Shoulder pain and injury are commonplace. Your shoulder is the most mobile of all your joints. Just think about how much it can move.
The reason for this movement is a tiny shoulder joint contact zone. This small contact area essentially means that your shoulder is quite unstable. That is why your shoulder muscles are vital to a normally functioning shoulder.
When Should You Worry About Shoulder Pain?
In most cases, if you are suffering shoulder pain, your muscles are not strong enough or uncoordinated.
Luckily, you can normalise these dysfunctions: a high-quality shoulder assessment and specific exercises prescribed by a skilled shoulder healthcare practitioner such as your physiotherapist.
But some cases of shoulder pain require urgent attention.
Sudden Onset Shoulder Pain
Fall or contact injuries such as a tackle or heavy bump may fracture or dislocate your shoulder. It is imperative if you are experiencing a shoulder joint that appears deformed, muscle weakness, intense pain, or sudden swelling. Please seek immediate medical attention if a traumatic injury causes your shoulder pain.
If you are experiencing shoulder pain with difficulty breathing or feelings of tightness in your chest, you may be experiencing a heart attack. You require immediate medical attention. Please call 000 immediately.
Sudden Pain That Fails to Improve
What Are 6 Common Shoulder Injuries?
Most shoulder pain falls into one of the following categories:
- Rotator Cuff
- Shoulder Bursitis
- Shoulder Dislocation (Instability)
- Frozen Shoulder
- Shoulder Fractures
- Shoulder Arthritis
Would you please discuss your shoulder condition with a trusted shoulder physiotherapist?
Common Shoulder Pain & Injury Conditions
- Rotator Cuff Syndrome
- Shoulder Tendinopathy
- Rotator Cuff Calcific Tendinopathy
- Rotator Cuff Tear
- Bicep Tendinopathy
- Shoulder Impingement
- Swimmer's Shoulder
- Subacromial Decompression
- Shoulder Arthroscopy
- Rotator Cuff Repair
- SLAP Repair
- Biceps Tenodesis
- Biceps Tenotomy
- Total Shoulder Replacement
Researchers have discovered that managing your shoulder injury with physiotherapy is usually successful. Typically, you have two options: a non-operative or a surgical approach. Your condition will dictate which option is best for you at this time. Non-operative care is conservative rehabilitation.
If shoulder surgery is required, then your physiotherapist may undertake:
Pre-operative rehabilitation - either trial a non-operative/conservative treatment approach or condition and prepare your shoulder and body for a surgical procedure.
Post-operative physiotherapy will safely regain your normal range of movement, strength and function.
PhysioWorks physiotherapists have a particular interest and an excellent working relationship with leading shoulder surgeons. Our physiotherapy team provide you with both conservative and post-operative shoulder rehabilitation options. We aim for you to attain the best possible outcome for your shoulder injury.
For specific information regarding your shoulder, please consult your trusted shoulder physiotherapist.
Shoulder Pain FAQs
- When Should You Worry About Shoulder Pain?
- 6 Common Shoulder Injuries?
- What Causes Shoulder Pain?
- What is Your Scapulohumeral Rhythm?
- What is Your Rotator Cuff?
- How Can You Tell If You Have Torn Your Rotator Cuff?
- Will Your Shoulder Blade Hurt With A Torn Rotator Cuff?
- Will A Cortisone Injection Help A Torn Rotator Cuff?
Common Shoulder Pain Causes
Shoulder pain can commence after a traumatic injury or present gradually.
Traumatic shoulder injuries include:
- Shoulder fractures (broken bones),
- Shoulder dislocation (out of position),
- AC joint injury (torn ligaments),
- Shoulder tendinopathy (tendon injuries) or
- Rotator cuff or muscular injuries.
The most common cause of traumatic shoulder injuries would be sports injuries or lifting injuries.
Gradual onset shoulder injuries include:
- Previous injuries that are inadequately treated (e.g. old joint or ligament sprains)
- Shoulder impingement or shoulder bursitis from poor muscular control, soft tissue tightness or joint position issues (biomechanical faults)
- Stiff joints (lack of movement diminishes joint nutrition), e.g. frozen shoulder
- Joints laxity (excessive sloppiness causes joint or tendon damage through poor control)
- Shoulder Arthritis
Your shoulder physiotherapist will be able to assist with your diagnosis and treatment plan. Please consult with them regarding your shoulder condition.
