), a stiff phase (4 to 12 months), and a thawing phase (5 to 24 months).

It is more common in women aged 40 to 60, in people with diabetes (around five times more likely), and in those with thyroid disease. It can be triggered by a period of shoulder immobilisation — for example, after a fracture or stroke — or arise without an obvious trigger.

Impingement-like pain and subacromial bursitis

Some people develop a pattern of pain that worsens with overhead reaching, often with tenderness over the top and outer shoulder. This sits within the rotator-cuff-related shoulder pain umbrella and is managed the same way — rather than as a separate diagnosis requiring a specific intervention.

Acromioclavicular (AC) joint problems

The AC joint sits at the top of the shoulder where the collarbone meets the shoulder blade. Pain here is felt right at the top of the shoulder, is worse when reaching across the body, and is often point-tender. It can result from a direct injury (a fall onto the shoulder), from arthritis, or from repetitive overhead loading. Mild AC joint problems usually settle with activity modification and exercise.

Osteoarthritis of the shoulder

Osteoarthritis (OA) of the glenohumeral joint is less common than OA of the knee or hip but does occur, typically in older adults. Movement is restricted in all directions and there may be grinding or crepitus. X-rays show joint-space narrowing and bone changes. Management mirrors OA elsewhere — exercise, weight management, pain relief — with joint replacement reserved for refractory disabling disease.

Other causes

Less commonly, shoulder pain may come from biceps tendinopathy or rupture (where the upper arm muscle develops a “Popeye” bulge), a labral tear (which causes mechanical clicking or catching), shoulder instability, calcific tendinopathy (sudden severe pain with calcium deposits visible on X-ray), polymyalgia rheumatica in older adults, or septic arthritis. Pain can also be referred from the neck, heart, lungs, gallbladder, or diaphragm — which is why a thorough history is essential.

How shoulder pain is diagnosed

In most cases, the cause of shoulder pain can be identified from a careful history and physical examination alone. Your GP will ask about how the pain started, where it is felt, what makes it better or worse, how it affects daily activities and sleep, any associated symptoms such as neck pain or numbness, and your general health.

Examination usually includes looking at the shoulder for wasting or deformity, feeling for tender areas, testing how far you can move the arm both actively and passively, and a series of specific provocation tests for the rotator cuff, AC joint, biceps tendon, and shoulder instability. Your GP may also examine the neck, do a brief neurological check of the arm, and — depending on the picture — listen to the chest or examine the abdomen.

Investigations

Both Australian and international guidelines recommend against routine imaging at the first presentation of typical rotator cuff pain. The reason is that ultrasound and MRI commonly show wear-and-tear changes — including partial-thickness rotator cuff tears in around a quarter of people over 60 — that are not actually causing the pain. Routine early imaging can drive unnecessary intervention without improving outcomes, as documented in Australian general practice data.

Imaging is appropriate when:

• There is a significant injury or suspected fracture
• There is sudden weakness suggesting an acute rotator cuff tear
• Osteoarthritis, calcific tendinopathy, or another bony problem is suspected
• Symptoms have not improved after about six weeks of guideline-based treatment
• Surgery is being considered

X-ray is the first imaging test for injuries, suspected arthritis, and chronic refractory pain. Musculoskeletal ultrasound is used for suspected rotator cuff tears and to guide injections. MRI is generally reserved for surgical planning or for suspected labral injuries.

Blood tests are not usually needed but may be ordered if inflammatory arthritis, polymyalgia rheumatica, or infection is suspected, or to check thyroid and blood sugar levels in someone with frozen shoulder.

Treatment options

The right treatment depends on the cause of the pain, but there are some clear themes across the common conditions.

Active rehabilitation: the strongest evidence

For rotator-cuff-related shoulder pain — by far the most common pattern — the strongest evidence supports a structured, progressive exercise program delivered by a physiotherapist with shoulder expertise. This typically runs over 6 to 12 weeks and progresses through gentle isometric holds, controlled muscle contractions, and finally functional movements that mirror the activities the person needs to return to.

Education matters. Pain doesn’t equal damage, recovery often takes 3 to 6 months, and persisting with rehabilitation through some discomfort is generally safe and effective. Relative rest from aggravating overhead activities — rather than complete avoidance of using the arm — is the right approach.

For frozen shoulder, gentle range-of-movement exercises within pain tolerance are introduced. The natural history is long but recovery is usually substantial.

Pain relief

Short-course anti-inflammatory medication (oral or topical) can help control pain enough to participate in rehabilitation. Paracetamol is a useful adjunct. Opioids are generally avoided in shoulder pain because of limited benefit and significant harms, including a risk of dependence with long-term use.

