The cause of shoulder pain is a broad and complicated discussion. Or is it?
A diagnosis of 'shoulder pain' covers a broad list of aches, pains, and injuries. And it can be easy to feel overwhelmed by the seemingly endless list of predisposing factors, special tests, and individual rehab protocols.
Terms such as shoulder impingement, subacromial bursitis, rotator cuff tear, frozen shoulder, biceps tendonitis, labral tear, shoulder arthritis, etc, are all becoming more widely recognized and understood by the general public. And they should be considering shoulder pain affects between 16% - 26% of all people.
Yet despite this, it's easy to feel like your specific shoulder pain is a complicated issue to solve. It becomes even more difficult if you don't have a clear understanding of its cause.
But from what I find clinically as a Physiotherapist, the cause of shoulder pain may not be as complicated as it appears. And I'd like to discuss why it's not just the shoulder we should be thinking about.
Shoulder Pain is a Consequence of Something Else
The shoulder joint is an amazing piece of human machinery. As the attachment of the arm to our trunk, it holds a special role. It needs to be strong and stable for force transfer and movement. It also needs to be mobile enough for us to express huge amounts of motion at the same time.
But in order to do this, the shoulder needs help from other areas of the body. Many of the muscles that control shoulder motion anchor somewhere else.
Muscles like the trapezius physically connect the head, neck, and upper back to the shoulder.
The shoulder joint itself sits on top of the scapula which glides across the upper back as needed. However, we often neglect this broader context when talking about the cause of shoulder pain.
Instead of thinking about shoulder pain as just a problem with the shoulder, we need to think of it as another joint of consequence - just like the knee.
The shoulder doesn't function in isolation from the rest of your body. It functions as just one part of a broader machine - the human body.
And it's this lack of context that makes it hard to appreciate the overall cause of shoulder pain. It also becomes much harder to fix on your own if you're not working with all the relevant information.
What is the Cause of Shoulder Pain?
From my experience as a Physiotherapist, I've come to understand the following about the cause of shoulder pain:
The moment you noticed your shoulder pain - whether gradual or sudden, is usually the last straw not the start of something new. The onset of pain is just the point you finally breached its threshold of tolerance. It was coping until it couldn't.
Shoulder pain is a signal for you to figure out what set it up to fail in the first place. Otherwise, your pain may go away but you haven't truly solved the issue long-term.
Clinically, there are some key areas that will force a change in our shoulder mechanics if they become dysfunctional. This can open us up for shoulder pain and dysfunction over time.
But, What About Traumatic Shoulder Injuries and Sports Injuries?
And before we discuss what these are I just want to quickly touch on something. I want to explain how this thinking relates to acute, sudden, or traumatic shoulder injuries. This is important as it's a common question that pops up clinically, and I'd like you to have this in the back of your mind during our deep dive.
On the surface, things like sporting accidents, falls, etc don't seem to fit this narrative. There's an element of bad luck that makes it hard to tie to poor mechanics. Interestingly, I find the very same idea still applies.
Yes, there's a level of trauma that will damage even the strongest and most robust shoulder. But this level of force is (thankfully) not all that common in most traumatic shoulder injuries. Instead, I find the quality of a person's shoulder mechanics pre-trauma has a strong say in whether they tolerate the accident or succumb to it.
In essence, the cause of shoulder pain in a traumatic setting is more than just the trauma itself. It's a stress-test for vulnerable mechanics.
For example, consider being tackled and having the point of your shoulder driven into the ground. There's a chance you may injure your AC joint or even break your collar bone. Traditionally, we see the accident as an acceptable explanation for why you injured your shoulder. It makes perfect sense.
However, some of the hidden features mentioned below may rob your tissue of its ability to buffer that trauma and come out unscathed. In short, accidental injury may have less to do with bad luck than we first think. It may have more to do with how well your shoulder was functioning long before getting tackled.
So let's finally look at some of the hidden features that might be setting your shoulder up to fail.
