Shoulder pain can be challenging to live with sometimes. Pain levels can often be high and shoulder issues will often force you to have to do things differently i.e. work differently, not lift the grandchildren, ask for help etc. Pain of any sort can be worrying and the longer it goes on for, that worry can take your thoughts to some interesting places. However, as mentioned before, most shoulder problems are not from anything ‘nasty’. It is important to know this as what you think and how you feel about your shoulder can influence the chances of you getting better from it or not (Chester et al, 2018). We have intentionally written this information to give you the right advice and guidance to see your way through to a better place with your shoulder.
Shoulder Pain
This page has been designed to provide you with the right information about shoulder pain and the rehabilitation that may help you in your recovery.
What is shoulder pain?
Shoulder pain normally relates to the discomfort caused by an irritation of one or more structures within the shoulder region. This could include the joints, soft tissues (muscles, ligaments and tendons) or nerves.
It is often made worse with movements of the shoulder or lifting. In most cases, shoulder pain can make normal movement difficult such as reaching, carrying or putting your hand into your back pocket.
But my pain is in my arm, not my shoulder, is that the same thing?
In most cases, shoulder pain is felt within the shoulder itself, however, for a number of people the pain can be mostly felt further down into their arm. If your pain is mostly in your upper arm and not necessarily in the shoulder, it is still right to call it shoulder pain as it is most likely that the pain is travelling down from the shoulder to that area. This is called referred pain. In some cases, it is possible for shoulder pain to travel all the way down to the hand.
Someone mentioned something called the rotator cuff, is that part of the shoulder?
It sure is and it is classed as part of the soft tissues that work around the shoulder.
To help explain what the rotator cuff is, it is useful to understand some basics of what your shoulder looks like on the inside (its anatomy).
Most people are aware that their shoulder is a ball and socket joint and interestingly, so is your hip, however they are actually quite different because their jobs are different. Your hip is primarily built for stability i.e. taking your weight, running, kicking and jumping and as such, the ball is a bit smaller than the socket to allow it to fit in snugly and very securely. As a result of the shape, you get lots of strength and stability from the hip, but not quite as much movement.
Your shoulder’s main job is movement and therefore its shape is different to your hip. The ball is actually quite a bit bigger than the socket and the socket itself is quite small and shallow. The best way to think about this is that your shoulder is like a golf ball sitting on a golf tee. The shape of the shoulder means that it can give you lots of movement but it can’t rely solely on the bony shape to make it work properly. As such, the shoulder has some really important soft tissues (muscles, ligaments and tendons etc.) that not only help it do its job, but help it stay strong and move properly.
You haven’t exactly said what the rotator cuff is though!
You’re right.
The rotator cuff is part of the soft tissues that we’ve mentioned that help the shoulder work properly. They are a group of 4 muscles and their tendons wrap around the top of the ball (of the ball and socket joint). They help to provide movement, strength and stability to the shoulder.
So, what causes shoulder pain?
Like with most aches and pains in most parts of the body, there are a number of things that make things sore. This could include trauma (a fall or a sports injury), repetitive movements, or doing more or less activity than you’re used to.
A common cause of shoulder pain is soft tissue irritation (muscles, tendons). The following information will largely be aimed at addressing this type of shoulder issue, however, the advice and exercises will be suitable for most other types of shoulder issue.
Feel free to explore our other shoulder information pages if you feel your symptoms are different to those described here, as you may find the advice and exercise ideas may suit your needs better.
So, what is soft tissue irritation and why does it cause shoulder pain?
Muscles and tendons are a normal part of your anatomy. A tendon’s main job is to connect muscle to bone so that when your muscle contracts (works), it passes the force (or energy) to the tendon and then to the bone which creates movement.
Tendons are incredibly strong and robust things. This means they are designed to work and sometimes work hard, and they normally do this without any issues. Just like any other body part, they can be trained to work harder if you need them to (i.e. by lifting weights or doing your job) but equally, they can become less efficient at doing their job if you don’t use them.
Tendon irritation can be caused by many things but in a lot of cases it is normally caused by one of the following three things:
OK, so what happens to the tendon?
If you think of your tendons as being really good at doing their job (passing the energy from the muscle to bone to create movement), it means they can put up with a lot of work when they need to. If you find yourself doing more than you are used to, doing something you are not used to doing or more importantly, having a period of doing less activity before, then you can push your tendon’s ability to cope. Most of the time you notice very little, maybe a bit of an ache here and there, but sometimes your tendons can react and say “I’m struggling”.
If this happens, you will normally notice some discomfort and may find that moving can be uncomfortable. Think of this as your tendon being an ‘unhappy worker’ and as now struggling to do its normal day job, complaining about the work it has to do. Most of the time the soreness will settle with time, but sometimes it can last a bit longer, maybe into weeks or months.