Any medication choice should be discussed with your GP, who will take into account your other health conditions and current medications. Heat or cold packs, gentle massage, and adjusting sleep position (avoiding the affected side, supporting the arm with a pillow) can also help.

Steroid injections — used selectively, not first-line

A subacromial corticosteroid injection can provide modest short-term pain relief — typically 2 to 6 weeks — and may be a reasonable option when severe pain is preventing someone from participating in rehabilitation. However, a Cochrane review in 2019 found that injections do not improve long-term outcomes compared with exercise alone. Repeated injections (more than three in 12 months) increase the risk of tendon rupture and are not recommended.

For frozen shoulder in the painful phase, an injection of corticosteroid into the shoulder joint itself can offer modest pain and movement benefit alongside physiotherapy and time.

Surgery — reserved for specific situations

Surgery has a smaller role than was once thought. A major Australian and UK randomised trial called CSAW, published in The Lancet in 2018, showed that arthroscopic subacromial decompression — for years a common operation for “impingement” — offered no benefit over placebo surgery for non-specific shoulder pain. This has substantially reshaped practice.

Surgery is appropriate for:

• Acute traumatic full-thickness rotator cuff tears in younger or active patients
• Massive cuff tears with significant weakness in older adults
• Refractory frozen shoulder where physiotherapy, injection and time have not helped (hydrodilatation, manipulation under anaesthesia, or capsular release)
• Advanced glenohumeral osteoarthritis (joint replacement)
• Recurrent shoulder instability after dislocation
• Persistent disabling rotator-cuff-related pain after at least 3 to 6 months of optimised conservative care

Referral pathways from a GP go through orthopaedic surgeons, sports physicians, or radiologists for image-guided procedures.

Other supportive strategies

A few additional measures can help in the broader picture: optimising sleep position, treating sleep apnoea if present, smoking cessation (smoking is linked to worse tendon healing), workplace ergonomic adjustment for people whose work involves overhead loading, and management of any underlying diabetes or thyroid disease — particularly relevant for frozen shoulder. For chronic shoulder pain, psychological strategies such as cognitive behavioural therapy and mindfulness, accessed via a Mental Health Care Plan, can play a useful supportive role.

When to see a GP

See your GP for any new shoulder pain that limits your daily activities, work, or sleep — particularly if it has not improved after a couple of weeks of rest and simple measures. Earlier review is sensible if the pain is severe, if it followed a significant injury, or if your overall function is dropping. A GP review provides an accurate diagnosis, a clear treatment plan, and appropriate referrals to physiotherapy and other services.

Red flags — seek urgent care

Some shoulder presentations need same-day medical attention. Seek urgent care from your GP or the nearest emergency department for:

• A recent shoulder dislocation or significant trauma
• Sudden weakness in the arm, especially after a fall — this can indicate an acute massive rotator cuff tear
• Fever with severe shoulder pain — suggesting possible joint infection
• Shoulder pain together with chest pain, sweating, shortness of breath, or pain into the jaw or arm — possible cardiac cause
• Numbness, tingling, or weakness running down the arm, particularly with neck pain
• A new lump or visible mass around the shoulder
• Shoulder pain in a person who smokes, particularly with arm pain or a droopy eyelid — needs a chest X-ray to exclude a Pancoast tumour
• Severe, unrelenting night pain that is not relieved by changes in position

If you are unsure whether your shoulder pain needs urgent assessment, HealthDirect provides a 24-hour helpline on 1800 022 222.

What this article is and is not

This is general health information drawn from current Australian clinical guidelines — the RACGP shoulder pain guideline, Therapeutic Guidelines (eTG), Australian Medicines Handbook, and Choosing Wisely Australia — alongside peer-reviewed clinical evidence. It is not personal medical advice and does not create a doctor–patient relationship. Decisions about investigations, medication, injections, physiotherapy, or surgery are made collaboratively with your own GP and other clinicians, taking into account your individual circumstances.

For Australian consumer-friendly information: HealthDirect — Shoulder pain and Better Health Channel — Shoulder problems.

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Sources cited

1. RACGP. Shoulder pain (AJGP)
2. RACGP. Shoulder stiffness: management
3. Therapeutic Guidelines — eTG complete (Pain: Shoulder pain)
4. Australian Medicines Handbook
5. Walker-Bone et al. General practice management of rotator cuff related shoulder pain (PLOS One 2020)
6. Beard et al. CSAW Trial — Arthroscopic subacromial decompression vs placebo (Lancet 2018)
7. Karjalainen et al. Subacromial corticosteroid injection (Cochrane 2019)
8. Choosing Wisely Australia
9. HealthDirect — Shoulder pain
10. Better Health Channel — Shoulder problems