Shoulder in Mid-Life Crisis
A patients guide on the management of mid-life non-traumatic shoulder pain.
This blogpost is a ‘guide’ only, should not be taken as medical advice and does not replace the recommendations from a registered and regulated healthcare professional who has conducted a comprehensive assessment.
Non-traumatic (eg: overload injury) or gradual onset (eg: out-of-nowhere, seemingly-spontaneous) shoulder pain in those who are 40–65 years of age is unfortunately quite common. This blogpost will not discuss pain/injuries arising from a traumatic episode (direct impact) however may relate to pain that develops down the track as a result of it.
This gradual onset shoulder pain can seemingly come out of nowhere, much like tennis elbow, but like tennis elbow it can also be due to an too-much too-soon increase in ‘external load’, with things like digging holes, painting ceilings, sanding walls or simply from an increase in ‘looking after and lifting up the grandkids’ more than usual.
Shoulder pain really stuffs around with life, the role of the shoulder is to place the hand where you need it to do stuff, when it’s painful it can really impact on day to day life, and sometimes the patients occupation too. Worse still, out of all the common Musculoskeletal ailments patients can get in their middle ages, shoulder pain is often the one that is most likely to cause evening and night pain, making it difficult to get a good night sleep, indeed this is one of the main reasons patient eventually present my clinic to get help.
Where is the “Shoulder”? Point to it!
It’s very important to recognise that term “shoulder” means different things to different people. In anatomical terms the ‘shoulder complex’ can include everything from your neck to your upper arm, and your upper chest into your upper back.
However if you see a GP and report a “shoulder” issue, 95% of the time they will think you are talking purely about your ball-and-socket shoulder joint (the glenohumeral joint).
So to avoid any miscommunication here’s my #1 BEST ADVICE for patients with “Shoulder” pain:
If you hurt:
- From your shoulder joint (glenohumeral joint) and down the upper arm, tell your Clinician it’s SHOULDER pain and then indicate with your other hand, just to make sure everyone is clear.
- Anywhere between your neck and your shoulder joint, tell your Clinician it’s NECK pain and then indicate with your other hand, just to make sure everyone is clear.
- Anywhere around your shoulder blade, tell your Clinician it’s UPPER BACK pain and then indicate with your other hand, just to make sure everyone is clear.
That’s a bit pedantic! Why do the Words matter? It hurts all the same!
…because I’ve seen too many “shoulders” that were actually “necks” misdiagnosed due to a lack of a thorough assessment by the Clinician, leading to the Clinician ordering diagnostic imaging for the area the Patient was saying, not the area where the pain is actually arising from which would have been found on a thorough assessment.
Here’s a scary case that actually happened (consent given by patient):
A 55yo female told her GP that she had “shoulder” pain for 2 years, he ordered imaging for her “shoulder” (glenohumeral joint) which showed lots of tears and seemingly nasty things.
Her GP referred her to the surgeon who also heard that she had “shoulder” pain and told her the MRI “was one of the worst he’s seen” and he’ll have to do a rotator cuff tendon repair (big surgery).One of her friends recommended she see me for another opinion.
When I probed further she reported that she had “shoulder” pain (but pointing at the area between the Shoulder Joint and The Neck, closer to the Neck) and said she had been swimming and rock climbing for the past 2 years and those things really didn’t stir it up much at all, in fact the swimming seemed to make it better. The MRI report was consistent with the changes we’d expect to see in someone who used to be an elite athlete with a high upper limb load… which she used to be, once I probed further, but she didn’t tell the GP and Surgeon any of that (athletic history, activity makes shoulder feel better) as they didn’t ask.
I did an assessment:
Her shoulder (Glenohumeral joint) had full pain-free range of motion and great rotator cuff strength, which essentially rules out the shoulder.
I checked her cervical spine and it referred pain (you guessed it…) to her “shoulder”, which in her case was her upper traps area.
I referred her to a different GP, she started some prescription oral anti-inflammatories, she did some simple neck exercises and she was better in less than a month and avoided having unnecessary and costly surgery .
This case study is sadly not an uncommon occurrence and can occur because the primary care clinicians who get 10mins or less to fully assess a patient don’t recognise that when patients say “shoulder” they might mean “neck” or “upper back”. Clinicians also may not themselves understand that the glenohumeral joint rarely refers UP to the neck, it mostly refers DOWN the arm, and patients certainly can’t be expected to know this.
So if you are a ‘shoulder’ pain patient, please make that distinction, or do everything you can to be as specific as possible and physically point (with the other arm) to where it hurts.
Turns out I have Neck Pain
Then you’ll need to go on a Neck Pain diagnostic and magament journey with your nearest registered and regulated healthcare professional. Neck pain is not discussed in this article, however I have written about it before here.
