How Does Rheumatoid Arthritis Affect the Shoulders?

Medically reviewed by David Ozeri, MD

Rheumatoid arthritis (RA) is known for causing all-over inflammation and pain. It happens when the immune system malfunctions and attacks the synovium, the lining of the joints. RA can target the synovial lining of the shoulder joint.

People with RA have an increased risk of shoulder problems as a consequence of ongoing inflammation. While the number of people with shoulder problems in the general population is smaller, people with RA will have notable shoulder tenderness and swelling as early as two years after diagnosis.

This article discusses the symptoms and conditions associated with shoulder RA, as well as diagnosis and treatment options for shoulder RA.

Related: Anatomy of the Human Shoulder Joint

What Are the Symptoms of RA in the Shoulders?

People with RA who have shoulder involvement will have pain in both shoulders. About 5% of people with RA report shoulder pain within two years, and after 12 years of living with the condition, 96% will have erosive shoulder damage.

Additional shoulder symptoms experienced with RA may include:

• Tenderness and warmth

• Stiffness, especially in the morning upon waking

• Rheumatoid nodules under the skin of the shoulders and arms

• Limited range of motion

• Reduced muscle strength

• Fatigue, fever, or weight loss, resulting from severe shoulder inflammation

• Crepitus—grinding, clicking, or cracking notices of the joints

• Lock-up of the shoulder because the surfaces lining the joint are no longer smooth or slide in certain positions

• Pain aggravated by activity

Shoulder involvement tends to be worse in people who have long-term RA and who are older at the onset of the disease. As shoulder involvement worsens, movement of the shoulder gets harder and there may be significant pain. Night pain is common and makes it harder to sleep.

Does RA Affect One Shoulder or Both?

Because RA is a symmetrical condition—affecting the same joints on both sides of the body—people with shoulder RA often experience pain and swelling in both shoulders at once. Shoulder RA may cause erosion and deformity of the shoulder joints over time.

About the Shoulder Joint

The shoulder is made up of three bones: the humerus (the upper arm bone), the clavicle (collarbone), and the scapula (shoulder blade). There are two joints in the shoulder that help it to move: the acromioclavicular joint and the glenohumeral joint.

The acromioclavicular joint is located where the highest point of the scapula meets the clavicle. The glenohumeral joint is the ball and socket joint between the scapula and humerus.

A combination of muscles and tendons—called the rotator cuff—keeps the arm centered into the shoulder socket. The joints of the shoulder are protected by the synovium, which also lubricates them and makes them easier to move.

Damage to the shoulder joints is often caused by inflammation or injury to the cartilage of the shoulder joint. Cartilage breakdown can affect both the glenohumeral joint and the acromioclavicular joint.

What Causes RA in the Shoulders?

It is not known what causes RA in the shoulders specifically or why some people develop this chronic condition. RA is an autoimmune disease, which means the immune system attacks its own tissues (such as cartilage and ligaments) and softens bone.

Shoulder Conditions Linked to RA

Rheumatoid arthritis has been linked to other shoulder conditions because of chronic inflammation. This includes rotator cuff degeneration and tears, frozen shoulder syndrome, and bursitis.

Rotator Cuff Degeneration

The rotator cuff is a group of four tendons that stabilize the shoulder joint. These tendons connect to four muscles that help to move the shoulder in various directions.

Research shows that people with RA have a higher risk of rotator cuff degeneration and tears. Ongoing RA inflammation can cause the rotator cuff to become damaged.

Related: What Is Rotator Cuff Pain?

Frozen Shoulder Syndrome

Also known as adhesive capsulitis, frozen shoulder is characterized by shoulder pain and stiffness. RA is significantly associated with frozen shoulder, and people with systemic conditions like RA have the highest risk for the condition.

Symptoms will begin gradually and eventually get worse. Over time, frozen shoulder causes shoulder movement to become harder. The condition tends to resolve within three years.

Treatment for frozen shoulder can help resolve symptoms, reduce pain, and improve range of motion and muscle strength in the affected shoulder.

Related: Adhesive Capsulitis Overview

Bursitis

Bursitis causes inflammation of the bursae, the small, fluid-filled sacs found near the joints. Bursitis of the shoulder causes painful inflammation of the shoulder joint extending into the upper arm.

Bursitis pain increases with movement, especially with lifting the arms above the head. RA is known for causing bursitis because of the ongoing inflammation it produces.

Related: Shoulder Bursitis Overview

How Is RA in the Shoulders Diagnosed?

Your healthcare provider can make a diagnosis of shoulder RA by looking at your symptoms, medical history, and overall health.

