The Shoulder Pain That Was Not an Injury

This page is for people with shoulder pain that has no clear injury behind it or is not getting better. It covers when to get help, the usual causes, and the rare pattern that can point to a tumor at the top of the lung.

Seek emergency care now for shoulder or arm pain with chest tightness, sweating, nausea, or breathlessness. Also seek emergency care for shoulder-tip pain with severe abdominal pain, dizziness, or fainting.

Book an appointment sooner if any of these apply.

• There was no injury at all.
• The pain wakes you consistently at night.
• It is getting worse each week rather than settling.
• Any of the neurological or eye features below have appeared.

Pain that followed a clear strain, and that changes with position and movement, is often managed with activity changes and physiotherapy (physical therapy), with a check-in after four to six weeks. Ask your care team what fits your situation. If you have already had six weeks of treatment with no improvement, ask specifically whether imaging should include the chest, not only the shoulder.

The overwhelming majority of shoulder pain is mechanical. Nearly all of it comes from a short list:

• rotator cuff tendinopathy (tendon damage) and tears
• subacromial impingement (tendons pinched under the top of the shoulder blade)
• adhesive capsulitis (frozen shoulder)
• osteoarthritis
• pain referred from an arthritic neck

These share a recognizable pattern. The pain links to particular movements or positions. A clinician can reproduce it by moving your arm. It is often tender to press. It tends to improve over weeks with rest, activity changes, and physiotherapy.

Cancer is an uncommon cause of shoulder pain. It appears on this list because when it does cause shoulder pain, the pain behaves differently. That difference is learnable.

Structures that have nothing to do with the shoulder joint can send pain there.

The diaphragm shares nerve supply with the skin over the tip of the shoulder. So irritation beneath it can cause shoulder pain with an entirely normal shoulder exam. This includes irritation from the liver, gallbladder, spleen, an abscess, or the lining of the lung. Heart problems refer pain to the left shoulder and arm, usually with chest heaviness, sweating, or breathlessness.

The pattern most relevant here comes from the very top of the lung. Tumors in that position are known as Pancoast or superior sulcus tumors. NCI describes them as non-small cell lung cancer that begins in the upper part of the lung and can spread to nearby tissues such as the chest wall, large blood vessels and spine. NCI also notes that lung cancer sometimes causes no signs or symptoms, and lists a cough that gets worse, breathing trouble, chest pain, hoarseness, unexplained weight loss and fatigue among the common warning signs. Because shoulder pain from a tumor can look like a joint problem, tell your clinician if the pain does not behave like an injury.

Consider raising these specifically if they apply to you.

• No injury, strain, or unaccustomed activity preceded the pain.
• The pain is not reproduced by moving the shoulder, and moving it freely does not make it worse.
• Pain wakes you at night and does not settle whatever position you take.
• The pain is steadily worsening over weeks rather than fluctuating.
• Six weeks of physiotherapy or rest have produced no change at all.
• Numbness, tingling or weakness in the hand on the same side.
• A change in an eye or eyelid on the same side as the pain.
• Hoarseness, breathlessness, a cough that is getting worse, or unexplained weight loss.

Any of these together with shoulder pain is a reason to see a clinician promptly.

A thorough assessment examines the shoulder, the neck, and the chest. It includes a neurological exam of the arm and hand. Reproducing the pain with shoulder movement points strongly toward a joint or tendon cause. Being unable to reproduce it is itself informative.

Which tests are used depends on your history and examination, and your clinician decides. If there was no injury, it is reasonable to ask whether imaging should include the chest, not only the shoulder.

• StatPearls: Pancoast Syndrome.
• NCI: Non-Small Cell Lung Cancer Treatment (PDQ).