Understanding Shoulder Pain and Injuries
Causes, Treatment, and What You Can Do
Robert Inesta
9/20/20269 min read
Shoulder pain is one of the most common musculoskeletal problems I treat in practice. It can develop suddenly after a fall, collision, or heavy lift, or gradually from repetitive activity, sports, posture, or simply years of accumulated stress on the area.
The shoulder is also one of the more complicated regions of the body. Unlike some joints that primarily move in one or two directions, healthy shoulder function depends on multiple joints, muscles, tendons, ligaments, and fascial tissues working together in a highly coordinated way.
This complexity gives the shoulder tremendous mobility. It also creates plenty of opportunity for something to go wrong.
Understanding how these pieces work together can help explain why shoulder pain develops and why effective treatment often requires looking beyond the exact location where it hurts.
Why Is the Shoulder So Vulnerable to Injury?
What we commonly call the "shoulder" actually involves four articulations:
Glenohumeral joint: the primary ball-and-socket joint between the upper arm and shoulder blade
Acromioclavicular (AC) joint: where the shoulder blade meets the collarbone at the top of the shoulder
Sternoclavicular (SC) joint: where the collarbone connects to the sternum
Scapulothoracic articulation: the functional articulation where the shoulder blade glides over the rib cage
The glenohumeral joint is a ball-and-socket joint, but its structure is quite different from the hip.
The hip has a relatively deep bony socket that provides considerable inherent stability. The glenoid, the socket portion of the shoulder, is much shallower. A ring of fibrocartilage called the labrum surrounds it and helps deepen the socket.
One way I like to visualize the shoulder is in layers.
Closest to the joint is the joint capsule, a strong envelope of connective tissue that surrounds and helps stabilize the glenohumeral joint.
Over the capsule are the four rotator cuff muscles:
Supraspinatus
Infraspinatus
Teres minor
Subscapularis
These relatively small muscles perform an enormously important job. In addition to helping create movement, they provide dynamic stability, helping control and center the head of the humerus within the glenoid as the arm moves.
Surrounding these are larger muscles responsible for producing and controlling movement, including the deltoid, pectoralis major, latissimus dorsi and biceps, along with other important muscles such as the pectoralis minor and coracobrachialis.
Then there is the scapula, or shoulder blade, itself.
The scapula must move and stabilize appropriately against the rib cage as the arm moves. Muscles including the trapezius, rhomboids, serratus anterior and levator scapulae help control this process.
All of this has to happen in a coordinated sequence.
Shoulder Health Is About More Than Strength
Imagine reaching overhead.
Your upper arm doesn't simply rotate at one joint. The humerus moves within the glenohumeral joint while the scapula simultaneously rotates and glides along the rib cage. The rotator cuff stabilizes the humeral head while larger muscles generate movement. Meanwhile, the thoracic spine must provide an appropriate foundation for the shoulder blade.
This coordinated relationship is sometimes referred to as scapulohumeral rhythm.
If one part of the system isn't moving or stabilizing well, another area may have to compensate.
That doesn't necessarily cause pain immediately. The body is remarkably adaptable. But repeated thousands of times during work, weight training, throwing, swimming, tennis, hockey or simply everyday life, small mechanical problems can potentially contribute to increased stress and eventually symptoms.
This is one reason I rarely look only at the painful part of a shoulder.
How Shoulder Injuries Happen
Shoulder problems can broadly be divided into acute injuries and repetitive or overuse problems, although there can certainly be overlap.
Acute Shoulder Injuries
These occur suddenly from a specific event.
A fall onto an outstretched arm can injure muscles, tendons, ligaments, the labrum, AC joint or bone. Direct impact to the shoulder can produce an AC joint sprain, contusion, fracture or other injury. Sudden overloading, such as trying to catch or lift something unexpectedly heavy, can strain or tear muscular and tendon tissue.
Sports create their own mechanisms of injury through falls, collisions, tackles and sudden forceful movements.
Significant trauma, deformity, inability to move the arm, sudden substantial weakness, numbness or other concerning symptoms warrant appropriate medical evaluation by a sports medicine physician or orthopedist and sometimes imaging before conservative treatment begins.
Repetitive and Overuse Shoulder Problems
Other shoulder problems seem to appear gradually.
Common contributors can include:
Repetitive overhead activity
Throwing
Racquet sports
Swimming
Repetitive occupational tasks
Weight training
Sudden increases in training volume or intensity
Poor movement patterns
Reduced shoulder or thoracic mobility
Altered scapular control
Muscular or fascial restrictions
Prolonged postural stress
Often there isn't one single cause. Instead, several smaller factors accumulate until the shoulder can no longer comfortably tolerate the demands being placed on it.