Your healthcare provider will also perform a physical examination, which will look for:

• Signs of a previous injury, including to the muscles, tendons, and ligaments around the joint

• Weakness of the shoulder muscle

• Pain when pressure is applied to the joint

• Involvement of other joints

• A grating sound when the joint is moving

• Tenderness

• Diminished range of motion

Your healthcare provider will also order X-rays to look for narrowing of the joint space, changes to bone, and the formation of bone spurs.

Another method of diagnosis involves injecting a local anesthetic to the shoulder joint. If the injection helps relieve pain, then a diagnosis of RA in the shoulder joint can be made.

How Is RA in the Shoulders Treated?

Your healthcare provider will treat RA-related shoulder problems first by managing the source of them, which is ongoing inflammation. This might mean changes to your RA treatment plan.

Shoulder symptoms will also be treated separately. Treatment for shoulder RA may include:

• Range of motion exercise

• Pain control

• Lifestyle modifications

• Surgery

Range of Motion Exercise

Treatment for shoulder RA often starts with range of motion exercises to keep your shoulder mobile. If range of motion has not been affected, the goal will be to prevent things from getting worse. Physical therapy can help teach you exercises to strengthen your shoulders and improve range of motion.

A physical therapist will give you guidelines regarding how long you should do the range of motion exercises each day.

Assistive Devices

Your physical or occupational therapist may suggest assistive devices to help you with tasks that have become harder. One popular device is a reacher, which helps you to remove and replace objects from high places without having to lift your arm. There are also assistive devices that can help you get dressed, such as zipper pulls and dressing sticks.

Pain Control

Pain control can be done in several ways.

• Ice packs. These are great for managing pain and can be used as needed. You should always place a towel between your shoulder and the ice. Try applying the ice pack for 20 to 30 minutes at a time, two to three times a day.

• Heating pads. These can also help treat shoulder pain and relax pain and stiffness in the shoulder. You can use a hot water bottle, a heating pad set on low, or a warm, moist towel applied for 15 to 20 minutes.

Related: When to Use Heat and When to Use Cold

• Medications. Medications available over-the-counter (OTC) or prescribed by your healthcare provider may be used to control pain. OTC medications may include acetaminophen (Tylenol) or ibuprofen (such as Advil, Motrin). You should discuss with your provider all the benefits and potential complications of medications you are using to manage shoulder pain.

• Injections. Your healthcare provider may recommend injections to offer pain relief for shoulder RA. There are two types of injections that are used to treat shoulder RA. The first type is a cortisone shot. It is given directly into the shoulder joint and can offer pain relief and reduce inflammation. Another type of injection for treating shoulder RA contains hyaluronic acid— a substance similar to the one that occurs naturally in the joints. Hyaluronic acid works by acting like a lubricant and shock absorber to keep the joints moving properly. A hyaluronic injection can improve pain for weeks or even months.

Related: Intra-Articular Injections to Treat Joint Disorders

Lifestyle Modifications

Your healthcare provider may suggest you avoid or cut off activities that make your shoulder painful, especially if the pain is affecting you on a daily basis or keeps you up at night.

For example, if you play a sport that requires shoulder and arm movement, you may want to stop doing it or cut down on how often you play that sport. Or if your job requires lifting, you may want to ask your employer for light-duty where you are not doing as much lifting or carrying of heavy objects.

Surgery

Although it's used as a last resort, surgery might be needed for people who don’t respond to nonsurgical therapies. Surgical options may include:

• Arthroscopy: The doctor inserts a small camera, called an arthroscope, into the shoulder joint. Using very small surgical instruments, they remove inflamed synovium or other debris. Although the procedure provides pain relief, further surgery may be needed in the future.

• Shoulder joint replacement: Also called arthroplasty, this procedure removes damaged parts of the shoulder and replaces them with artificial components, called a prosthesis. Just the head of the humerus might be replaced or both the head of the humerus and the glenoid may be replaced.

• Shoulder arthrodesis: This procedure fuses the affected areas of the shoulder joint with a metal plate and screws or a bone graft. Of the surgical options, it is considered a last resort.
  

Summary

People with RA can develop shoulder tenderness and swelling as early as two years after diagnosis. Shoulder RA is caused by the immune system attacking the lining of joints, including the shoulder. Symptoms may include pain, joint stiffness, reduced range of motion, and crepitus (grinding, clicking, or cracking in the shoulder joint).

Treatment options for shoulder RA include range of motion exercises, pain control, lifestyle modifications, and surgery (as a last resort). Talk to your healthcare provider if you have rheumatoid arthritis and start to develop shoulder pain or other shoulder symptoms. Since these symptoms can get worse with time, you shouldn’t ignore them. Your practitioner can order imaging and bloodwork to help determine the source of shoulder pain and symptoms.

Read Next: Causes of Shoulder Pain and Treatment Options

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