Shoulder Pain


Shoulder Pain, What is it?

Shoulder pain is a common thing. The shoulder joint is complex.  Not only is it a multi-directional joint, but it is also a compact joint where numerous muscles, tendons, ligaments, bones, and nerves pass through and allow movement and stabilize the joint. Shoulder pain can have many causes, so to understand shoulder pain, a basic understanding of the shoulder anatomy is important.

Shoulder Pain

The shoulder joint has three main bones called the humerus (upper arm), scapula (shoulder blade), and the clavicle (collarbone).

The upper arm bone is rounded and fits tightly into a concave space of the scapula which creates a ball and socket joint. A ball and socket joint allows for a lot of movement in all directions. As part of the socket, a structure of cartilage called the labrum, helps hold the bones together tightly enough to stabilize, but not so tight that movement is restricted.

While movement is necessary, so is stability.  Stability of the shoulder joint is important to the overall health of the joint.  Even minor changes in the shoulder dynamics can cause pain and irritation, and if not properly treated, can lead to more serious shoulder conditions.

In addition to the bony and cartilage structures of the shoulder, muscles, tendons, and ligaments assist with mobility and stability.  “Rotator cuff” is the name for four muscles that are responsible for movement and control of the humerus.  These muscles originate on the scapula and narrow down to tendons which attach around the rounded part of the arm bone.  Three of the muscles are named for their location on the scapula: supraspinatus, infraspinatus, subscapularis, and a fourth is called the teres minor.  While they are involved in rotation of the shoulder, their main job is to roll and slide the humeral head to enable elevation of the arm above the head.

The fibrous tissue that makes up the rotator cuff, along with the compact structure of the shoulder, is what makes this group of muscles susceptible to injury. With the movement of the shoulder, shearing and compressing forces can cause wear and tear on the tissue.

One structure which cushions the shoulder and limits wear and tear of the rotator cuff is called the bursa.  A fluid-filled sac, the bursa helps protect the rotator cuff from such shearing and compressive forces. However, due to the nature of the shoulder joint, when one structure breaks down there is a higher likelihood of other surrounding tissue in the area to be affected. For example, if the bursa starts to break down or become inflamed, which is called bursitis, this can impact the health of the rotator cuff.

No matter where the breakdown or irritation has occurred – in the tissue or within the bone structure – a consultation with a medical professional like a physical therapist (PT) is a great place to start. A comprehensive evaluation performed by a PT will help determine the structures involved and how the relationships between those structures of the shoulder may be contributing to pain and limited function. Managing your shoulder symptoms early on is key to a healthy shoulder.

What causes shoulder pain?

There are multiple potential causes of shoulder pain. A thorough examination of the shoulder will reveal whether the pain is coming from the joint, muscles, tendons, or ligaments of the shoulder, or if it may be originating from somewhere else.

While pain may be felt in the shoulder, sometimes the source is someplace else, and then it is known as referred pain.  The cervical spine can refer pain to the shoulder, and some internal organs can do so as well.  Some special tests performed by the PT can help determine if the pain is referred.  If the PT is concerned that the findings are beyond the treatment scope of physical therapy or require additional medical assessment, the PT will communicate with the patient’s medical providers and refer the patient to the medical team for further investigation.

Many conditions can cause shoulder pain. While this list does not include every possible condition, it does name some of the more common causes.

  • Arthritis
  • Broken, or fractured, bone
  • Bursitis
  • Cervical radiculopathy
  • Collarbone fracture
  • Dislocated shoulder
  • Frozen shoulder
  • Humerus fracture
  • Impingement
  • Instability: muscle imbalance and weakness
  • Labral tear
  • Rotator cuff tear or injury
  • Separated shoulder
  • Sprains of ligaments
  • Strains of muscles
  • Tendinitis
  • Tendon rupture
  • Torn cartilage

There are few less common causes of shoulder pain, including:

  • Infection
  • Nerve injury involving the brachial plexus
  • Tumor

Symptoms of Shoulder Pain

Shoulder pain symptoms can vary from a dull ache to sharp, piercing pain. Since the shoulder is a complex joint, understanding the type, location, and onset of symptoms is important when establishing the primary cause and plan to resolve shoulder pain.