Shoulder Impingement Syndrome
Your Shoulder Impingement Zone is where your shoulder tendons and bursa are most likely to impinge against the (acromion) bone as it moves. The shoulder impingement zone is the most likely area when injuries to your rotator cuff or shoulder bursa occur due to the narrowing of the sub-acromial (space below the acromion) during this shoulder position.
Postures that significantly narrow the sub-acromial space are:
- Your arm is working at or near shoulder height.
- Your arm is directly overhead.
Injuries that result fall under the Shoulder Impingement Syndrome group of injuries.
Who Suffers Shoulder Impingement Syndrome?
Shoulder Impingement Syndrome is more likely to occur in people who engage in physical activities that require repeated overhead arm movements, such as tennis, golf, swimming, weight lifting, or throwing a ball. Occupations that require repeated overhead lifting or work at or above shoulder height are also at risk of rotator cuff impingement.
What are the Symptoms of Shoulder Rotator Cuff Impingement?
Commonly rotator cuff impingement has the following symptoms:
- An arc of shoulder pain occurs approximately when your arm is at shoulder height or when your arm is overhead.
- Shoulder pain can extend from the top of the shoulder to the elbow.
- Pain when lying on the sore shoulder.
- Shoulder pain at rest as your condition deteriorates.
- Muscle weakness or pain when attempting to reach or lift.
- Pain when putting your hand behind your back or head.
- Pain reaching for the seatbelt.
How is Shoulder Impingement Syndrome Diagnosed?
A thorough clinical examination will identify a rotator cuff impingement in most cases. Your physiotherapist will ask about your shoulder pain and its behaviour and examine your shoulder with specific tests that identify impingement signs.
A problem with your neck joints can commonly cause shoulder pain. Your physiotherapist will examine this area to rule out this cause or include its treatment in your care plan.
For specific shoulder impingement advice, please consult your shoulder physiotherapist.
More info: Shoulder Injuries
Rotator Cuff Muscles
Your rotator cuff muscles hold your arm (humerus) onto your shoulder blade (scapula). Most of the rotator cuff tendons hide under the bony point of your shoulder (acromion), which, as well as protecting your rotator cuff, can also impinge on your rotator cuff structures.
The shoulder joint is a relatively unstable ball and socket joint. It is often likened to a golf ball on a tee. Your subscapularis, supraspinatus, infraspinatus and teres minor are small muscles that stabilise and control your shoulder movement. Collectively, these four muscles are known as the rotator cuff.
What is your Rotator Cuff?
Rotator cuff syndrome is a prevalent shoulder injury. Your shoulder joint is a relatively unstable ball, and the socket joint is moved and controlled by a small group of four muscles known as the rotator cuff.
As the name suggests, the rotator cuff muscles are responsible for shoulder rotation and form a cuff around the humerus's head (shoulder ball). The subscapularis, supraspinatus, infraspinatus and teres minor are your rotator cuff muscles. These muscles stabilise and control your shoulder movement on your shoulder blade (scapula).
Rotator Cuff Injury
Your rotator cuff muscles and tendons are vulnerable to rotator cuff tears, rotator cuff tendonitis, rotator cuff impingement, and related rotator cuff injuries.
Rotator cuff injuries vary. Medium severity injuries include acute or subacute rotator cuff tendon damage (rotator cuff tendinopathy). The lesser end is mild soft tissue pinching and catching (shoulder impingement), an inflamed subacromial bursa (shoulder bursitis). The more significant injury end of the spectrum is more longstanding tendon damage (calcific tendinopathy), a rotator cuff tear, or complete tendon rupture.
Rotator Cuff Treatment
Fortunately, most rotator cuff injuries respond to physiotherapy treatment that addresses how your shoulder moves, e.g. avoid clicking impingement positions. This treatment approach helps with short-term pain and long-term damage such as rotator cuff tears or repeat bursitis.
More significant injuries include partial and full-thickness rotator cuff tears, which may require rotator cuff surgery.
Some shoulder rotator cuff injuries are more common than others.
What Causes Rotator Cuff Impingement?
Rotator cuff impingement and bursitis causes have primary (structural) and secondary (posture & movement related) causes.
Primary Rotator Cuff Impingement – Structural Narrowing
Some of us are born with a smaller sub-acromial space. Conditions such as osteoarthritis can also cause the growth of sub-acromial bony spurs, which further narrows the space.
Because of this structural narrowing, you are more likely to squash, impinge and irritate the soft tissues in the sub-acromial space, which results in bursitis or rotator cuff tendonitis.
Secondary Rotator Cuff Impingement – Dynamic Instability
Impingement can occur if you have a dynamically unstable shoulder.
