Pain guide
Shoulder pain has a handful of common causes: the rotator cuff, a stiff (frozen) shoulder, arthritis, a shoulder that slips, and pain coming from the neck. Where it hurts, and what makes it worse, is the best first clue to which.
For the common causes, exercise is the first treatment, but it does not need to be complicated. In the largest trial in rotator cuff pain, a course of up to six physiotherapy sessions of progressive exercise did no better over a year than one good advice session with a home exercise plan, and both groups improved a lot. Doing a sensible home programme consistently is the core of it.
Start with the warning signs below. Then find your pain on the map, read what helps, and follow the plan from stage 1 if you are not sure of the cause.
Exercise is for pain that has been checked or is clearly mild and settling.
Location narrows the likely causes; it does not diagnose.
Sore lifting the arm out or overhead (often a painful arc partway up), lying on that side, or reaching behind you. Usually the rotator cuff, often called impingement, most often between 35 and 75. Movement hurts but is not blocked: someone else can lift your arm higher than you can.
Read: Shoulder impingement (rotator cuff pain) →Deep ache, stiff in every directionHard to turn the arm outwards (doing up a coat, reaching a back pocket), and bad at night. Points to frozen shoulder, usually between 40 and 65, more often in women and strongly linked to diabetes. Someone else cannot move the arm further either.
Read: Frozen shoulder →Deep ache, stiffness and grinding, usually over 60Comes on gradually over years, with a big loss of turning the arm outwards: arthritis of the shoulder joint.
Read: Shoulder arthritis and AC joint pain →Top of the shoulder, at the end of the collarboneYou can point to it with one finger, it is tender right over the joint, and reaching across the body hurts: the AC joint (arthritis, a sprain or separation, or in lifters, bone thinning at the end of the collarbone).
Read: Shoulder arthritis and AC joint pain →Weakness lifting or turning the armEspecially after a fall or a jerk, or in your 60s and over, often with night pain: a possible rotator cuff tear. Some tears cause weakness without pain. Sudden weakness after an injury needs a same-day check.
Read: Rotator cuff tear →Slipping, clunking or a "dead arm"After a dislocation, or in a very flexible person: shoulder instability. Mostly younger people; the chance of it happening again is highest in teenage and young men.
Read: Shoulder dislocation and instability →Neck, top of the shoulder blade, and down past the elbowWith pins and needles, or changing when you move your neck: pain coming from the neck. See "Is it my neck or my shoulder?" below.
Read: Neck pain →Can come from the heart, the lungs, the diaphragm, the gallbladder or, in pregnancy, an ectopic pregnancy. See the warning signs above.
The NHS tells readers not to try to diagnose shoulder pain themselves. A primary-care review notes that a painful arc partway up when lifting the arm supports a rotator cuff cause, but is neither specific nor sensitive.
So use the map to choose where to start. If the pain does not settle, or does not fit any of the descriptions, get it checked.
Neck problems typically cause pain in the lower neck and above the shoulder blade that can spread to the shoulder and arm; moving the neck may bring it on, and there may be pins and needles in the arm. An international consensus of shoulder physiotherapists agreed that neck and shoulder problems can exist together, sometimes affecting each other and sometimes not.
The clues that point to the neck: symptoms further down the arm than the shoulder, neck pain now or in the past, symptoms that change when you move your neck, and pins and needles, burning or numbness. In general practice, having neck pain at the same time predicted a higher chance of shoulder pain lasting or coming back.
A plain self-check, built from those clues (it does not diagnose):
The GRASP trial followed 708 adults with a new episode of rotator cuff pain in 20 NHS trusts. Up to six physiotherapy sessions of progressive exercise over 16 weeks did no better over 12 months than one best-practice advice session of up to an hour, with a booklet, a resistance band, videos and a simpler home programme. Every group improved substantially.
Note what it compared: more exercise support with less, not exercise with nothing. Both groups did exercises with a band. What it suggests is that a clear explanation and a home programme you keep doing may be enough for many people. The progressive programme focused on resisted turning out, lifting forwards and lifting out to the side, 5 days a week.
A meta-analysis found exercise beat no exercise for impingement pain, and rotator cuff and shoulder-blade exercises beat general exercise, but rated the evidence very low quality. The one high-quality trial that compared manual therapy plus exercise with a placebo found no clinically important difference.
Shaving bone to make room for the tendon (subacromial decompression) did no better than a sham operation in two placebo-controlled trials, CSAW and FIMPACT, now followed for up to 10 years. A Cochrane review found high-certainty evidence of no improvement in pain, function or quality of life over placebo surgery, and a BMJ guideline panel recommends strongly against it.