Common Causes of Shoulder Pain
"Shoulder pain" is a symptom rather than a diagnosis. Many different structures can generate symptoms in and around the shoulder.
Some of the more common conditions I see include:
Rotator Cuff Strains and Tendinopathy
The rotator cuff is subjected to tremendous repetitive demand, particularly with overhead activities. Irritation can range from mild muscular or tendon overload to more persistent tendinopathy (often referred to as rotator cuff tendinitis) and partial or full-thickness tears.
Muscle Strains
The deltoid, pectoral muscles, biceps, latissimus and other muscles surrounding the shoulder can become strained or overloaded, eventually causing pain.
Subacromial Pain and Bursitis
The tissues around the rotator cuff and subacromial region can become irritated and painful, particularly during elevation of the arm. Historically, many of these problems were broadly labeled "shoulder impingement." We now know that the causes are often more complex than simply one structure mechanically pinching another.
AC Joint Injuries
The acromioclavicular joint at the top of the shoulder can become injured through direct trauma or irritated through repetitive loading and degeneration.
Labral Injuries
The labrum helps deepen and stabilize the shoulder socket. It can be injured through trauma, repetitive throwing or other forces placed on the shoulder.
Arthritis
Degenerative changes can occur within the glenohumeral, AC or, less commonly, sternoclavicular joints. As with many areas of the body, however, the presence of arthritis on an X-ray does not automatically mean it is responsible for someone's pain.
Rotator Cuff Tears
Rotator cuff tears become increasingly common as we age and can range from small partial tears to large full-thickness tears.
Importantly, a tear on an MRI does not automatically mean surgery is necessary or that it is a pain generator.
The significance of a tear depends on many factors: how it occurred, its size and location, strength and function, age, activity demands, symptoms and whether the imaging finding actually corresponds with the clinical presentation.
Frozen Shoulder
Adhesive capsulitis, commonly called frozen shoulder, produces progressive pain and significant restriction in shoulder movement. It can occur after trauma or surgery but can also develop without an obvious cause and is associated with certain metabolic and hormonal factors.
Because frozen shoulder behaves differently from many other shoulder conditions, it deserves a discussion of its own.
An MRI Finding Isn't Always the Same as a Diagnosis
This is an important concept with shoulder pain.
Imaging can be extremely valuable, particularly after significant trauma or when a serious structural injury is suspected. But imaging findings need to be interpreted within the context of the person in front of us.
Structural changes, including rotator cuff tears, can exist in people who have little or no shoulder pain. Conversely, someone can have significant shoulder pain and dysfunction without a dramatic finding on imaging.
Therefore, the question shouldn't simply be "What does the MRI show?"
It should also be, "Does what we're seeing on the MRI actually explain the symptoms and functional limitations?"
That distinction can sometimes make the difference between treating an image and treating a person. Imaging results should be considered in the context of the whole clinical picture.
Treating Shoulder Pain Starts With Figuring Out Why It Hurts
Before treating a shoulder, I want to understand what is actually happening.
That means looking at pain location, range of motion, strength, stability, previous injuries, movement patterns and the activities that aggravate or relieve symptoms. But the evaluation shouldn't necessarily stop at the shoulder.
Look Above and Below the Pain
The cervical and thoracic spine can have a significant influence on shoulder mechanics.
The trapezius connects the shoulder girdle with the cervical and thoracic spine. The latissimus dorsi connects the upper arm with a broad region extending through the thoracic and lumbar spine and pelvis. The scapula itself moves over the rib cage.
If the thoracic spine is excessively stiff or the scapula isn't moving appropriately, the shoulder may have to compensate.
This becomes even more important in athletes.
For a throwing or overhead athlete, I may also evaluate the hips and trunk. A baseball player, tennis player or other rotational athlete generates force through the entire kinetic chain. If adequate motion and force aren't coming from the hips and trunk, the shoulder may be asked to do more work.
The location of the pain therefore isn't always the location of the entire problem.
My Approach to Treating Shoulder Pain
Treatment depends on what I find during the examination. There is no single shoulder protocol that is appropriate for everyone.
In many nonsurgical shoulder problems, I use a combination of hands-on treatment and progressive exercise, with each addressing a different part of the problem.
1. Myofascial Treatment
Restrictions within muscles and fascia can affect movement, produce pain and alter the way forces are distributed through the shoulder.
I use techniques including Stecco Fascial Manipulation® and Active Release Techniques® to identify and treat relevant soft-tissue restrictions rather than simply massaging the area that hurts. My own experience recovering from shoulder surgery and undergoing intensive soft-tissue rehabilitation was actually what first inspired me to make this type of work a major focus of my practice.