The Upper Back
Upper back dysfunction is by far and away the most missed component of any shoulder injury. And I genuinely mean this. It's amazing how much shoulder pain is a direct compensation for thoracic joint stiffness, rib joint stiffness, and upper back muscle tightness.
Dysfunction here is important for two reasons:
- The shoulder and shoulder blade literally sit on top of the upper back. We require perfect function here to express perfect shoulder function.
- Stiffness and tightness usually doesn't hurt. So we often aren't made aware of this relatively hidden dysfunction, just its consequences.
These two features mean that it's easy to miss (and misunderstand) why your shoulder has become sore. Unless you know what to look for.
Mechanically, a rusty and tight upper back changes the way the entire shoulder girdle is positioned and used. This often leads to a shoulder that feels hard to 'pull back' into a good shoulder posture. Interestingly, many put this feeling down to a lack of scapular muscle strength. However, from what I find clinically, this apparent decrease in muscle activation is a direct consequence of restrictions back there.
And it's easy to figure this out for yourself. By freeing up the upper back we can see how much easier it feels to pull those shoulders back into a good position.
Upper back stiffness can change how we load our shoulders. This can leave us open to literally any and all shoulder pain - both traumatic and gradual. You can't expect your shoulder tissue to buffer bad loading and mechanics forever. And whether it's sudden or gradual pain, there's usually some hidden underlying upper back dysfunction there pulling the strings.
Test For Upper Back Mobility:
As Physiotherapists, we'd usually ask you to sit down, cross your arms across your chest, and rotate left and right. Stiffness in the thoracic spine is usually exposed with rotational movements. However, I'd like to show you something far more specific and ultimately more effective at figuring out exactly what's going on. It'll give you a clear understanding of how thoracic stiffness is specifically contributing to your shoulder dysfunction.
First, lift both arms up above your head taking special care not to let your back arch as you do so. Take note of how far both go and how it feels to do so. Does it hurt? Do you feel stiff or tight anywhere? Does one go further?
Next, take a tennis ball or lacrosse ball and lie down. Gently let the ball press into areas of your upper back (see the video below).
The aim is to hunt around for any feelings of stiffness and tightness - that may or may not be tender. This basically mimics how a therapist might feel for motion (or lack thereof) in these areas.
Better still, you can immediately see the impact of these stiff areas by freeing them up and then re-assessing your original shoulder movement. Any change will be obvious.
Exercise to rectify: Lacrosse Ball Mobility Exercise
Here's an in-depth video on how to use a ball to explore and self-treat any hidden upper back dysfunction.
Now, the connection between the chest and shoulder pain is more widely understood. We often see tight chest muscles "pulling the shoulders forward" into bad positions creating the potential for dysfunction.
However, based on what I'm finding clinically, the root cause of chest muscle tightness might actually be the very same upper back and ribcage stiffness mentioned above. In short, the chest muscles anchor to the front of the ribcage. They can tighten if things get stiff and overloaded at the back. Furthermore, I'm finding this upper back stiffness is caused by poor resting shoulder postures, not the other way round.
Basically, not only can upper back stiffness and tightness set the shoulder up to fail from behind, but it can cause some potentual havoc from the front as well.
Exercise to rectify:
- Thoracic Ball Mobility Exercise (Above)
- PNF Chest Stretching
Due to its close proximity to the shoulder, the neck also has the potential to contribute to the cause of shoulder pain.
As mentioned before, muscles like the upper traps and others like the levator scapula (below) connect from the neck to the shoulder blade. And much like our chest muscles, they can tighten if the areas they anchor to become overloaded and stiff.
Further to this, the neck houses the nerves that supply much of the shoulder skin and musculature. This makes referred pain and dysfunction more common than we realize.
Below is an image of the distribution of our neck dermatomes. These are essentially referral patterns. They can be very useful to highlight whether your shoulder pain is actually coming from your neck.
If turning your neck reproduces your shoulder pain it could be a neck joint issue. It could even be a first rib issue. Either way, you won't know until you look for it.
Exercise to rectify: Neck Mobility with a Ball
Shoulder Internal Rotation
It may sound strange to suggest one aspect of your shoulder is responsible for another part becoming sore. But clinically, internal shoulder rotation is hugely important.