Rotator cuff tears and other cuff changes become more common with each decade in people with no symptoms at all. In one village's ultrasound screening, about two-thirds of full-thickness tears caused no symptoms. A scan report is not a diagnosis on its own.
In GRASP, a steroid injection gave a small improvement at 8 weeks and none at 6 or 12 months. A UK care pathway advises no more than two injections. Frozen shoulder is different: there, an injection into the joint speeds up early improvement (see the frozen shoulder guide).
A systematic review of 10 studies found no clear link between upper-back rounding and having shoulder pain. Sitting tall does give more arm range in the moment, but only single-session studies exist. The NHS advice to sit and stand tall with your shoulders relaxed is fine for comfort; fixing your posture is not a proven fix for your shoulder.
In a small trial in people without shoulder pain who had a side-to-side difference, the cross-body stretch improved turning the arm inwards by about 20 degrees in 4 weeks; the sleeper stretch's gain was not significant. The successful Holmgren rotator cuff programme included just one stretch, for the back of the shoulder. For frozen shoulder, a guideline recommends stretching matched to how irritable the shoulder is.
In a study of 349 people seeing a GP with new shoulder pain, about 59% had fully recovered at 1 year. Having neck pain at the same time predicted slower recovery.
Source 34
During shoulder strengthening, pain up to about 5 out of 10 is acceptable, and a little is expected. By your next session it should be back to where it was before. If it isn't, use a lighter band or weight or a smaller range next time, not nothing.
This is how the Holmgren trial set each person's load: pain was not allowed above 5 out of 10 during the exercises, and any increase had to settle back to the starting level before the next session; otherwise the load came down. If pain climbs week on week, or a warning sign appears, stop and get it checked.
For arthritis, NICE says joint pain may go up when you start exercising and that regular, consistent exercise will still help.
Frozen shoulder is the exception. Keep stretches to mild discomfort, especially in the painful early stage: a frozen shoulder guideline says the exercises should be done without significant pain, and in a study, gentle exercise within the pain-free range did better than intensive stretching through pain.
After a dislocation, stop if you get the feeling the shoulder is about to slip out.
Start at the first stage. Each move opens a full guide with a 3D demo.
For the first one to two weeks. Keep the shoulder moving and give the rotator cuff light work. Doses are editorial starting points.
3D demoTable slide (seated forward reach)Beginner · A bench or box10 slow reps, 1 to 2 times a day
Easier: Pendulum exercise (Codman's pendulum) · Harder: Overhead lat stretch at a bench
3D demoStanding band external rotationBeginner · A band + An anchor point2 sets of 10 to 15, light band, elbow at your side · Pain up to 5/10, the Holmgren trial's rule
Harder: Side-lying external rotation
3D demoBand rowBeginner · A band + An anchor point2 sets of 12 to 15
3D demoThoracic rotationBeginner · No equipment8 slow reps each way
Harder: Reverse lunge with rotation
3D demoTreadmill walkingBeginner · Cardio machine10 to 20 minutes most days, arms swinging naturally · Or walk outdoors
Harder: Treadmill jogging
Move on when: Daily tasks feel a little easier, and the shoulder is back to its usual level by the next session.
About weeks 2 to 6, about 5 days a week, the frequency used in the GRASP trial. Doses are editorial unless marked.
3D demoSide-lying external rotationBeginner · A dumbbell3 sets of 10 to 15, light dumbbell · The highest infraspinatus activity of seven external rotation exercises in a lab study
Easier: Standing band external rotation · Harder: Cuban rotation
3D demoScaption raiseBeginner · A dumbbell3 sets of 10 to 15, thumbs up, to shoulder height, lowering over 3 s
Easier: Band lateral raise · Harder: Smith machine upright row
3D demoBand internal rotationBeginner · A band + An anchor point2 to 3 sets of 15
Harder: Side-lying external rotation
3D demoScapular push-up (push-up plus)Beginner · No equipment2 to 3 sets of 10, on a wall or bench first
Easier: Dumbbell shoulder-blade punch · Harder: Pike push-up
3D demoProne Y-T-W raisesBeginner · No equipment2 rounds of 8 of each shape
Easier: Wall angel · Harder: Bent-over reverse fly
3D demoCross-body shoulder stretchBeginner · No equipment3 holds of 30 s, if the back of the shoulder is tight · The Holmgren trial used 30 to 60 s, 3 times, twice a day
Harder: Sleeper stretch
Move on when: You can finish every set within the pain rule, and the shoulder is no worse the next day.
From about week 6. Full-body pushing and pulling, overhead if that is a goal, and keep it going. Doses are editorial starting points.
