top of page
banner pic 02_edited.jpg

News & Info

THE PAINFUL SHOULDER

Shoulder pain is the 3rd most common musculoskeletal complaint (behind low back and neck pain). 70% of us will experience at least one episode of shoulder pain in our lifetime. It may resolve on its own within days or weeks, however, up to 70% of individuals will still experience problems at 6 weeks and 40-50% can still experience pain after 1 year.

When determining the course of management for a painful shoulder, taking a thorough subjective history is vital.  This involves gathering information regarding pain severity and behaviour, location and duration of symptoms, symptom onset (sudden or gradual), and what movements and activities provoke. The subjective history provides valuable information and will help determine which relevant objective assessments to perform, or if a specialist referral is required.

shoulder-joint.jpeg

Although serious pathology is rare, it should be screened for.  Serious pathology in the shoulder includes:​

  • Joint infection (fever, systemically unwell, red skin)

  • Fracture or unreduced dislocation (significant trauma, seizure, acute disabling pain)

  • Malignancy (history of cancer, mass, swelling, deformity, unexplained weight loss, constant/night pain)

  • Neurological lesion (unexplained sensory or motor deficits – loss of feeling, numbness, severe weakness)

Once the above have been screened for, it is useful to determine:

back_4615550_edited.png

Is the shoulder stiff?

A clinically stiff shoulder is described as having a significant and equal loss of active range of motion (you can’t move it) and passive range of motion (we can’t move it) beyond 50% of the unaffected side. The most common causes of a clinically stiff shoulder are:

​

  • Advanced osteoarthritis

  • Frozen shoulder

shoulder_6024631_edited.png

Is the pain referring from elsewhere?

The most common non-shoulder source of shoulder pain is referral from the neck 

​

  • does moving the neck provoke / ease shoulder symptoms?

body_13834287_edited.png

Is the shoulder unstable?

Instability refers to a clinical condition in which unwanted translation of the humeral head (top of the arm bone) on the glenoid (shoulder socket) compromises the comfort and function of the shoulder. Broadly speaking, shoulder instability can be the result of:

​

  • Family history / congenital

  • Traumatic injury, history of dislocations 

  • Degenerative structures due to overuse in certain positions

If it is determined the painful shoulder is not truly stiff, is not unstable, and the pain is not referring from elsewhere, we arrive at a classification of shoulder pain known as ‘subacromial shoulder pain’, otherwise known as ‘rotator cuff related shoulder pain’.  These terms are replacing the more traditional diagnosis of ‘subacromial impingement’ as ‘impingement’ implies a mechanism of injury that has been called into question by the recent evidence base.

subacromial-space.jpeg

There are several structures in and around the subacromial space that may contribute to pain.  We will take a closer look at the rotator cuff as it is estimated in the research that up to 80% of individuals who present will have pain and/or pathology related to the rotator cuff. ​

What is the Rotator Cuff?

It is a collection of muscles and tendons in the shoulder:

  • supraspinatus

  • infraspinatus

  • subscapularis

  • teres minor

The rotator cuff assists with moving the arm and adds dynamic control to the shoulder. It is direction specific, meaning different parts of the rotator cuff will work harder depending on the direction the arm moves.​

What-is-the-rotator-cuff.jpeg

Risk factors for developing rotator cuff pain/pathology:

  • overuse

  • underuse

  • occupation – repetitive overhead activity

  • age​

​

  • external rotation strength deficit

  • smoking

  • genetic influences

  • diabetes (for rotator cuff tendinopathy)

Individuals presenting with rotator cuff related shoulder pain will be able to reproduce their pain in a consistent manner.  Commonly, this involves:

  • raising the arm to the side

  • overhead activities 

  • reaching the arm behind the body (when dressing or washing)

  • sleeping on the affected side

Problems with the rotator cuff that may result in pain include:

  • tendinopathy

  • partial or full thickness tears

  • weakness relative to the demands being placed on it

Management of these rotator cuff related conditions will utilise the same rehabilitation principles.  Aspects of rehab that will differ include the starting point of rehab, exercise and load progressions, and the length of time it takes for symptom improvement.  Individuals experiencing a first episode of shoulder pain should factor in approximately 12 weeks to see significant improvement in symptoms.  For degenerative tears or those who have had symptoms over 6 months plus 2 or more episodes of pain, it may take 6 months or more to see significant improvement.

If a rotator cuff tear is suspected there are further tests that can help identify this and imaging may be utilised.  Degenerative tears (that occur over time) usually do well with good rehabilitation and conservative management.  Surgical opinion is more likely warranted with traumatic tears that are associated with a sudden onset of severe pain and weakness.  Generally, imaging is not required for rotator cuff related shoulder pain. Changes seen on scans correlate poorly with pain and abnormalities are found in over 90% of pain free 40-70 year olds.  Changes on imaging, therefore, are often referred to as ‘normal age-related changes’.

Rehabilitation and Exercise Prescription

Exercise-based rehab is recommended as the primary intervention alongside appropriate education.  Some research suggests the addition of manual therapy may help some individuals, whereas other trials have demonstrated manual therapy offers no benefit above exercise therapy alone.

