Common, and mostly a problem of mid-life and laterStrong evidence
In 12 English general practices, women consulted about the shoulder a little more often than men (1.11 times as often), and men's consultations climbed with age: 59 per 10,000 men a year at 15 to 24, 177 at 25 to 44, 312 at 45 to 64 and 366 at 65 to 74. The gym and sport years bring injuries, but most men's shoulder consultations come in mid-life and later. Men see a GP less in general: across 446 UK practices, men's consulting rate was 32% lower than women's, most of all between 16 and 60, though it was similar when men and women had comparable illnesses.
The main causes are the same in men and women. In 766 people at a Norwegian hospital shoulder clinic, 45% of them men, the commonest diagnoses were rotator cuff related pain (36%), muscle pain (17%) and frozen shoulder (11%); full-thickness rotator cuff tears (8%) and shoulder joint arthritis (4%) came mostly after 60. Few differences were seen between the sexes, though arthritis was 6 times as frequent in men as in women at 50 to 69. A UK review names the rotator cuff, the shoulder joint, the acromioclavicular (AC) joint, where the collarbone meets the shoulder blade, and pain referred from the neck as the four commonest causes in general practice.
Sources 1, 2, 3, 4
Young men: a shoulder that comes outStrong evidence
In UK general practice records, 72% of shoulder dislocations were in men (40.4 against 15.5 per 100,000 a year), and the highest rate of all was in men aged 16 to 20 (80.5 per 100,000 a year). Men's rate was higher than women's at almost every age, until 61 to 70. In men, dislocations happen mostly during sport and recreation, and in women more often at home, a Dutch guideline says.
The chance of it happening again depends mostly on age. The UK care pathway's table, modelled from one Edinburgh cohort of 252 people aged 15 to 35, estimates that in men it comes out again within 2 years in about 86% after a first dislocation at 15, 72% at 20, 56% at 25, 41% at 30 and 29% at 35 (in women, 54%, 40%, 28%, 19% and 13%), and almost 90% of repeats come within those 2 years. Beyond 35 the risk keeps falling: people aged 40 or under had about 13 times the odds of a repeat of those over 40 in one meta-analysis.
Whether men's risk is higher than women's at the same age is mixed. Two meta-analyses found about 3 times the odds in men (odds ratios 3.18 and 2.68, the second from low-quality evidence), but a Swedish cohort of people aged 12 to 40, followed for 25 years, found no effect of sex, and 43% of its shoulders never came out again.
Sources 5, 6, 7, 8, 9, 10, 11
The gym and contact sportEmerging evidence
Weight training injuries are mostly in men: 82.3% of an estimated 970,801 visits to US emergency departments from 1990 to 2007. But lifting isn't especially risky: injury rates per hour of training in weightlifting and powerlifting were similar to other non-contact strength sports and low compared with contact sports. Some injuries are seen almost only in men. All 664 torn pec tendons in one pooled analysis were in men (average age 31), 63.2% of them during weight training, and 454 of 483 people with weightlifter's shoulder, a bone stress at the end of the collarbone, were men, with bench pressing the commonest activity (49.1%).
Acromioclavicular joint dislocations, mostly from sport and nearly half from cycling, affected 34.9 per 100,000 men a year against 4 per 100,000 women in Copenhagen, peaking at 20 to 24 and 55 to 59. In 142 male bodybuilders aged 35 to 55, 22% of those who had used anabolic steroids had ruptured a tendon, against 6% of non-users, and every upper-body rupture was in a user; 26% of the ruptures followed warning pain. In 77 men, signs of impingement went with lateral raises and upright rows taken above shoulder height, and were less common in men who trained their external rotators. These are surveys and records, not trials.
Sources 12, 13, 14, 15, 16, 17, 18
From your 40s: the rotator cuff, frozen shoulder, the neck and arthritisStrong evidence
Rotator cuff changes become nearly universal with age. On magnetic resonance imaging (MRI) of 602 Finnish adults aged 41 to 76, 98.7% had some, as often in men as in women, and full-thickness tears rose from 4% at 45 to 49 to 28% at 70 and over. In a Japanese village, full-thickness tears were found in 15.2% of people in their 60s and 26.5% in their 70s, two thirds of them without symptoms. Whether men have more tears is mixed: more men than women had them in their 50s and 60s in that village, but there was no difference between the sexes on Finnish MRI or in a meta-analysis of 6,653 people. A tear caused by an injury is different: those tears were in relatively young (average age 54.7), largely male patients after a fall or a forced arm.
Frozen shoulder is less common in men but not rare: there were 1.6 women for every man in 223 people followed over the years. Diabetes is the strongest link: 10.8% of people with diabetes had it against 2.3% without, in the UK care pathway's figures, and about 30% of people with frozen shoulder have diabetes. A trapped nerve in the neck was diagnosed in 107 per 100,000 men a year against 64 per 100,000 women in Rochester, Minnesota, from 1976 to 1990, peaking at 50 to 54, and NHS inform says shoulder pain can come from the neck "even when you don't feel pain in your neck".