Unfortunately, our tendency to slouch and drop our shoulders down and forward directly sacrifices this capacity over time. The tissue at the back of the shoulder can adaptively tighten and stiffen as a result. This restriction can then limit our ability to internally rotate the shoulder.
However, we need this internal rotation to express normal shoulder motion. And a lack of this forces the shoulder complex to compensate by dumping forward (as per the video below). This sets the shoulder up for any number of injuries and dysfunctions.
Whether you have a biceps tendon injury, rotator cuff tear, subluxation of the shoulder, etc, poor internal rotation changes the way the entire shoulder moves and is used. And addressing it will go a long way to allowing your painful shoulder tissue to recover as efficiently and permanently as possible.
Exercise to rectify: Internal Rotation Stretches
This hopefully goes without saying, but your shoulder postural habits are almost the most important governing feature of almost all shoulder pain and dysfunction. It also has such a strong correlation to your ability to buffer accidents and trauma.
If you're looking for the true underlying cause of basically everything mentioned here, you have to pay attention to your daily positions and postures. It's certainly a boring conversation. But it's a necessary one if you want to fully understand what may have secretly robbed you of your healthy function over time.
By allowing your shoulders to drop and slouch forward, you unknowingly increase the load under gravity of basically everything. The neck, the upper back, the posterior shoulder tissue, and posterior shoulder capsule, etc all will adaptively change over time to meet that increased loading demand. Interestingly, these are the very same issues that, when dysfunctional, force the shoulder to compensate and potentially get sore.
Exercise to rectify: Practice Better Postures
How to Best Treat Your Shoulder Pain Once It's There
As with any pain, the best way to treat your shoulder should be highly individualized. However, there are some essential basics to lay the foundation for optimal recovery.
Improve Your Broader Shoulder Mechanics
As mentioned above, any long-term solution must involve improving how your shoulder functions as a whole. If upper back stiffness, neck tightness, and sub-par postural awareness were the hidden cause of your shoulder pain, we have to take the time to rectify these issues if we want to give that shoulder the best chance of success.
Better still, restoring normal function to the area will give any irritated or injured tissue a chance to settle. This provides a healthier environment for those more specific treatments.
Feed Slack to the Tissue Around Your Shoulder Pain
We know that uncovering and changing your broader hidden handbrakes is important. And so is going after the more local tissue restrictions as well. The tissue around your pain is also likely to have become dysfunctional. As a result, it can also contribute to your shoulder pain in some way.
Take a tennis ball or lacrosse ball and explore how the rotator cuff muscles on the back of the scapula feel. Look through the rear deltoid area as well. Check on those chest muscles closer to the shoulder too. They're often tight and caught up in the whole pain and injury process. Releasing these areas could provide you with some vital mechanical relief.
Avoid Using Ice and The RICE Protocol
This next sentence may sound incredibly weird coming from a Physiotherapist. But, seriously consider avoiding ice (and the RICE protocol) for shoulder pain. It may literally be doing the opposite of what you're hoping for and slowing down your recovery.
Despite being the poster child for injury management over the last 50 years, there's a real misunderstanding between why we use ice, what ice does to injured tissue, and what we actually need the body to do for optimal healing and recovery. Yes, we use ice in an attempt to reduce pain, swelling, and inflammation. However, these are not only normal processes but vital for optimal tissue healing.
We promote rest and immobilization despite the body needing movement to flush out accumulated swelling and promote optimal tissue regeneration and remodeling.
Furthermore, RICE dictates we use compression to limit swelling coming into the area. Yet it also limits optimal fluid and waste removal.
And finally, we nobly elevate to promote swelling removal. But this same action impedes crucial blood flow back to the same area. This blood carries the required cells and nutrients to support the healing process.
We do all this with the best intentions of course. But hopefully, you can appreciate that we might actually be getting in the way of a speedy recovery - not facilitating one.
Encourage Respectful Pain-Free Movement
With question marks over our use of ice in pain and injury management, we need other alternatives. One of these is respectful, pain-free movement.