As with all musculoskeletal pain, shoulder pain should be approached from a biopsychosocial perspective (Biological/Psychological/Social - see more on this in our low back pain info page).  Education forms part of the rehab process because understanding your pain can aid recovery. A positive expectation of recovery is associated with better outcomes, whereas catastrophising, unnecessary fear, and ruminating on the pain is associated with worse outcomes. 

The primary goal of rehabilitation is to improve the capacity, function and load tolerance of the rotator cuff and surrounding structures.  Rehab does not need to be complicated and current evidence suggests we do not need to unduly worry about things like:

  • scapula dyskinesis (altered shoulder blade motion)

  • the position of the scapula during exercises (we don’t need to set the scapula ‘down & back’ or fuss over positioning)

  • harmless asymmetries in movement

A good shoulder rehab program should:

  • be personalised

  • focus on individual goals

  • be incrementally progressed

  • involve the kinetic chain (utilise the body, not just the shoulder)

  • include education around pain and advice on how to manage it

  • remove unnecessary or unhelpful fear of movement

  • identify the provoking movement(s) and find ways to modify them to reduce symptoms (in other words, we don’t have to avoid the provoking movements, we modify them and use them as part of rehab in a structured and sensible way).

Movement variables we can modify include:

  • speed of movement

  • range of motion

  • loads used

  • start and end position

​​

  • offering assistance or directional resistance

  • lever arm length

  • context of movement

For a highly irritable shoulder it is advised to begin with low loads and exercises that offer a high level of control.

Examples include:

For a less irritable shoulder we can select a more challenging entry level.  For example:

It is important to note that exercise does not need to be completely pain free. Gently pushing into levels of discomfort that don’t invoke fear or lingering pain can offer benefits to recovery in the longer term. It is therefore helpful to understand the parameters regarding what is, and what is not, acceptable.

Exercise progression will be determined by how you respond and your end goals. End stage rehab will look quite different for an individual looking to get back to playing tennis or swimming multiple times a week, versus someone simply looking to return to pain free everyday activities.

Examples of later stage rehab for individuals returning to higher level sport or dynamic activities include

Shoulder rehabilitation does not need to be complicated and as such also does not require lots of exercise equipment.  Later stage rehab may require access to a gym or training space.  Rehab can be performed face to face as well as online.

The Vitruvian Team.

Comparative effectiveness of treatment options for subacromial shoulder conditions: A systematic review and network meta-analysis

Babatunde et al. Therapeutic Advances in Musculoskeletal Disease. 2021

 

Effects of adding scapula stabilisation exercises to a periscapular strengtheining exercise program in patients with subacromial pain syndrome: A randomised controlled trial

McQuade et al. Physical Therapy. 2016

 

Staged approach for rehabilitation classification: Shoulder disorders (STAR-Shoulder)

Mclure et al. Physical Therapy. 2015

 

Scapular dyskinesis is not an isolated risk factor for shoulder injury in athletes: a systematic review and meta-analysis

Hogan et al. American Journal of Sports Medicine. 2020

 

Shared decision making should be an integral part of physiotherapy practice

Hoffmann et al. Physiotherapy. 2020

 

Diagnosing, managing, and supporting return to work of adults with rotator cuff disorders: A clinical practice guideline

Lafrance et al. Journal of Orthopaedic & Sports Physical Therapy. 2022

 

Is exercise therapy the right treatment for rotator cuff-related shoulder pain?  Uncertainties, theory, and practice

Powell et al. Musculoskeletal Care. 2024

 

Tolerance and effectiveness of eccentric vs concentric muscle strengthening in rotator cuff partial tears and moderate to severe shoulder pain: A randomised pilot study

Macias-Hernandez et al.  Journal of Clinical Orthopaedics and Trauma. 2020

Degenerative Rotator Cuff Tears: Refining Surgical Indications Based on Natural History Data

Keener et al.  JAAOS. 2019

​

What happens to patients when we do not repair their cuff tears? Five-year rotator cuff quality of life index outcomes following non-operative treatment of patients with full-thickness rotator cuff tears.

Boorman et al. Journal of Shoulder and Elbow Surgery. 2017

 

A self-managed single exercise programme versus usual physiotherapy treatment for rotator cuff tendinopathy: a randomised controlled trial (the SELF study)

Littlewood et al. Clinical Rehabilitation. 2016

 

Is there a relationship between subacromial impingement syndrome and scapular orientation? A systematic review

Ratcliffe et al. British Journal of Sports Medicine.  2014

                                                                                                    

Adding manual therapy to an exercise program improves long-term patient outcomes over exercise alone in patients with subacromial shoulder pain: A randomised clinical trial

Michener et al.  Journal of Orthopaedic & Sports Physical Therapy. 2023

 

Effectiveness of combined program of manual therapy and exercise vs exercise only in patients with rotator cuff-related shoulder pain: A systematic review and meta-analysis

Paraskevopoulos et al.  Sports Health. 2023

Next Page>>
bottom of page