Shoulder pain is a common condition and can have a big impact on an individual's daily functioning as well as their ability to work.
Defining shoulder pain can be quite complex since symptoms can be spread to other nearby areas of the shoulder. Shoulder symptoms can be quite diverse and can originate from ranges of pathologies that can be coming from:
glenohumeral joint (shoulder joint)
acromioclavicular joint (collar bone joint near the shoulder)
sternoclavicular joint (collar bone joint near the chest bone)
rotator cuff muscles or other tissue and muscle in the shoulder complex.
Sometimes pain and symptoms can be felt in the shoulder but really coming from your neck or in some cases the visceral organs. It is always important to note that the amount of tissue damage that may be present on scanning does not usually correlate with shoulder pain intensity and sometimes may not be relevant to the symptoms that someone may be experiencing. For example, 20-40% of individuals have no symptoms or pain in the shoulder but when imaged it showed that they had a rotator cuff tear. This shows that sometimes we should not rely strictly on what imaging presents and it may not be 100% reliable.
Prevalence of Shoulder Pain
Prevalence of shoulder pain increases with age and peaks at the age of 50. Shoulder pain is most common in people in their middle age (45 to 65 years old) which may be due to the normal ageing process of shoulder structures such as the rotator cuff. But it is also becoming more common in younger individuals such as those in adolescence (12 to 18 years old). This may be due to the increase in technology use and increased sitting time which causes a defect in posture that may contribute to shoulder pain.
Risk Factors in Developing Shoulder Pain
Like other musculoskeletal conditions, genetics, hormones, smoking, alcohol consumption, comorbidities, being sedentary and sleep disorders may play a role in developing shoulder pain. However, one of the main reasons that someone can develop shoulder pain is due to too much or mal-adaptive load that is applied to the shoulder complex.
Work related risk factors that can lead to shoulder pain is repetitive work in overhead tasks, work that involves high force or vibration and work that involved sustained sitting or standing postures. Other work-related risk factor may include stress, job pressures, social support and job satisfaction.
About 50% of people that get shoulder pain for the first time will resolve in 8 to 12 weeks. But 40% of those individuals can have shoulder pain longer than a year and may be a chronic issue. Many individuals do not get a full resolution of symptoms and some report getting a re-occurrence of pain 1 to 5 years after their first episode.
Poor prognosis of shoulder pain is related to increasing age, female, severe pain, recurrent symptoms and neck pain. Individuals that report a high baseline pain and previous episode of pain usually have an unfavourable outcome. Favourable outcomes with shoulders usually are associated with mild trauma, mild overuse before onset of pain and getting treatment in its early stages of pain.
Treatment Based Model of Shoulder Pain
Recent research has indicated that specific tissue or pathology that may have been diagnosed as causing shoulder pain symptoms with specific treatment to that tissue have been shown to be unsuccessful. For example, if a test indicates that one of the rotor cuff muscles in the shoulder is injured and the therapist just treats that specific muscle, the individual may continue to have symptoms, it is difficult to pinpoint a particular structure that may be causing shoulder pain. Current guidelines suggest to treat the shoulder based on clinical findings during an assessment rather than to diagnose a particular pathology that may be wrong with the shoulder.
With individuals presenting with shoulder pain, it is important the examiner looks at possible reasons that may be contributing to the shoulder pain such as the mid-back structures, shoulder blade, neck structures as well as posture. Initially the physiotherapist will identify aggravating movements, activities or posture that can reproduce your shoulder symptoms and may find alternate ways to perform those movements to reduce your symptoms.
Shoulder Pain and Physiotherapy
The strongest evidence in treating and managing shoulder pain is exercise. Physiotherapists have a great understanding of the shoulder complex and can deal with pain related mechanisms. They can develop great exercise prescriptions to deal with shoulder pain and help individual return to normal function and reducing the their burden of their symptoms.