Ok, I have ‘Actual Shoulder Pain’
If you have ‘actual shoulder pain’ (glenohumeral joint) and it has come on truly spontaneously (without you doing too-much, too-soon) and especially if you have night pain your GP will likely refer you for an Xray. This isn’t particularly to rule out a fracture (for spontaneous shoulder pain), it’s to rule out tumours, infections, and other nasties (including Calcific Tendinosis) which can occur around the shoulder. If you don’t have these, then read on.
Once your Xray comes back clear, if the ‘quality’ (type of) pain you have suggests inflammation then your GP hopefully will prescribe you with an oral anti-inflammatory if it’s appropriate based on your medical health. It may be over-the-counter if your inflammation is deemed mild, however in my experience those with long-standing inflammation, particularly affecting sleep, benefit from stronger prescription anti-inflammatories (eg: Meloxicam, Celebrex etc).
At this point, if you know of any Physiotherapists who are excellent Clinicians and can do a thorough glenohumeral joint assessment I would recommend finding them and booking yourself in, if you don’t know of any, keep with your GP for now.
Your GP really should be across screening for Frozen Shoulder/Adhesive Capsulitis which is a very painful condition that causes a huge loss in range of motion of the shoulder, especially with external rotation. If your GP doesn’t know how to rule out a Frozen Shoulder on assessment they really should refer you to someone who does.
The other condition that can gradually present with pain and big loss of range of movement is Calcific Tendinitis, this can also be seen on Xray most of the time, but will not be discussed here as it isn’t one of the common causes of ‘mid-life shoulder pain’.
“Diagnostic” Imaging for the Shoulder
After the Xray and oral anti-inflammatories, after 2–4 weeks if there has been no improvement with the oral anti-inflammatories, your GP might recommend you get “Diagnostic Imaging”.
Diagnostic imaging isn’t very diagnostic but is more often useful for ruling things out. Imaging alone isn’t used to diagnose injuries. It should only be interpreted with reference to the physical assessment (if one was done) and the patients story (if one was heard) as there are many age-related findings (labelled “degeneration”) on imaging that happen naturally over the life span (eg: tendon tears, osteophytes etc). Unnecessary worry about not-very-nice imaging results can result in a Patient becoming a V.O.M.I.T.
MRI is useful for “diagnostic imaging” of the shoulder as it gives a broad overview of many structures, deep and close to the surface. However, because MRIs are much more expensive than ultrasounds, GPs tend to go with ultrasounds.
Ultrasounds & Bursitis
The big problem with ultrasound investigations is that nearly every shoulder appears to have “bursitis” but sometimes it’s a false positive. The other problem with ultrasounds of the shoulder is they often miss some important information about the rotator cuff tendon complex, which is then found on MRI follow up down the track.
If your GP does send you for an ultrasound however, you should ask them to put “+/- HCLA” on the referral. This is a request for the sonographer to offer a hydrocortisone/local anaesthetic injection at the time of the ultrasound if they feel one is appropriate due to a bursitis — an inflamed bursa.
Hopefully it’s an obviously-inflamed bursitis on the ultrasound scan to warrant an injection, the problem is it’s very difficult to tell the difference between a thickened bursa (that thickened over time as a positive adaptation to better tolerate load — like a callous on your hand), vs a bursa that is thickened, swollen, sensitive inflamed (like a blister). Sometimes the report will say “thickened Bursa that impinges on Abduction” as if it’s the problem, however the primary role of Bursas IS to impinge on abduction, that’s their job. 78% of pain-free shoulders (aged 40–70) years have bursal thickening on ultrasound (Girish et al., 2011).
Either way, at least once you’ve had a HCLA you’ll know where it was Bursitis or not, with the LA (local anaesthetic) the first 3 days should be remarkably better (if it’s Bursitis) however it will wear off and the HC (hydrocortisone) will kick in over the next 10 days or so (ideally you shouldn’t do too much with the shoulder over that time). But if there’s no improvement 2 weeks after it, it makes it much less likely that you had Bursitis in the first place. Some longer-term shoulders that have “obviously-inflamed bursitis” might need a 2nd injection.\
Is an MRI better than Ultrasound?
I often say that an Ultrasound is good when you already have an idea of what is going on and you want to ‘do something’ about it (suck or spray — injection or aspirate). Rarely will I recommend an ultrasound for diagnostic purposes across the body.
An MRI is a better choice of imaging to see the deeper internal structures in greater detail such as the rotator cuff and the labrum, as well as the other structures closer to the surface such as the bursae (plural for bursa) and the long-head biceps tendon. But even an MRI isn't the gold-standard for seeing what's going on in the shoulder.. to be honest, the best way is an arthroscopic investigation (aka keyhole surgery – sticking a tiny camera in there and having a look). The MRI is also useful if you are recommended to see a Shoulder Specialist for another opinion.
Is my Shoulder Pain from my Rotator Cuff Tear?