We know the body is wired for movement. And one of the benefits of this is it helps with pain and swelling management. If your shoulder pain won't allow you to move far, that's OK. You need to do what you can. Can't move at all? At the very least obsessively tense and relax as many muscles surrounding the area as possible.
Figure out your comfortable threshold for movement and activity and build as your shoulder pain allows. Too much movement may cause extra pain, swelling, and inflammation. Too little won't facilitate optimal progress and may result in extra stiffness, tightness, and also pain. A quick conversation with your Physiotherapist (Physical Therapist) might help you figure this out if you're unsure.
Improve Your Shoulder and Shoulder Blade Muscle Strength
This one probably sounds obvious, but it's important to strengthen your individual shoulder and scapula muscles. Furthermore, it's even more important to strengthen them in context. We need them to work together, not just in isolation. After all, it's how the body works - as a functional unit, not individual muscles.
As a general rule, make sure you are improving the individual and functional strength of the following muscles:
- Rotator Cuff
- Scapular Stabilizers
- Upper Traps
- Core muscles of the neck and back
It's important to note there will always be a level of strength training appropriate for you.
Much like the upper back and neck mobility exercises, sometimes it helps to target relatively peripheral areas like the scapula and core muscles first before going after the rotator cuff. This may again help improve the way you load your specific shoulder injury making things easier in the process.
Shoulder and Shoulder Blade Taping
If you are struggling to make an impact on your shoulder pain, consider some rigid sports tape. The right technique can respectfully force things a little. A great one to try is postural taping. This can potentially unload the shoulder and everything around it giving any stiff, tight, tender, and overloaded tissue a break.
Shoulder taping can also be a great stop-gap option while your corrective mobility and strength exercises take effect.
Frequently Asked Questions
The cause of shoulder pain isn't as mysterious as it might seem. Aside from the more obvious, acutely traumatic shoulder injuries, most shoulder pain is the end result of a breakdown in the way the shoulder is supposed to move over time. The moment many feel their pain or injury is rarely the start of something brand new. It's often the last straw of something bubbling away behind the scenes for weeks, months, or years. Common root causes of shoulder pain include upper back stiffness, neck dysfunction and less than perfect postural habits.
The secret to quickly fixing shoulder pain relies on treating any specific symptoms and also identifying and correcting the reasons for that shoulder pain in the first place. As mentioned in this article, the root issues are often missed despite being crucial factors in the onset and persistence of most shoulder aches and pains.
Common effective treatments include mobilizing any upper back and neck joint stiffness, postural correction, shoulder and scapular muscle strengthening and natural pain-relieving techniques
The best exercise for shoulder pain can be varied based on the specific cause of someone's pain. However, despite the breadth of different issues that can go wrong with the shoulder, there are often some common root issues that connect them together. Therefore, creating one generic "best" exercise to treat most, if not all shoulder pain may not be as difficult as first thought.
Easily one of the most common root causes of shoulder pain is upper back stiffness. So when defining what the best exercise for shoulder pain might be, the lacrosse ball mobility exercise (see above) has to be up there.
As you can hopefully appreciate, most shoulder pain is often a consequence of something else. The onset of pain and injury is often the moment specific tissue could no longer tolerate broader mechanical issues. So it's important to take a step back and consider what these issues might be.
Whether it's upper back and neck joint stiffness, surrounding muscle weakness, a lack of shoulder internal rotation, or your everyday postural habits and shapes, we have to think of our shoulder pain as just one piece of a broader mechanical puzzle. It's just often hard to appreciate these relatively hidden factors if you aren't looking for them. So please start looking for them.
Ultimately, a slight shift in perspective could provide you with an array of very simple solutions to what may have felt like an insurmountable obstacle. And as these change, you'll hopefully appreciate what the hidden cause of your shoulder pain might be. You might also be pleasantly surprised at how much influence they could be having over your shoulder pain.
If you'd like some more helpful tips and tricks to conquer your shoulder pain, please head over to the Your Wellness Nerd YouTube channel for more like the video below!