Shoulder Pain

Shoulder pain can be referred from the neck and muscles around the neck. This section is referring to pain produced directly by the shoulder complex, this includes the shoulder joints (glenohumeral, acromioclavicular and coracoclavicular) and the muscles that control shoulder movement (mainly rotator cuff, deltoids, pecs & lats). The most common causes of shoulder pain include muscle trigger points, biceps tendonitis, shoulder impingement & frozen shoulder. Below is a brief outline of these conditions and what can be done about them.

Muscle trigger points: So the simplest cause and easiest to correct is tight knots called trigger points in one or more of the muscles around the shoulder. The pec muscles both major & minor are important areas to check as excessive tightness in these will protract (rotate forward) the humerus (upper arm bone) in the shoulder joint. This in turn will make the muscles above and behind the shoulder joint (rotator cuff muscles) work harder to stabilise the shoulder during movement leading to them developing trigger points and possibly even strains if they are exposed to that sort of stress over many years (rotator cuff disease) or after a major traumatic event such as a fall onto an outstretched arm.

What can we do? Thoracic spine mobility is vital for good shoulder movement so manipulation/mobilisation of the thoracic spine will help along with soft tissue work to the muscles around the shoulder joint such as trigger point therapy, acupuncture, stretching and/or IASTM. We can also give you a more specific set of exercises for your problem or you can follow the generic list below.

What can you do yourself? Look at the stretches on this page and also the neck pain page, they are all of potential benefit in the average shoulder complaint. Strengthening the rotator cuff is a common recommendation but I would suggest that the first things to get right are improving thoracic spine mobility and improving the stability/control of the shoulder blades (scapula) since they should provide a solid base before the rotator cuff muscles can function properly. For any recent injury that is worse when you are resting/first thing in the morning/at night then apply ice 10 mins at a time a few times a day.

What does the evidence say? The Bronfort report is one of the largest systematic reviews ever commissioned on the effectiveness of manual therapy. It supports the use of manipulation/mobilisation and massage. Unfortunately NICE do not have any guidelines at present for the treatment of shoulder pain.

Shoulder Impingement Syndrome: Several nerves, tendons and blood vessels must pass through the shoulder joint on their way to supply the arm with their goodies. Significant degeneration or malposition of the humerus within the shoulder joint can “pinch” any or all of these delicate structures leading to symptoms like pain, numbness, weakness & tingling. If the impingement on these structures is in the shoulder joint (usually under the acromion process) then the generic term shoulder impingement syndrome is applied. Biceps tendonitis is one of the more common symptoms of shoulder impingement syndrome.

What can we do? As with muscle trigger points, manipulation/mobilisation of the thoracic spine will help as will soft tissue work to the associated muscle trigger points. The success of manual therapy for shoulder impingement will depend on the degree of degeneration of the joints. If there is no joint space left then injections or even surgery may be the best option. However in most cases there is more than enough joint space left it just takes a few treatments (usually 6-12) and some home stretching (mostly pecs) to get the shoulder functioning properly again. Rocktape can also help maintain the benefits between treatments.

What can you do for yourself? You need to do the stretches you are advised to do regularly and try and reduce your aggravating factors. Also use ice regularly for 10 mins at a time to reduce the pain of inflammation.

What does the evidence say? A recent review of over 30 randomised controlled trials (RCT’s) involving over 2000 patients suggests that exercise in combination with other treatments such as manual therapy, acupuncture, kinesiotaping and steroid injections is more effective than any such treatments on their own.

Frozen Shoulder/Adhesive capsulitis: Rotator cuff disease and shoulder impingement are often misdiagnosed as frozen shoulder so the first thing to do if you think you might have frozen shoulder is get a proper diagnosis from a qualified musculoskeletal expert like a chiropractor. The types of treatment and exercises for frozen shoulder are significantly different to the other shoulder complaints described above so it is important to know the difference!

True frozen shoulder goes through 3 main phases, the first phase is the most painful and is known as the freezing phase due to the progressive stiffening of the shoulder joint over several weeks/months to the point that you can barely lift the arm away from the body (the “frozen” phase). Fortunately the final phase is the “thawing” phase as the pain continues to subside so does the stiffness and movement slowly returns to the shoulder.

The overall process can last years there is no immediate cure but treatment and exercises can help to speed up the process so you are back to normal quicker than without intervention. If you haven’t already you should also get checked for diabetes as a high percentage of frozen shoulder cases are linked to diabetes.

What can we do? Manipulation/mobilisation of the thoracic spine is still worth doing for long term shoulder function but it is less likely to directly help frozen shoulder. If you catch the freezing phase early enough then soft tissue work and mobilisation of the shoulder joint combined with home exercises can help you avoid the full frozen phase. Dietary advice may also be useful depending on the likely cause of frozen shoulder.

What can you do yourself? Home exercises are important especially for full recovery in the thawing phase. In the worst part of the freezing/frozen phases the main home exercise is pendular swings of the arm as there will not be much movement possible for other exercises.

What does the evidence say? There has been a recent cochrane review on frozen shoulder and it concluded that steroid injections were similar in effectiveness and adverse events to manual therapy and exercise. The quality of all the studies on this topic is low though so it is difficult to know what the best treatment combination is at this stage.

General shoulder exercises (not frozen shoulder)

Level 1 – Start with improving flexibility of the neck,shoulders and thoracic spine. The pec stretches and chin tuck/brugger exercises from the neck pain page are just as appropriate for shoulder conditions.

Level 2 – Now its time to start strengthening. The seated row exercise from the neck pain page will help. More specific exercises for the shoulders include;

Wall press ups: Start a short distance from the wall and place your hands on the wall just above elbow height. Keep your shoulders/shoulder blades down throughout the movement and slowly lower your trunk (held like a plank) towards the wall. Using mostly you pectoral (chest) muscles and triceps push through the heel of your hands to bring your body back to standing upright. If you shoulders raise up start again as this exercise is pointless if you don’t keep the shoulders down.

wall press up

Rotator cuff rotations: It is essential to get the scapula in the right position and hold it there before you attempt these so make sure you own the wall press ups/brugger/seated row exercises first. With the shoulder blade held down and flat against the rib cage slowly rotate the shoulder back and forwards against resistance like a band or cable.

shoulder rotations

Please note the plastic snake around your shoulders and 70’s style moustache are optional extras.

Level 3 – To help encourage good scapula positioning and thoracic mobility as well as hip/ankle mobility and better core stability the overhead squat is really the king of general warm up exercises. You need to be at a good level of mobility in the first place however so you should have mastered the previous levels first. Start with a bar/stick held above your head, hands widely spaced. Squat as low as possible without the bar moving forward or your lower back flexing.