Stiff shoulder: it’s really a “pain in the neck”

A stiff shoulder can be caused by various things and it may cause pain in other parts of your body, such as your neck. How do you know if they are related or what to do if you are experiencing this pain? Highly experienced consultant orthopaedic surgeon Mr Alun Yewlett explains basic information about stiff shoulder in this first of two articles.

Why do I have a stiff shoulder?

There are a number of reasons why patients can have stiff shoulders. This can be due to traumatic or non-traumatic conditions. In practice, most patients will know they've had a traumatic injury, in which case we would advise trauma patients to be seen in an accident or emergency department in the first instance, and the rest of this article will concentrate on the non-traumatic causes of stiff shoulders.

Conditions which tend to affect shoulders and make them stiffened depend very much on the age of the patient. Patients from the age of 40 to 60 are likely to develop a frozen shoulder. This is very topical at the moment because we’ve had so many lockdowns during the COVID pandemic and people haven’t enjoyed their usual activities.

What happens when you have a frozen shoulder is that the shoulder becomes very, very inflamed, stiff, and goes through a series of phases.

When a shoulder is "freezing" initially, it becomes very, very painful and often disrupts patients' sleep, and movements become more restricted during this early phase. During the early stages, it can sometimes be made worse by trying to mobilise it too aggressively at this stage. Frequently, patients' shoulders may be beginning to freeze unbeknownst to the patient initially, as it would only be apparent on extreme stretching, and a common theme patients mention is that they noticed it for the first time when reaching behind them to get something from the backseat of a car, for example.

When the shoulder has finished freezing, it goes into a "frozen" phase where it is less painful but the movement is still restricted, then it gradually goes into a "thawing" phase. The way I try to explain it to patients is if you think about the shoulder capsule like wearing a jacket over your shirt; normally, when it's loose, you can move the limb freely, then with a frozen shoulder it's like somebody is pinching the jacket and pulling it tight to stop you moving in any direction. And that's the kind of sensation the patients have, and that's something that's very, very common.

The other common thing we see in older or "vintage" patients (>60 years of age) which causes stiff shoulders is arthritis. Although more common in older patients, we do sometimes see this in people who have very physical jobs, and that tends to be something diagnosed with persistent pain; it doesn't tend to get easier over time, but it is less commonly globally stiff in all directions compared to a frozen shoulder.

The main investigation to differentiate these from each other is a simple X-ray. Ultrasounds are less helpful in patients with stiff shoulders as it is difficult to position the arm in the correct position to see the shoulders rotator cuff muscles.

My neck is also stiff, are they related?

That’s an excellent question; it’s one of the topics we teach to our students. Shoulder pain can be a “pain in the neck”. The reason for that is there is an awful lot of overlap between pathologies from the neck to the shoulder and vice versa. The shoulder girdle is made up of the shoulder blade, the ball and socket, and also the joint between the collarbone and shoulder blade. Those three structures together actively show the shoulder girdle how to put our hands into space to reach the things we need to reach. Whenever the shoulder is painful in one particular part, your body compensates to try to allow us to reach the objects we need to.

In order to facilitate this, the body sometimes attempts to move the shoulder girdle in a slightly different way to adapt; what can happen is that the shoulder, and especially at the back, the muscles and scapula can in an abnormal manner leading to a condition of malcoordination of the shoulder blade, known as scapula dyskinesia.

Some of the muscles that roate the scapula to compensate for the stiff ball and socket actually connect to the back of the neck. For this reason, it's not uncommon for neck pain, in particular what we call occipital headaches (headaches in the back of the head), to be driven from shoulder pathology. So for that reason, it is always worth checking how the shoulder blade is moving in patients with painful necks and headaches in the presence of a stiff shoulder.

If you are experiencing stiffness in your shoulder and you would like to book a consultation, you can do so at Mr Yewlett's profile.