SHOULDER PAIN

What is Shoulder Pain

Shoulder pain is one of the most common musculoskeletal issues, affecting individuals across all age groups. The shoulder joint is a complex structure that provides a wide range of motion, making it particularly susceptible to injury, overuse, and degenerative changes.

The shoulder joint consists of the glenohumeral joint, acromioclavicular joint, scapulothoracic articulation, and associated muscles, tendons, and ligaments. The shoulder joint is a special joint that allows for much mobility. However, the stability is compromised because of the incongruence of the articular surfaces making the joint more prone to injury. 

Prevalence:

Shoulder pain is a common problem with an estimated prevalence of 4% to 26%. (1). A systematic review by Lucas, J et al. reported that the prevalence of shoulder pain varies across global communities with a median of 16%. The occurrence of shoulder pain varies widely with age, gender, physical activity, occupation, underlying medical condition, and several anatomical and biomechanical factors.

What are the risk factor for shoulder pain?

hip pain Risk factor

Non-Modifiable factors

  • Age
  • Gender
  • Family/Genetic predisposition
  • Structural abnormalities
  • Previous injury & Interventions

Systemic risk factor

  • Inflammatory conditions like RA, AS
  • Metabolic disorders (diabetes, gout)
  • Systemic diseases like lupus, chronic kidney disease
  • Bone health- Osteoporosis, AVN

Potentially modifiable

Biomechanical factors

  • Reduced hip range of motion
  • Hip muscle weakness & Imbalance
  • Type, level, and volume of sport high impact sports
  • Repetitive overuse

Lifestyle factors

  • Sedentary lifestyle
  • Smoking (avascular necrosis)
  • Obesity
  • Nutritional deficiency
shoulder pain risk factor

Causes

The hip pain is usually located in one of these three locations- anterior, lateral, or posterior. The specific location of the hip pain often provides valuable clues about its underlying cause.

  • Fractures
  • Dislocations
  • Soft tissue
  • Injuries
  • Contusions or sprains

Shoulder Fractures:

A partial or complete break in the bones that make up the shoulder joint i.e., the clavicle, humerus, and scapula usually occurs when loaded beyond the tolerance/capacity. It can occur due to a fall on an outstretched hand or direct blow to the shoulder, collision injury in sports, or road traffic accidents.

Dislocations

The shoulder joint is highly mobile but lacks stability, making it susceptible to dislocations. In the shoulder, the glenohumeral joint is most often dislocated, but the acromioclavicular joint can also dislocate. 

Shoulder dislocation can occur due to accidents, falls on the outstretched arm, injuries sustained during high-impact sports such as rugby, and repetitive overuse which leads to joint laxity over time.

Soft tissue injuries

Tendinopathies of rotator cuff tendons and biceps brachii tendon occur due to overuse or degeneration that might lead to shoulder pain.

 

Labral tears such as SLAP lesions associated with repetitive overhead activities and Bankart lesions associated with shoulder dislocation can also result in shoulder pain.  

 

Subacromial impingement syndrome caused by the compression of rotator cuff tendons between the acromion process and the humeral head is another common cause of shoulder pain, especially in those who are involved in repetitive overhead activities.

Contusion and sprains

Falls and dislocations result in a sprain or tearing of ligaments of the acromioclavicular joint & glenohumeral joints causing shoulder pain.  Less commonly, the coracoclavicular ligament can also be sprained.

Atraumatic causes

  • Degenerative conditions
  • Inflammatory conditions
  • Overuse syndromes

Degenerative conditions

Shoulder Tendinosis is the degeneration of a tendon in the shoulder due to chronic overuse or aging. It commonly affects the rotator cuff tendons, particularly the supraspinatus tendon, but can involve the infraspinatus or biceps tendon.

Shoulder Osteoarthritis is less common than osteoarthritis of other joints. It is seen in older individuals and more commonly in younger individuals with a history of previous shoulder injury or repetitive overhead activities.

Inflammatory conditions

Rheumatoid arthritis is a systemic autoimmune condition affecting joints all over the body including the shoulder joint. This causes significant pain, swelling, and morning stiffness.

 

Bursitis is the inflammation of the small fluid-filled sacs around the shoulder joint especially the subacromial bursitis.

 

Adhesive capsulitis, otherwise known as Periarthritis shoulder, or frozen shoulder is another common condition contributing to shoulder pain. It occurs due to inflammation of the joint capsule resulting in pain and mobility restriction in the shoulder.

Overuse syndromes

It includes rotator cuff tendinopathy and impingement syndrome which usually occurs because of repetitive overloading of the shoulder muscles especially the rotator cuff muscles beyond their load tolerance. This results in degeneration and inflammation of the tendons over time presenting with symptoms such as pain and functional decline.

How to prevent Shoulder pain?

To prevent shoulder pain, it is necessary to improve the stability and joint mobility in the shoulder.

 

  • Building up muscle strength and improving load tolerance.
  • Avoiding repetitive overload beyond tolerance, especially in overhead activities.
  • Providing adequate rest and recovery.
  • Proper rehabilitation of sports injuries to prevent recurrence.  
  • Involving in regular physical activity and staying healthy.
  • Practicing proper form and techniques during weight lifting, throwing, and overhead activities.
  • Maintaining a healthy weight
  • Treating underlying causes such as diabetes, and arthritis.