Shoulder joint arthritis causes 2% to 5% of new shoulder pain over 45, came earlier in men than in women in the Norwegian clinic, and is common years after a dislocation: 25 years after a first dislocation at 12 to 40, 61% of shoulders showed some arthritis, 34% moderate to severe. Polymyalgia rheumatica (pain and stiffness in both shoulders, often the neck and hips too) is less common in men, with a lifetime risk of 1.7% against 2.4% in women in a US population; it is mostly over 65 and very rare under 50.
Sources 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 3, 29, 30, 31
Causes outside the joints: the heart, the lungs and the tummyStrong evidence
Coronary heart disease kills 1 in 8 men in the UK (1 in 15 women), and about 1.5 million UK men live with it; the NHS says angina is more likely in men from 45. The heart can cause shoulder or arm pain: across 27 studies of more than a million people having a heart attack or unstable angina, left arm or left shoulder pain was reported by 37% of men and 38% of women, and chest pain by 79% of men. In a US registry of 1,143,513 people having a heart attack, 30.7% of men (and 42.0% of women) had no chest pain. The British Heart Foundation says women and men generally have the same heart attack symptoms, and the review's authors say symptoms shouldn't be labelled typical or atypical. The NHS angina page lists pain that spreads to your left or right arm, or your neck, jaw, shoulder, stomach or back, among its signs to call 999.
In people with chest pain, pain spreading to one or both shoulders or arms, or brought on by exertion, made a heart cause more likely (likelihood ratios 2.3 to 4.7), and pain that was stabbing, worse on breathing in, changed with position or hurt to press made it less likely (0.2 to 0.3), but no single feature rules the heart in or out. We found no study of how often shoulder pain on its own, with no chest symptoms, comes from the heart. Most shoulder pain comes from the shoulder or the neck: in the Norwegian clinic, 8 of 766 people (1%) had a cause outside the shoulder, including a lung tumour and polymyalgia rheumatica.
Other causes outside the joint: a clot in the lungs, where breathing suddenly becomes difficult or chest or upper back pain comes on suddenly with breathlessness or a very fast heartbeat; pleurisy, a sharp chest pain on breathing in that can spread to the shoulders and back; and gallstones, where pain just under the right ribs can spread to the side or shoulder blade (NHS inform). Rarely, a tumour at the top of the lung (a Pancoast tumour) is the cause: it makes up 3% to 5% of lung cancers, is linked mainly with smoking, usually appears in the 50s and more often in men, and shoulder pain is its commonest early symptom. The NHS lists chest or shoulder pain among the symptoms of lung cancer.
Sources 32, 33, 34, 35, 36, 37, 3, 38, 39, 40, 41, 42
When a scan or test helpsStrong evidence
Usually not at first. The UK care pathway for rotator cuff pain says ultrasound or MRI of the cuff "is rarely indicated in primary care", X-rays can help if you aren't improving, and a tear on a scan "does not imply a definite need for surgery in every case". Cuff changes on MRI are close to universal after 40.
After a dislocation, X-rays before and after it is put back find breaks that the first X-ray can miss. Over 40, the UK pathway asks for the rotator cuff to be checked with an ultrasound or MRI scan. In small imaging studies, about 4 in 10 people over 40 had a rotator cuff tear on a scan after a dislocation (24 of 63 on ultrasound in one, and 41% at 40 to 55 in another), more with age, up to all of those over 70; the same pathway says clinically relevant tears, in people with weakness who were then investigated, are about 1 in 10, at an average age of 69. A scan with dye injected into the joint (an arthrogram), or a computerised tomography (CT) scan, helps when the shoulder keeps coming out or surgery is planned.
Other tests answer specific questions: an MRI for weightlifter's shoulder that isn't settling; X-rays to confirm arthritis in a stiff shoulder in later life, though routine X-rays for a suspected frozen shoulder rarely find anything else; a blood sugar check with a frozen shoulder (our suggestion, given the strength of the diabetes link); an electrocardiogram (ECG) and blood tests for a suspected heart attack; and a CT or MRI scan for a suspected tumour at the top of the lung.
Sources 43, 19, 6, 7, 44, 45, 15, 28, 24, 46, 41
How it usually goesStrong evidence
Most shoulder pain settles, slowly. The NHS says self-care usually takes 2 weeks to start helping, and recovery can take 6 months or longer; NHS inform says many new problems begin to settle within 6 weeks, and every group improved a lot over a year in a UK trial of 708 adults with rotator cuff pain. After a dislocation, recovery usually takes 6 to 12 weeks, and up to 16 weeks before some sports, "but for some recovery can take longer" (the NHS); the risk of it coming out again is highest in young men and mostly within the first 2 years.
With worn rotator cuff tears, physiotherapy worked for about 75% of 452 people followed for 2 years, and most of those who chose surgery did so at 6 to 12 weeks. With a frozen shoulder, 59% had normal or near-normal shoulders after an average of 4.4 years, and most of the rest had mild symptoms. With a trapped nerve in the neck, 90% had no symptoms or only mild ones at follow-up. No one can promise a timescale.
Sources 47, 27, 48, 49, 7, 50, 23, 26