Does this mean that my shoulder/shoulder tendons are damaged?
No. Pain can be very misleading at times and is very good at making people feel worried or vulnerable. Even if your shoulder is very sore, as they can be sometimes, it does not necessarily mean that there is something significantly wrong with you or your shoulder. Your body is strong, robust and very good at doing its job, but it can be sore from time to time. Moving and using a painful shoulder may be sore, but it is safe to be sore.
So, what are the common symptoms of shoulder pain?
As described above, shoulder pain will generally be felt around the shoulder and/or upper arm region. In a lot of cases, moving the arm can make the pain worse but equally, it can be sore when resting or after activity. Some people find helping the sore arm move (by using the other arm) seems to feel a little easier.
People with shoulder pain will often feel that they might not be as strong, as lifting weight makes their shoulder sore and the arm gets tired more quickly i.e. you cannot do the things you want to do for as long before your discomfort starts.
Night pain is common with most soft tissue irritations of the shoulder.
My shoulder clicks, is that normal?
All joints have the ability to cause noise. Clicks, clunks, cracks and pops can sound very worrying, but in the vast majority of cases, it is nothing more that friction (the force created by two moving surfaces).
Noises from your body are quite normal and your shoulder is no different. An example of this might be if you are hungry, you might hear your tummy rumble but that doesn’t mean there is actually anything wrong with it, you just need some food. Noises from joints often conjure up frightening images in our heads that something is wrong, that you are making your shoulder worse or wearing something away. However, it is important to know that despite your soreness, your shoulder is strong, robust and amazing at doing its job, and it is normal for it to occasionally makes some noise.
Ok, so I’ve got shoulder pain which sounds like it could be soft tissue irritation, what can I do?
Firstly, you should know that it is possible to feel better. Sometimes, these issues can be really quite sore and can get in the way of things that you would normally take for granted, making you feel that you’ll never get better. However, most cases of shoulder pain will get better by themselves over time. If it hasn’t settled by itself then physiotherapy can help.
Understanding the issue is often the best place to start. Reading the information above can help you better understand that shoulder pain does not normally mean damage or that it is a dangerous problem and that it can get better.
Secondly, there are two important things that can help you on your recovery journey:
What does ‘calm the problem down’ mean?
If you think back to the idea that your irritated tendon is an unhappy worker, then if you keep asking your tendon to do the same job, in the same way that it always has, the tendon will keep being sore. In other words, when something is sore, think of it like your tendons saying “I can’t do that as easily as I used to right now”. Making some changes to the things that are sore may help calm the issue down to then allow you to move on with your recovery. Think of it as putting the tendon on lighter or amended duties whilst it’s sore.
We have written a whole page on ‘calming things down’. You can find it here along with some homework to try to help your shoulder’s recovery: Load Management
Can you give some examples of what you mean?
Sure, but remember everyone is different and you will have to do some thinking yourself around how your shoulder is affecting you and some of the changes you might need to make.
|
Things that are sore |
Why is it sore? |
Possible solution |
|
Dressing |
Sore tendons will find certain positions uncomfortable |
Try putting your sore arm in sleeves first or asking for help if you can |
|
Lifting |
Sore tendons will tire more quickly and will find hard work more challenging |
Reduce how much you are lifting, use the other hand, ask for help or lift with a bent shoulder |
|
Sleeping |
Sore tendons can grumble after a day’s work |
Use pillows behind or under the arm to support it, review what you’re asking your shoulder to do during the day |
|
Reaching
|
Sore tendons find hard work and certain positions more challenging |
Don’t press it! |
So, should I just rest it and do nothing?
No, this is not what we are trying to say.
Firstly, it is impossible to completely rest your shoulder as you still have everyday tasks to complete like brushing your teeth, making a cup of tea, working etc.
Secondly, completely resting your shoulder may temporarily ease the symptoms, but it will not address the underlying cause. If you simply rest and make no other changes (such as looking at the things that make your shoulder sore and completing the exercises set out below), then you are unlikely to progress as well or as quickly as you might like.
How long will it take to get better?
Shoulder issues can take a long time to settle. It is worth knowing that it can sometimes take a matter of months to ease a shoulder problem, rather than weeks or days.
You are likely to have time where you feel that you are getting nowhere or your progress has just hit a bit of a roadblock, but with most shoulder issues, being patient, persevering with the exercise/ advice laid out here on this page and being kind to yourself are key to improving things.
OK, so how long should I work on ‘calming things down’?
This is a little tricky to be specific about and it is probably best to think about what your shoulder is saying. If you have been really good at adjusting, modifying and looking at the things that make your shoulder sore, then you should notice some changes within a few short weeks.
Ok, what do I do once it feels calmer?
Firstly, well done! Often ‘calming it down’ is the hardest part of your recovery.