When symptoms impact daily activities including sleep, work, and hobbies – or if symptoms are worsening – it becomes important to consult with a PT for a comprehensive evaluation and development of a treatment plan based on clinical findings and history. Appropriate treatment begins with the understanding of what is causing the pain symptoms.

How is shoulder pain is diagnosed?

A physical therapist or primary care physician is a good place to begin.  PT’s are the musculoskeletal experts and have advanced degrees and skills in evaluating and treating conditions related to bones, joints, muscles, ligaments, and nerves, and do so without expensive imaging.   They are professionals within the medical community who are exceptionally well-trained to complete a full shoulder exam to determine the primary cause and establish a proper plan.

The examination and assessment process begins with discussing the patient’s medical history along with performing a physical exam of the shoulder, neck, and possibly the chest wall area. The medical professional needs to rule out referred pain or any other significant medical causes.

A physical therapist will look for swelling, tenderness, discoloration, or deformities.  Posture and movement patterns will be assessed.  He or she will also evaluate shoulder muscle strength, weakness, and instability. Additionally, the physical therapist will complete several special shoulder examination tests to rule out, or rule in, any specific cause of the shoulder pain.  If the PT has concerns that there is a more serious condition or the shoulder pain requires further treatment beyond that which the PT can treat, the PT will refer the patient to a medical provider, which may include an orthopedic specialist.

If you seek care from a primary care physician or orthopedist first, they also can assess the shoulder.  The physician may wish to include imaging, such as an X-Ray or magnetic resonance image (MRI), depending on their findings. The X-Ray will provide pictures of the bones within the shoulder joint, and identifies arthritic changes and fractures well.  MRI will provide different views of the joint, and shows surrounding muscles, tendons, and ligaments that cannot be seen on X-rays. The medical provider may use the findings on the images to help determine causes of pain or contributing factors, although it should be noted that some findings on imaging are “incidental,” meaning they are present but do not appear to be relevant.   The treatment plan developed by the physical therapist or physician will include the patient’s input and goals.

Treatment of Shoulder Pain

Treatment will vary widely depending on the cause of shoulder pain. In the situation where referred pain is ruled out, and the causes are determined, it is then when a customized treatment plan can begin.

In an acute phase of shoulder pain, meaning within 24-48 hours of onset, ice and rest are encouraged:

  • Rest the shoulder from any major activities. Limit use of the shoulder for 48 hours.
  • Ice the shoulder to reduce swelling and to help reduce pain symptoms. The skin needs to be protected from frostbite, and ice should be limited to 10-15 minutes’ time for application.

Pain should not be increasing during this time.  If symptoms persist for more than 48 hours or if pain worsens, medical attention is appropriate.  If there has been trauma to the shoulder, such as a fall or accident, medical attention may be needed quickly to rule out fracture or other injury.

Beyond the acute phase, the most conservative approach is physical therapy. Based on the examination, the physical therapist will establish a treatment plan to include an exercise program, among other treatment strategies deemed to be most appropriate to the condition.  By addressing the primary cause of the shoulder pain, pain is reduced, symptoms are improved, and function is restored.

In more severe cases, medications or injections may be included by a physician in the treatment plan to manage symptoms.   In some situations, surgery may be needed. Conservative treatment for most patients with shoulder pain is the treatment of choice, but occasionally, patients may require further treatment or surgery.   Physical therapy will likely be part of a post-injection or post-operative treatment plan as well, to maximize the patient’s function and achieve a return to previous functional levels.

Next Steps

Patients should seek out medical attention if shoulder pain is persistent, worsens, or is impacting daily activities such as work, hobbies, or sleep.  Early intervention leads to better success and faster recovery.

Find A Clinic will help identify a PT that has excellent outcomes in treating neck pain including cervical radiculopathy.

In all states, patients can see a PT first, without a physician’s order. However, each state has different guidelines for this.  More information on direct access can be found on the American Physical Therapy Association’s webpage Physical Therapy Direct Access By State.


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