If there are any rotator cuff tears in the 40yrs+ glenohumeral joint, this is very common (Tempelhof, Rupp, & Seil, 1999) and often nothing to worry about, asymptomatic (symptom free) rotator cuff changes are seen on imaging across the lifespan (Teunis, Lubberts, Reilly, & Ring, 2014). We have an ageist saying “if you have grey hairs you have tendon tears” (I’m allowed to be ageist due to my age and grey hairs (and likely tendon tears). In the 60–69 age bracket, over 50% of pain-free shoulders have a partial to full thickness tear of the rotator cuff (Milgrom, Schaffler, Gilbert, & Van Holsbeeck, 1995).
The rotator cuff is like a ‘blanket that covers a ball’, tears are like ‘a hole in a blanket’, as long as there’s plenty of ‘blanket’ left the rotator cuff can still function well in life. UK Physio Adam Meakins describes it well here.
Often some simple rehabilitation for the rotator cuff is enough to help most of these shoulders out and you should seek the guidance of an experienced, registered and regulated Rehab provider (Physiotherapist, Exercise Physiologist etc). The other important reason to “use it or lose it” and do ongoing upper limb resistance exercises to maintain rotator cuff strength is asymptomatic (no pain) rotator cuff tears (partial or full thickness) tend to become symptomatic (painful) over time (Lawrence, Moutzouros, & Bey, 2019; Moosmayer, Tariq, Stiris, & Smith, 2013). So get in the gym and lift!
Will I need surgery?
Most Surgeons will want their rotator cuff tear patients to trial rehab for at least 3 months before considering surgery so you might as well track down someone who knows what they’re doing (a Physio, an Exericse Physiologist — your local Shoulder Specialist can recommend someone for you if you don’t know anyone) and get lifting!
But let’s not sugar coat it too much. Some people do need an operation. If after doing rehab for > 3months there is still significant shoulder weakness +/- loss of range of movement (especially if there is a calcific tendinitis), night pain, and everything else has been ruled out, it’s a strong possibility. Some Surgeons might recommend waiting up to a year to do it though to give the shoulder time, however it depends on the “irritability” of the patient (how much the pain sucks.)
The usual operation is a ‘rotator cuff repair’ +/- a biceps tenodesis (they snip the long-head biceps tendon and reattach it somewhere else, it’s usually a very irritable structure in those with rotator cuff related pain).
What is “Non-Specific Rotator Cuff Pain”?
This is a a term from the research/literature that is in common use now (as of 2022/2023) that means:
- We don’t know what exactly is causing the pain
- We suspect it’s something to do with your rotator cuff
- Knowing the exact cause of the pain won’t change the management anyway (ie, we’d do exactly the same thing even if we did know the exact cause)
- Management will aim to restore function of the rotator cuff, ideally pain-free but in reality significantly less.
Hopefully no patient is ever labelled with/diagnosed as/told:
“You have Non-Specific _____ Pain”
This terminology is reserved for discourse amongst academics and clinicians and it serves purpose as a label for patients unless the conversation in the dot-points above has already occurred and is understood by the patient. I have written about specific vs non-specific diagnoses here.
Summary
Shoulder pain in the ‘mid-life’ is common. There are some serious things to rule out which is why it’s important you see a registered and regulated healthcare professional (GP, Physiotherapist, Sports and Exercise Medicine Physician, Orthopaedic Specialist). More often than not some simple exercises can assist and Physiotherapists and Exercise Physiologists are best placed to help you with this.
Did you enjoy this blog or learn something new that will help you with your clinical practise?
Are you a patient and has this helped you in some way?
‘Buy Me A Coffee’ to say thanks and help me continue to be motivated to share everything I’ve learned in the clinic with the world for free.
References
Girish, G., Lobo, L. G., Jacobson, J. A., Morag, Y., Miller, B., & Jamadar, D. A. (2011). Ultrasound of the shoulder: asymptomatic findings in men. American Journal of Roentgenology, 197(4), W713-W719.
Lawrence, R. L., Moutzouros, V., & Bey, M. J. (2019). Asymptomatic rotator cuff tears. JBJS reviews, 7(6), e9.
Milgrom, C., Schaffler, M., Gilbert, S., & Van Holsbeeck, M. (1995). Rotator-cuff changes in asymptomatic adults. The effect of age, hand dominance and gender. Bone & Joint Journal, 77(2), 296–298.
Moosmayer, S., Tariq, R., Stiris, M., & Smith, H.-J. (2013). The natural history of asymptomatic rotator cuff tears: a three-year follow-up of fifty cases. JBJS, 95(14), 1249–1255.
Pribicevic, M. (2012). The epidemiology of shoulder pain: A narrative review of the literature: IntechOpen.
Tempelhof, S., Rupp, S., & Seil, R. (1999). Age-related prevalence of rotator cuff tears in asymptomatic shoulders. Journal of Shoulder and Elbow Surgery, 8(4), 296–299.
Teunis, T., Lubberts, B., Reilly, B. T., & Ring, D. (2014). A systematic review and pooled analysis of the prevalence of rotator cuff disease with increasing age. Journal of Shoulder and Elbow Surgery, 23(12), 1913–1921.