Now that your shoulder feels somewhat calmer, the temptation might be to start going back to your normal activities in the same way you did before your shoulder issue. Sometimes this can be ok, but equally, sometimes you might find that your shoulder is not quite ready to return to normal just yet and may get irritated again. It may be best to think that your shoulder needs to get fit and strong again in order to get back to doing normal things in normal ways.
As we’ve said before, if you consider your sore shoulder as an unhappy worker, then you’ve adjusted and modified things (put it on ‘lighter duties’) to help calm it down. Now you’ve got to start a gradual or phased return to work (or normal). Jumping in at the deep end and going back to normal might result in your shoulder becoming grumpy and sore again.
As well as the advice above, it is now time to consider ‘building it up’ again.
So, how do I build it up?
It is very important to understand that it might take some time and your shoulder will be more likely to cope better if you do things in a gradual way, as the temptation will be to rush in, especially if it’s less sore than before.
No one is the same just like no shoulder problem is the same as the next, therefore there are no ‘formulas' that will be right for everyone. However, we have provided (below) some exercise ideas that, if followed, can be effective in helping you move forwards with your shoulder complaint.
Before I start, I’d like to know what the exercises are trying to do.
Excellent point, as it’s often useful to know what you’re aiming to do before you start.
Firstly, the exercises are aiming to introduce a little bit of work into the tendon/ shoulder by asking the muscles to do some work.
As you move through the exercises (as your shoulder allows), you will notice that the amount of work/effort and the amount of movement increases.
Lastly, one of the most important things about all of these exercises, is they are trying to help you regain some trust in your shoulder. If your shoulder has been sore for some time, it is only normal to be a little cautious when you start to move back into doing things that caused you pain before. This is why the exercises are best done gradually and shouldn’t be rushed too much.
What should I expect with these exercises? Will they be painful?
This is a very important question.
If your shoulder has been sore for some time, it would be a bit unrealistic to expect that it will be pain-free when doing these exercises. However, it is important that you don’t do too much to then upset the problem all over again.
A good marker for how hard to work is that you should feel some discomfort (not too much though), but it should settle within 24 hours. If you are still obviously sore the following day, you may have done too much/ pushed too hard, therefore next time you do the exercises, reduce the effort a bit.
Will this get better with just adjusting the things that are sore and doing the exercises?
Excitingly, there is considerable scientific research (experiments with people who have/have not got shoulder pain) that suggests that rehabilitation (exercise, lifestyle changes, education etc.) can really help.
Rehabilitation for shoulder pain can be:
Will I need to have surgery?
Although notoriously slow, most shoulder problems settle with rehabilitation (advice, exercises and lifestyle changes).
Is there anything I should look out for?
With shoulder pain, most cases are likely to be due to some kind of muscle or bone irritation. However, it is worth being aware of the following symptoms that would be considered less common:
If you have any concerns about any of the symptoms listed above, you should speak with your GP or physio.
Apart from these exercises, is there anything else I can be doing to help myself?
Yes there is, here are just a couple of the most important things:
Frequently asked questions
Q: Would an injection help my shoulder?
A steroid injection for shoulder pain is an option, however like most drugs, steroids come with side –effects. For some, a steroid injection can really help ease their pain and for others, it might have no effect at all. It is worth thinking about why your shoulder is irritated in the first place before deciding on an injection, as the pain relief offered by an injection may only be temporary if you don’t spend time working on the reason why it was sore in the first place. In other words, putting all your eggs into one basket (i.e. relying just on the injection) might only result in a brief improvement in pain. This appears to be supported by some of the available research into shoulder pain and injections (Mohamadi et al, 2017). If an injection is something that is being offered for your shoulder, it might work better alongside your rehabilitation, not instead of it.
A: Scans (MRIs or ultrasound scans) are very useful in a lot of cases. However, they are not normally needed for the assessment or management of shoulder pain. If your GP or physio decides they would like to arrange a scan for you, it is likely they are checking for something in particular, but the treatment (outlined above) remains the same and the most effective way of managing shoulder pain.
Q: Someone told me that my rotator cuff might be torn, what does that mean?
A: Using the word torn in any walk of life can conjure up scary images of things not being attached, hanging limply and not being able to do their job. Often, when we think of things that are torn, we find ourselves thinking of a piece of paper ripped in half or a rope all frayed and broken, however, rotator cuff tears are not like this at all.
Firstly, it’s useful to know that if you’ve been told you have a rotator cuff tear (which normally needs an ultrasound to diagnose it), that often they are considered a normal sign of aging. In a large study of people (664), Minagawa (2013) found that 147 people had rotator cuff tears but only 35% had any pain. In other words, two thirds of people who had a rotator cuff tear DID NOT HAVE ANY PAIN!