What are the treatment option for Shoulder pain?

Shoulder pain can be managed through various treatment strategies, but there is no universal intervention applicable to all shoulder pain conditions. The choice of treatment largely depends on the underlying cause of the pain.

The keystone of effective treatment is a thorough assessment and a detailed understanding of the patient’s needs and goals, enabling the development of a personalized treatment program.

A meta-analysis by Anelise Silveira et al. highlights that exercise therapy is effective in managing shoulder pain, whereas the benefits of adjunct therapies, such as injections, manual therapy, and electrotherapy, remain uncertain.

Potential treatment strategies for managing shoulder pain are outlined below:

Non-surgical Intervention:

Physiotherapy treatment:

 

For acute injuries, the PEACE LOVE protocol is used.

 

PEACE

P- Protect from further injury
E- Elevation
A – Avoid anti-inflammatories

C- Compression
E- Education 

LOVE
L- optimal Loading
O- Optimism
V- Vascularization
E- Exercise for strengthening the shoulder joint

 

Exercise therapy is the mainstay of physiotherapy treatment for shoulder pain. A systemic review by Pieters, Louise et al., highlighted that exercise therapy should be prioritized as a principal intervention in shoulder management. Manual therapy can be used as an adjunct therapy. Other commonly prescribed nonsurgical interventions, such as ultrasound, low-level laser, and extracorporeal shockwave therapy, lack evidence of effectiveness.

Exercises that focus on strengthening the shoulder joint muscles to improve stability and mobility are proven effective. Improving shoulder stability, especially in those involved in frequent overhead activities, is essential for preventing the onset and recurrence of shoulder pain.

Pharmacological treatment:

NSAIDs are used to provide temporary pain relief in extremely painful conditions.

Corticosteroids can provide temporary relief for inflammation-related pain, such as in rotator cuff tendinitis or bursitis

Surgical Intervention:

Surgical interventions are indicated when there is severe structural damage such as displaced fractures, rotator cuff tears, impingement syndromes, or chronic instability that do not respond to conservative treatments.

 

Fracture Fixation is indicated for displaced fractures of the humeral head, clavicle, or scapula. Usually, Internal fixation using plates, screws, or rods is done while in severe cases, replacement with a prosthesis (hemiarthroplasty or TSA) is done.

 

Rotator Cuff Repair is indicated for full-thickness rotator cuff tears causing pain, weakness, or impaired function that do not improve with non-operative treatment.

 

Subacromial Decompression indicated in persistent impingement syndrome despite the physiotherapy treatment.

 

Labral Repair is indicated for labral tears like SLAP lesions, and Bankart lesions that cause shoulder instability which leads to recurrent dislocations or subluxations. It involves arthroscopic reattachment of the torn labrum to the glenoid rim using anchors.

How to Strengthen the shoulder?

Strengthening the shoulder joint involves targeted exercises to enhance the strength of muscles around the shoulder and promote stability.  Since the shoulder is a highly mobile but less stable joint, enhancing stability is important.

However, mobility improvement is necessary in certain cases like periarthritis shoulder. Aim for consistent practice, gradually increasing intensity, and prioritize proper form to prevent injury

What are the exercise for Shoulder Pain?

Exercises to relieve shoulder pain include exercises to improve

  • Overhead mobility
  • Rotator cuff strengthening
  • Shoulder stability 

Given below are a few exercise recommendations.

 

Overhead mobility exercises:

  • Lat stretch in babysitting
  • Lat eccentric with band 
  • T-spine extension

 

Rotator cuff strengthening exercises 

  • Side-lying External rotation
  • Standing ER eccentric
  • Overhead External Rotation
  • Kneeling ER eccentrics
  • Banded ER eccentrics
  • Windmill

 

Shoulder stability exercises

  • Push up
  • Australian pull-ups
  • Face pull
  • Dumbbell bench press
  • Standing shoulder press
  • Lateral raise D/B 

 

Click here to learn more about Physiotherapy exercises for shoulder pain

How do we approach shoulder Injury and Pain

We provide patient-centered care by optimizing the treatment outcomes to align with the patient’s needs and goals. An effective treatment approach starts with a comprehensive assessment.

 

 Comprehensive assessment:

  • History taking (obtaining information about the pain or injury).
  • Spending enough time to listen to the patient (it is very important because half of the diagnosis is made here)
  • Ruling out serious pathology/red flag conditions.
  • Assessing the psychosocial factors- fear of movement, thoughts, and beliefs.
  • Avoiding unnecessary radiological imaging unless required
  1. When serious pathology is suspected or
  2. Poor outcome with conservative management or
  3. Unexplained exacerbation of signs and symptoms
  • Physical examination includes mobility, muscle strength, and neurological examination.
  • Accurate diagnosis is made by clinically correlating the patient’s symptoms and physical examination.

Conclusion:

Shoulder pain is not always a serious problem. With proper treatment and care, most of the individual recover fully. However, it is important to identify the root cause and treat it accordingly. So, it is essential to consult a qualified physiotherapist before beginning any new exercise routine.

At Exercise Prescriptor Clinic, we provide a professional assessment that will help to determine the root cause of your pain and ensure that the given exercises are appropriate and tailored to your specific needs, reducing the risk of further injury or complications.