Shoulder Pain and Rotator Cuff Injury

What is Shoulder Pain?

Shoulder pain is pain felt in or around the shoulder, and it is a common reason for visits to primary care and orthopedic clinics. Shoulder complaints affect an estimated 7% to 34% of people, and subacromial impingement, a pinching of cuff tendons under the bony roof of the shoulder, has been reported in about 44% to 65% of them.^[1] Rotator cuff injuries range from tendinopathy (a painful, irritated tendon) to partial and full-thickness tears.^[2]

Common symptoms

Typical symptoms are pain with reaching or lifting overhead and aching at the outer shoulder or upper arm. Many people also have pain at night, stiffness and weakness.^{[1, 2]}

• Pain when lifting the arm or reaching behind the back
• Trouble sleeping on the affected side
• Weakness, or a sense of the arm tiring or giving way
• Clicking or catching with movement

Causes and risk factors

Most rotator cuff problems are degenerative, beginning as changes within the tendon, but some tears are caused by an injury.^[2] Overuse, repetitive overhead activity and age are common contributors. Shoulder pain can also come from the neck, the joint itself, or from frozen shoulder.^{[1, 3]}

How it is diagnosed and treated conventionally

A clinician assesses shoulder pain with a history and physical examination and sometimes imaging. Because the differential diagnosis is broad and varies with age, patients with acute injuries or red-flag findings should be referred urgently to a specialist.^[3]

Most people can be treated without surgery, usually with exercise-based physical therapy, activity changes and medicines.^{[2, 4]} A Cochrane review of 60 trials found the evidence for manual therapy and exercise alone was mostly of low or very low quality, and that mild, short-lived pain after treatment was the main adverse effect.^[5] Not all tears are symptomatic or progress, and surgery is considered for selected tears and for people who have not improved with non-operative care.^{[2, 3]}

Why Shoulder Pain calls for a whole-person approach

Shoulder pain is not only a tendon problem. The tendon, muscle, bone and nervous system interact, and several of these can be involved at once.^[2]

Care that also addresses muscle tension, posture, sleep and general health is therefore a reasonable addition to treatment aimed at the shoulder itself.

Tendon and muscle health

Rotator cuff tears start as degenerative changes in the tendon, with disorganized tissue and inflammation, and muscle quality (size and fatty change) influences symptoms and surgical outcomes.^[2]

Movement and exercise

Exercise-based approaches are central to the management of rotator cuff tendinopathy in current guidelines.^[4] A network meta-analysis of 33 trials in shoulder impingement found that treatments combining exercise with another therapy tended to give better pain results than single treatments, and its authors listed acupuncture among the therapies suited to early-stage impingement.^[6]

Persistent pain

Shoulder pain often lasts. In one cohort, 54% of patients with shoulder pain still had symptoms at 3 years.^[1] Long-lasting pain can involve changes in pain processing in the nervous system, which is one reason acupuncture is studied for chronic pain.^[7]

Neck and surrounding structures

Chronic shoulder pain has a broad differential that includes problems arising from the neck and other regions.^[3] This is why an accurate medical diagnosis comes before any complementary care.

Acupuncture for Shoulder Pain

What the research shows

Research suggests acupuncture may reduce shoulder pain and improve function, though the evidence is limited by small trials. A 2024 meta-analysis of 5 randomized trials of manual acupuncture for shoulder impingement found less pain and better function and disability than control treatments, and the authors called for more research because of small numbers and differences between trials.^[8]

Shoulder pain was one of the conditions in an individual patient data meta-analysis of 39 high-quality trials. It found acupuncture better than both sham and no acupuncture for chronic pain, with a modest difference from sham of about 0.2 standard deviations, and effects that lasted about a year.^[9] The authors said the results cannot be explained by placebo alone, and also that factors beyond needle placement contribute to the effect.

Results are less clear for dry needling, a related needling technique. A sham-controlled trial of 121 people with subacromial pain syndrome found that adding dry needling to physical therapy did not significantly change shoulder disability scores at 1 year, although some secondary outcomes favored it.^[10] A smaller sham-controlled trial of 46 patients after rotator cuff repair found no significant difference in pain at 4 weeks.^[11]

For frozen shoulder, a meta-analysis of 13 studies found that acupuncture combined with physical therapy reduced pain and improved range of motion more than physical therapy alone, but the studies varied widely.^[12]

How acupuncture may work

Researchers propose that acupuncture acts on the nervous system. Laboratory studies suggest it can quiet pain-amplifying glial cells in the spinal cord, lower inflammatory molecules and activate descending pain-control pathways involving endogenous opioids.^[7] These are proposed explanations from mostly animal studies, not settled facts for shoulder pain.

What treatment involves

Treatment uses fine, sterile, single-use needles placed at points around the shoulder, neck, upper back and arm, usually left in place for about 20 to 40 minutes. We reassess after a short course of visits, and acupuncture can be used alongside your physical therapy exercises.