3D demoDumbbell Shoulder PressIntermediate · A dumbbell + A bench or box3 sets of 8 to 12 · Once the band press is comfortable
Easier: Machine shoulder press · Harder: Bench press with bands
3D demoPush-upIntermediate · No equipment3 sets of 8 to 12 · Once incline push-ups are easy
Easier: Wall push-up · Harder: Close-grip push-up (close triceps position)
3D demoFace pullIntermediate · A band3 sets of 12 to 15
Easier: Prone Y-T-W raises · Harder: Barbell rear-delt row
3D demoFarmer's carryBeginner · A dumbbell + A kettlebell3 walks of 30 to 40 m
Harder: Suitcase carry
3D demoCable external rotationBeginner · A cable machine3 sets of 10 to 12, heavier
Harder: Side-lying external rotation
Move on when: Add load or move to the harder option one change at a time, keeping the pain rule.
In 55 recreational weight-training men, those with impingement signs had less inward and outward rotation and weaker external rotators and lower trapezius than those without. This is a snapshot: it cannot show whether the weakness caused the pain or followed it.
Source 43
In a lab model of 10 experienced lifters, a grip narrower than 1.5 times shoulder width lowered compression at the AC joint, and pulling the shoulder blades back with the narrower grip lowered the shearing load on the shoulder joint and the work the rotator cuff had to do. No injuries were measured.
Source 42
One hospital sports-medicine handout tells lifters to avoid behind-the-neck pulldowns and presses, wide-grip bench press, standing lateral raises, overhead triceps work and chest flys, to keep the bench grip about shoulder width, to stop dips at 90 degrees of elbow bend, and not to work through shoulder pain. That is useful practical advice, but no trial tests these bans, and some (all standing lateral raises) are stricter than the evidence requires.
A practical approach, built from the pain rule, the bench study and that handout (editorial):
Pec major tendon tears happen mostly in men and mostly during weight training: in 365 published cases, 48% happened during weight training, and in one surgeon's 104 surgical cases all the patients were men, with an average age of 36.5. A sudden pop or tearing pain at the front of the armpit or chest during a heavy press, with bruising or a change in the chest's shape, should be seen promptly: pain that started after an injury needs a same-day check.
No trial has tested sleeping positions; the NHS only suggests resting the arm on a cushion when sitting. A sensible start (editorial): sleep on your back or on the other side, with a pillow supporting the sore arm (hugged in front of you, or under the elbow if you are on your back), and avoid lying directly on the sore shoulder while it is irritable.
Night pain usually eases as the daytime pain does. In the Holmgren trial, night pain fell more with specific exercise than with generic exercise, by 20 points on a 0 to 100 scale.
Hold 2 to 3 times for 20 to 30 seconds, a mild stretch, never sharp.
| Stretch | Reasonable for | Take care or skip | Why |
|---|---|---|---|
| Cross-body shoulder stretch | A tight back of the shoulder; rotator cuff pain if it doesn't pinch; frozen shoulder once it is less irritable | AC joint pain (it presses on the joint); a pinch at the front (lower the arm) | Improved turning the arm inwards by about 20 degrees in 4 weeks in people without pain. Holmgren's one stretch was for the back of the shoulder. |
| Sleeper stretch | Overhead athletes with a clear loss of turning the arm inwards | A painful or unstable shoulder; early frozen shoulder | Its gain was not significant in a trial and no better than the cross-body stretch, and lying on the shoulder compresses it. |
| Doorway chest opener | A tight chest and rounded shoulders; frozen shoulder, elbow low at first | After a dislocation or with a loose shoulder: arm out and back is the position a shoulder dislocates in | A one-arm self-stretch lengthened the pec minor most of three stretches in healthy people; no pain-outcome evidence. |
| Pendulum exercise (Codman's pendulum) | The very painful stage of frozen shoulder, or a flare; arthritis | Large, fast swings early after rotator cuff surgery (follow your surgeon) | It mostly moves the trunk, not the shoulder joint, so it keeps the arm moving rather than stretching it. Larger swings work the supraspinatus more. |
| Table slide (seated forward reach) | Frozen shoulder, arthritis, early after a dislocation, rotator cuff tears | Pushing into pain | Assisted movement, which a frozen shoulder guideline recommends for irritable shoulders. |
| Stick-assisted external rotation (lying) | Frozen shoulder, arthritis | After a dislocation: keep the elbow at your side, short of any feeling of slipping | Turning the arm outwards is the key loss in frozen shoulder and arthritis. |
| Wall angel | A stiff upper back; frozen shoulder once it is only mildly irritable | Rotator cuff pain if the arms-overhead part pinches (stop lower) | Range and shoulder-blade control; no pain-outcome trials. |
| Overhead lat stretch at a bench | A thawing frozen shoulder; lifters wanting overhead range | A painful rotator cuff, a loose shoulder, early frozen shoulder | Takes the arm to the end of its overhead range. |
| Shoulder CARs (controlled articular rotations) | Low irritability; keeping range in every direction | A painful arc: work around it | Control through the whole range. |
| Thoracic rotation | Anyone; useful while the shoulder is too sore to stretch | Keep it within comfort | Sitting tall gives more arm range in the moment, but there is no evidence that fixing posture fixes shoulder pain. |
| Foam Roller Thoracic Extension | A stiff upper back | Osteoporosis: clear it with a clinician first | As above: helpful for comfort and range, not a proven fix for the shoulder. |
| Levator Scapulae Stretch | Pain from the neck and upper trapezius | Pins and needles in the arm: stop | For pain that comes from the neck; see "Is it my neck or my shoulder?" |
| Upper trap release | Pain from the neck and upper trapezius | Pins and needles in the arm: stop | As above. |
Impingement is now often called rotator cuff related shoulder pain. What trials found about exercise, injections and surgery, and a staged plan with 3D demos.