Some areas I commonly find involved in shoulder problems include the subscapularis, posterior shoulder tissues, anterior deltoid and pectoral region. However, treatment is based on the individual examination rather than a predetermined list of muscles.
Emerging research is also investigating the role of fascial treatment in shoulder problems. Studies of Fascial Manipulation have reported improvements in pain, function or shoulder range of motion, including research involving people with chronic shoulder pain and overhead athletes with posterior shoulder tightness. These findings are promising, although the research base is still developing and larger controlled studies are needed.
2. Acupuncture and Dry Needling
Acupuncture and dry needling can be useful tools for reducing pain and addressing muscular tension and trigger points around the shoulder.
Depending on the problem, I may use needling to address deeper muscles that are sometimes difficult to treat manually, including portions of the rotator cuff.
The goal isn't simply temporary pain relief. Reducing excessive muscular guarding or sensitivity can also make it easier to restore comfortable movement and begin appropriate rehabilitation.
3. Chiropractic and Joint Mobilization
Sometimes the shoulder isn't the only area that needs to move better.
When appropriate, I use chiropractic adjustments or other mobilization techniques to address restrictions in the thoracic spine and, when clinically indicated, the cervical spine or shoulder girdle.
Improving movement in these areas may give the shoulder a better mechanical environment in which to function.
4. Progressive Exercise
Hands-on treatment can help improve pain and movement, but maintaining and building upon those changes usually requires active rehabilitation.
Early exercise may focus on fundamentals such as:
Restoring comfortable shoulder range of motion
Improving thoracic mobility and extension
Developing scapular control
Strengthening the rotator cuff
Improving trunk and core stability
Readers interested in building some of these basic movement foundations may also find my free 10-Day Basics of Functional Stability and Posture Series helpful.
From there, exercise should become progressively more specific to the individual.
The needs of a 70-year-old who wants to comfortably reach into an overhead cabinet are different from those of a competitive swimmer, hockey player, tennis player or baseball pitcher.
The ultimate goal isn't simply to make the shoulder hurt less.
It is to restore its capacity to handle the demands you place on it.
Why I Often Combine Manual Therapy With Exercise
Exercise is one of our most important tools for treating many nonsurgical shoulder conditions. But in practice, there are times when pain, stiffness or soft-tissue restriction makes it difficult to perform those exercises comfortably or correctly.
That's where hands-on treatment can be particularly useful.
For example, if a shoulder has limited motion because of significant myofascial restriction, addressing some of that restriction first may allow the person to move more comfortably. Exercise can then reinforce the improved movement, build strength and gradually increase the shoulder's capacity.
Rather than thinking of manual treatment and exercise as competing approaches, I often see them as complementary tools.
The research is beginning to support this combined approach as well. In a recent randomized trial involving people with subacromial pain syndrome, both supervised exercise and exercise combined with myofascial release improved several outcomes, while the combined group demonstrated additional improvements in measures of pain, function, range of motion and scapular muscle activity.
What About Surgery?
Some shoulder injuries absolutely require orthopedic evaluation and, in certain circumstances, surgery. But structural damage does not automatically equal surgery.
Age, injury mechanism, functional loss, degree of weakness, size and type of tear, activity requirements, response to conservative care and overall health all matter.
For many shoulder problems, an appropriate trial of conservative treatment can be reasonable before considering more invasive options, provided there are no findings suggesting that more immediate orthopedic intervention is necessary.
The Goal Is to Treat the Shoulder and the Person Attached to It
One of the biggest lessons I've learned from treating shoulder problems is that two people with the same diagnosis can require very different approaches.
One person's shoulder pain may be driven primarily by a local rotator cuff overload. Another may have substantial thoracic stiffness and poor scapular control. An athlete may have adequate shoulder strength but limited hip or trunk mobility that forces the shoulder to absorb excessive stress. Someone else may have an old structural finding on MRI that has very little to do with the pain they're experiencing today.
That's why I believe good shoulder treatment begins with a thorough assessment rather than a predetermined treatment protocol.
Once we understand what is injured, what isn't functioning optimally and what demands the person needs to return to, treatment becomes much more specific.
The shoulder is complicated, but that doesn't mean every shoulder problem needs to become chronic.
With the right combination of treatment, movement and progressive loading, many shoulder conditions can improve substantially and allow people to return to the activities that matter to them.
Struggling With Shoulder Pain?
If shoulder pain or an injury is limiting your movement, exercise, sports, work, or everyday activities, a thorough evaluation can help determine what's contributing to the problem and the best way to address it.
At my Great Barrington practice, I combine myofascial treatment, chiropractic, acupuncture and dry needling, and individualized exercise strategies based on your specific needs.
Contact me to schedule an appointment and start working toward comfortable movement and better function.
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