In prospective studies, about 9 in 100 patients had a minor reaction such as bleeding, soreness or redness at a needle site, and serious events occurred in about 1 in 10,000 patients.^[13] Tell the practitioner first if you have a bleeding disorder, take blood thinners, are pregnant, have had recent shoulder or breast surgery or lymph node removal on the same side, or have a pacemaker (relevant to electroacupuncture).

Ayurvedic medicine for Shoulder Pain

The Ayurvedic view

Ayurveda describes a stiff, painful shoulder as Apabahuka (frozen shoulder) or Amsa shosha, and regards it as a disorder of Vata, the principle said to govern movement, with dryness of the lubricating substance of the joint.^[14] These are traditional categories for choosing care, not biomedical diagnoses, and rotator cuff tears have no distinct classical name.

Therapies that may be used

Care is chosen for the individual and traditionally combines:

• Diet and daily routine intended to calm Vata, such as warm, regular meals and steady sleep hours
• Warm oil massage and local heat over the shoulder and neck
• Nasya, the application of medicated oil through the nose, which a small study has tested in frozen shoulder^[14]
• Herbs traditionally used for joint and muscle pain, prescribed individually by a qualified practitioner

Panchakarma procedures are not appropriate during pregnancy, acute illness or frailty, or before red-flag symptoms have been medically assessed.

What the research shows

The research on Ayurveda for shoulder pain is very limited. We found no systematic reviews and no controlled trials of Ayurvedic treatment for rotator cuff problems. One uncontrolled study of 15 people with frozen shoulder treated with medicated oil nasya for seven days reported improvement in most, but it had no comparison group, so it cannot show that the treatment caused the change.^[14]

Ayurvedic products also vary in quality: about one fifth of those bought online in one study contained detectable lead, mercury or arsenic.^[15]

Herbal medicine for Shoulder Pain

Herbs and formulas that have been studied

Herbal research for the shoulder is sparse. A 2023 traditional Chinese medicine guideline for frozen shoulder made recommendations on acupuncture, manual therapy, needle knife and two herbal plasters applied to the skin, most of them weak or consensus-based.^[16] A supplement containing Boswellia serrata and turmeric (Curcuma longa) has been tested around rotator cuff repair surgery.^[17] A cream containing devil's claw, Boswellia, ginger and escin has been tested for neck and shoulder muscle strain.^[18]

What the research shows

The evidence is limited. In a placebo-controlled trial of patients having arthroscopic rotator cuff repair, those given the Boswellia and turmeric supplement had lower pain at one week, with no significant difference at later points.^[17] The cream study was a supplement registry in people with neck and shoulder muscle strain that compared groups without a placebo and reported less pain, stiffness and rescue medicine use, and it was not designed to show cause.^[18] Most of the Chinese guideline's recommendations were weak or based on consensus.^[16]

Safety and herb-drug interactions

Herbs are active substances and can interact with medicines. Case reports describe serious bleeding or clotting problems when warfarin was combined with herbs including dang gui (Angelica sinensis), dan shen (Salvia miltiorrhiza), ginger, ginseng and Boswellia.^[19] People taking blood thinners need a practitioner's review before using herbs for pain, and your surgeon should know about any herbs before an operation.

Herbs should come from tested sources and be prescribed individually. Tell us if you are pregnant or breastfeeding, have liver or kidney disease, or have surgery planned. Herbal preparations applied to the skin can irritate it and should not be put on broken skin.

Translating traditional medicine into modern biological language

The links drawn here are interpretation, not equivalence. Chinese medicine describes shoulder pain as obstruction of qi and blood in the channels of the shoulder, often attributed to wind, cold or dampness, or to poor nourishment of the tendons. Researchers studying acupuncture measure things that loosely parallel this picture: local tissue response, muscle tension, inflammatory signaling and the way the nervous system amplifies pain.^[7]

Ayurveda's aggravated Vata describes dry, stiff, painful joints with limited movement.^[14] No study has shown that a dosha corresponds to a specific biological process.

How this care fits with your medical care

Integrative care for shoulder pain is complementary. Keep your physician, physical therapist or orthopedic specialist, and do not stop or change prescribed medicines, injections or exercise programs without your prescriber. We do not diagnose the cause of shoulder pain, so new or worsening shoulder pain, or a suspected tear, should be medically evaluated.

Please bring your diagnosis, any imaging reports, a full list of medicines and supplements, and details of any injections or surgery, planned or past. We ask that you are under a physician's care for this condition and that your treating team knows you are receiving complementary care.

When to seek urgent medical care

Some shoulder symptoms come from a heart problem, infection or a serious injury rather than the shoulder itself.^[3]

• Shoulder, arm, jaw or chest pain with shortness of breath, sweating or nausea
• A hot, red, swollen shoulder, especially with fever
• Sudden inability to lift the arm, or a visible deformity, after a fall or injury
• New numbness, tingling or weakness in the arm or hand
• Severe pain at night that does not ease with rest, or shoulder pain with unexplained weight loss or a history of cancer

If any of these occur, call 911 or go to the nearest emergency department.