McClure, P. W., & Michener, L. A. (2015). Staged Approach for Rehabilitation Classification: Shoulder Disorders (STAR-Shoulder). Physical Therapy, 95(5), 791–800. http://doi.org/10.2522/ptj.20140156
Newton PA. Management of Shoulder and Shoulder Girdle Disorders. Maitland's Peripheral Manipulation E-Book: Management of Neuromusculoskeletal Disorders. 2013 Aug 27;2:142.
Lewis JS: Rotator Cuff Tendinopathy / Subacromial Impingement Syndrome: Is it Time for a New Method of Assessment? Br J Sports Med 43:236–241, 259–264, 2009.
Lewis J, McCreesh K, Roy JS, Ginn K. Rotator Cuff Tendinopathy: Navigating The Diagnosis-Management Conundrum. Journal Of Orthopaedic & Sports Physical Therapy. 2015 Nov;45(11):923-37.
Kooijman MK, Swinkels ICS, Leemrijse CJ, de Bakker DH, Veenhof C. National Information Service of Allied Health Care. 2011.
Barrett E. Examining the Role of Thoracic Kyphosis in Shoulder Pain [Phd Thesis]. Limerick: University of Limerick. 2016.
Pope DP, Croft PR, Pritchard CM, Silman AJ. Prevalence of Shoulder Pain in the Community: The Influence of Case Definition. Annals of the Rheumatic Diseases. 1997 May 1;56(5):308-12.
Murphy RJ, Carr AJ. Shoulder Pain. BMJ clinical evidence. 2010;2010.
Pribicevic M. The Epidemiology of Shoulder Pain: A Narrative Review of the Literature. InPain in Perspective 2012. InTech.
Miniaci A, Mascia AT, Salonen DC, Becker EJ. Magnetic resonance imaging of the shoulder in asymptomatic professional baseball pitchers. American Journal of Sports Medicine 2002; 30(1): 66-73.
Connor PM, Banks DM, Tyson AB, Coumas JS, D’Alessandro DF. Magnetic resonance imaging of the asymptomatic shoulder of overhead athletes: a 5-year follow-up study. American Journal of Sports Medicine 2003; 31(5): 724-727.
Djade CD, Porgo TV, Zomahoun HTV, Perrault-Sullivan G, Dionne CE. Incidence of shoulder pain in 40 years old and over and associated factors: A systematic review. Eur J Pain. 2020;24(1):39-50.
Harvie P, Ostlere SJ, Teh J, McNally EG, Clipsham K, Burston BJ, et al. Genetic influences in the aetiology of tears of the rotator cuff. Sibling risk of a full-thickness tear. The Journal of bone and joint surgery British volume. 2004;86:696-700.
Magnusson SP, Hansen M, Langberg H, Miller B, Haraldsson B, Westh EK, et al. The adaptability of tendon to loading differs in men and women. International journal of experimental pathology. 2007;88:237-40.
Baumgarten KM, Gerlach D, Galatz LM, Teefey SA, Middleton WD, Ditsios K, et al. Cigarette smoking increases the risk for rotator cuff tears. Clinical orthopaedics and related research. 2010;468:1534- 41.
Passaretti D, Candela V, Venditto T, Giannicola G, Gumina S. Association between alcohol consumption and rotator cuff tear. Acta orthopaedica. 2015:1-4.
Dunn WR, Kuhn JE, Sanders R, An Q, Baumgarten KM, Bishop JY, et al. Symptoms of pain do not correlate with rotator cuff tear severity: a cross-sectional study of 393 patients with a symptomatic atraumatic full-thickness rotator cuff tear. The Journal of Bone and Joint Surgery. 2014;96:793-800.
Cook JL, Rio E, Lewis JS. Managing tendinopathies. . In: Jull G, Moore A, Falla D, Lewis JS, McCarthy C, Sterling M, editors. Grieve's Modern Musculoskeletal Physiotherapy. 4th ed. London: Elsevier; 2015.
McCreesh K, Lewis J. Continuum model of tendon pathology - where are we now? International journal of experimental pathology. 2013;94:242-7.
Littlewood C, May S, Walters S. Epidemiology of Rotator Cuff Tendinopathy: A Systematic Review. Shoulder & Elbow. 2013 Oct 1;5(4):256-65.