Pain guideMany worn rotator cuff tears are managed without surgery, and many people with a tear have no pain. Who needs a surgeon fast, and a 3-stage exercise plan.
Pain guideFrozen shoulder exercises matched to how sore it is, why gentle did better than forced stretching, what injections and surgery add, and how long it can last.
Pain guideShoulder arthritis and AC joint pain: what exercise can do, how thin the evidence is, which moves to adapt, and when to ask about a replacement.
Pain guideAfter a shoulder dislocation: why a longer sling doesn't lower the risk, your chance of it happening again by age, and a staged rehab plan with 3D demos.
Eight gentle neck and shoulder stretches for desk stiffness, done standing or seated in ten minutes.
10 minBeginner8 movesA wallA 10-minute routine for a stiff upper back and rounded shoulders: chin tucks, wall angels, Y-T-W raises and open books.
10 minBeginner7 movesA foam roller, A wallA shoulder workout for all three heads: overhead press, lateral raises, reverse flyes, face pulls and rotations.
40 minIntermediate8 movesA band, A barbellNight pain is common with rotator cuff problems, frozen shoulder and arthritis, and on its own it is not a warning sign. No trial has tested sleeping positions; lying on your back or the other side with a pillow supporting the sore arm is a sensible start. Constant pain that does not change with position, with weight loss, fever or a history of cancer, needs checking.
Usually not. The NHS advises against stopping shoulder movement altogether because it can slow recovery, and with frozen shoulder keeping the arm still makes the pain worse. After a dislocation, follow your clinic's sling advice; keeping the arm still for longer than about a week has not been shown to lower the chance of it happening again.
For rotator cuff pain, strengthen: the trial evidence is for strengthening, and the successful Holmgren programme had just one stretch. Frozen shoulder is different: gentle stretching matched to how irritable the shoulder is is recommended. Most stretch studies were done in people without pain.
Exercise comes first for the common causes. Shaving bone to make room for an impinged tendon did no better than placebo surgery in two trials, and a guideline panel recommends strongly against it. For worn rotator cuff tears, a physiotherapy programme was effective for about 75% of people over 2 years in one large cohort. Surgery does have a place: a cuff tear after an injury, a dislocation in a young athlete in a high-risk sport, or arthritis that no longer responds to other care.
For rotator cuff pain, a little and briefly: in the GRASP trial an injection gave a small improvement at 8 weeks and none at 6 or 12 months. In frozen shoulder, an injection into the joint speeds up improvement over the first weeks to about 3 months, and adding a home exercise programme gave extra benefit later.
It depends on the cause, and no one can promise a date. In one GP study, about 59% of people with new shoulder pain had fully recovered at a year, and neck pain at the same time slowed recovery. Rotator cuff programmes in trials ran for 12 to 16 weeks; frozen shoulder can take a year or two to settle.
It can be: reduced blood flow to the heart is a recognised cause of pain felt in the shoulder. Call 999 if shoulder or arm pain comes with chest pain that feels tight or squeezing, or with shortness of breath, sweating or feeling sick. Shoulder tip pain with sudden severe tummy pain in someone who could be pregnant is also an emergency.
The evidence does not show that. A systematic review found no clear link between upper-back rounding and having shoulder pain. Sitting tall gives more arm range in the moment, so use it for comfort, but correcting posture is not a proven treatment.
Exercise education, not a diagnosis or treatment plan. It is written from the guidelines and studies listed above; review by a clinician is pending. If your pain follows an injury, is severe, is getting worse, or comes with any warning sign listed on this page, get it assessed. Health disclaimer.