The rotator cuff’s tendons are actually a bit more like a broad flat blanket, therefore a tear is a bit like having a hole in the blanket. The blanket might look different, but will still keep you covered and warm. Having a rotator cuff tear does not mean that surgery is inevitable and that nothing else can help. Rehabilitation is as effective at helping people with rotator cuff tears as surgery but with no side effects and at a fraction of the cost (Kukkonen et al. 2014).
Q: When can I go back to sport or work?
A: Often people will make a better recovery if they are able to remain at work rather than take time off sick. As mentioned before, the best way to approach shoulder pain is to adjust the things that are sore (including work and sport) and when you are ready, try to work the shoulder ‘better’ with exercises.
Q: I’ve tried the exercises and nothing works, why?
A: Firstly, ask yourself, are your expectations sensible? As mentioned before, shoulder pain can be very slow to respond and can hang around for months. If your shoulder has been sore for a long time, it might take a long time to see it through to being better. Ask yourself did you try the ‘calm it down’ approach thoroughly? If you didn’t, then that might be the reason why you haven’t moved forwards as it is often a very important stage to then allow your exercises to work. If you have tried the ‘calming things down’ approach, ask yourself if you did everything you could do and really commit yourself to adjusting/ modifying all the things your shoulder was telling you it was struggling with.
It’s worth thinking that the exercises are the easier bit as they tell you what and how much to do. Calming the shoulder down first to allow the exercises a chance to help does take more time, effort and energy, but if done well, is more likely to help your shoulder recover.
Q: What if I’ve done everything that I should do but I’m still no better?
A: Often these types of problems take a long time (weeks into months) to settle, so be patient with yourself. If you have been dedicated to the ‘calm it down’ work and the exercises, as well as being patient and giving it time and still you feel no better, do discuss this with your physio as they may be able to discuss other options with you.
Exercise Videos
Movement Exercises
Simply getting the shoulder moving can often be a good place to start with shoulder pain.
Choose a number exercises from the selection to explore little and often each day.
Shoulder Strengthening
Early Phase
Aim to explore these exercises little and often throughout the day.
Middle Phase:
Aim to explore these exercises approximately 3 times across the week, aiming to complete between 8-12 repetitions for 3 to 4 sets.
Exercises with Weights:
Advanced Phase:
Aim to explore these exercises approximately 3 times across the week, aiming to complete between 8-12 repetitions for 3 to 4 sets. With each workout, try to get your shoulder tired.
Banded Exercises:
Weighted Exercises:
Bodyweight Exercises:
Speed/Control:
References:
Chester, R., Jerosch-Herold, C., Lewis, J and Shepstone, L. (2018). Psychological factors are associated with the outcome of physiotherapy for people with shoulder pain: a multicentre longitudinal cohort study. British Journal of Sports Medicine. 52 (4) http://dx.doi.org/10.1136/bjsports-2016-096084. Accessed 05/05/2021.
Holgram, T., Bjornsson Hallgren, H., Oberg, B., Adolfsson, L. and Johansson, K., (2012). Effect of specific exercise strategy on need for surgery in patients with subacromial impingement syndrome: randomised controlled study. British Medical Journal. 344:e787. doi: https://doi.org/10.1136/bmj.e787. Accessed 05/05/2021.
Ketola, S., Lehtinen, J., Rousi, T., Nissinen, M., Huhtala, H., Konttinen, Y, T. and Arnala, I. (2013). No evidence of long-term benefits of arthroscopicacromioplasty in the treatment of shoulder impingement syndrome: Five-year results of a randomised controlled trial. Bone and Joint Research. 2(7): 132-9. doi: 10.1302/2046-3758.27.2000163. Accessed 05/05/2021.
Kukkonen, J., Joukaninen, A., Lehtinen, J., Mattila, K, T., Tuominen, E, K, J., Kauko, T and Aarimaa, V. (2014). Treatment of non-traumatic rotator cuff tears: A randomised controlled trial with one-year clinical results. The Bone and Joint Journal. 96-B(1):75-81. doi: 10.1302/0301-620X.96B1.32168. Accessed 05/05/2021.
Minagawa H (2013) Prevalence of symptomatic and asymptomatic rotator cuff tears in the general population: From mass-screening in one village. Journal of Orthopaedics. Feb 26;10(1):8-12.
Mohamadi, A., Chan, J, J., Claessen, F, M, A, P., Ring, D. and Chen, N,C. (2016). Corticosteroid Injections Give Small and Transient Pain Relief in Rotator Cuff Tendinosis: A Meta-analysis. Clinical Orthoapaedic Related Research. 475(1):232-243. doi: 10.1007/s11999-016-5002-1. Accessed 05/05/2021.
Tashani, O.A., Astita, R., Sharp, D. & Johnson, M.I. (2017). Body mass index and distribution of fat can influence sensory detection and pain sensitivity. European Journal of Pain. 21(7):1186-1196.
doi: 10.1002/ejp.1019 (accessed 16/12/2020).