Dynamic shoulder instability means excessive joint movement, ligament laxity and muscular weakness around the shoulder joint.
This impingement usually occurs over time due to repetitive overhead activity, trauma, previous injury, poor posture or inactivity.
In an unstable shoulder, the rotator cuff has to work harder, which can cause injury.
An overworking rotator cuff fatigues and eventually becomes inflamed and weakens due to pain inhibition or tendon tears.
Typically, when your rotator cuff fails, it cannot prevent the head of the humerus (upper arm) from riding up into the sub-acromial space, squashing your bursa or rotator cuff tendons.
Failure to properly treat this instability causes the injury to recur. Poor technique or bad training habits such as training too hard is a common cause of overuse injuries, such as bursitis or tendinopathy.
Will A Cortisone Injection Help A Torn Rotator Cuff?
Your rotator cuff is a group of four muscles and tendons surrounding the shoulder joint. They provide strength to lift the arm in all directions and provide stability to the shoulder to firmly hold the ball of the shoulder (head of the humerus) in the socket (glenoid).
Management for Rotator Cuff Tears
Tears of the rotator cuff can occur acutely through several mechanisms or can result from gradual changes over time and, in some cases, can cause shoulder pain and reduced function. Good quality research has suggested that physiotherapy and exercise rehab is effective and should be the first-line treatment for many types of rotator cuff injuries. However, in some particularly stubborn cases, other additional options may need to be considered.
A cortisone injection, also known as an HCLA (hydrocortisone + local anaesthetic) injection, is an injection that can help to reduce inflammation and provide pain relief. With the guidance of your physiotherapist and medical team, a cortisone injection may be considered for people with:
- Persistent high pain levels despite medication and relative rest.
- Night pain
- Where pain has restricted the progression of exercise rehab.
Pros and Cons of Injections
In the right circumstances, a cortisone injection can effectively reduce pain and inflammation in conditions such as bursitis. However, injections do also have some potential adverse side effects.
Recent studies show that repeat injections or injections involving large tendon tears can weaken the tendon structure and inhibit the cells that help repair damaged tissue. This is why healthcare professionals, such as your physiotherapist, will try to avoid unnecessary steroid injections and persist with rehab for at least 4-6 weeks before considering them.
Rehab Following Injection
Research shows that people experience significantly greater improvements in shoulder pain and function when completing a specific exercise rehab program following a cortisone injection (Holmgren et al., 2012). Following a successful cortisone injection, your physiotherapist can use this reduced pain “window” to allow the more effective exercise of the muscles in the area. Typically, relative rest is recommended for 1-2 weeks following the injection before commencing exercise rehab.
Consulting with one of our PhysioWorks physiotherapists can ensure that your shoulder injury is accurately diagnosed and treated accordingly. Book an appointment, or feel free to call us, and one of our physiotherapists will be happy to help.
What is Scapulohumeral Rhythm?
Your shoulder-scapula joint motion has a regular functional motion pattern known as scapulohumeral rhythm - to provide you with pain-free and powerful shoulder function. When elevating your shoulder overhead, roughly one-third of your shoulder motion occurs at your scapulothoracic joint. Two-thirds of movement occurs at the glenohumeral joint, or 'true" shoulder joint. However, the timing and coordination of your shoulder muscles and how they control your scapulohumeral rhythm are essential factors.
View it on Youtube here: http://www.youtube.com/watch?v=_Ia0VvT81xc
Alteration of this regular scapulohumeral movement pattern results in shoulder injuries, pain and impingement.
When your scapulohumeral rhythm becomes abnormal -due to pain, weakness or muscle incoordination - you are more likely to suffer shoulder clicking, pain or rotator cuff injury.
Shoulder Joint Anatomy
Your shoulder motion occurs via a complex group of joints that dynamically controls the movement of three bones (scapula, humerus and clavicle) upon your ribcage. Your shoulder blade (scapula) is the centralised triangular base for your shoulder and arm movements. Your scapular muscles guide your scapula as it articulates around your rib cage. This motion is known as scapulothoracic motion.
Your clavicle or collarbone is the only skeletal attachment of your arm. It attaches to your upper sternum and the lateral edge of your scapula at the acromioclavicular (AC) joint. Your shoulder ball and socket joint is the glenohumeral joint where your upper arm bone (humerus) articulates on the glenoid fossa of your scapula.
What are the Symptoms of Abnormal Scapulohumeral Rhythm?
Poor shoulder blade stability results in abnormal tipping and rotation of your scapular, which causes your acromion (bone) to pinch down into the subacromial structures (e.g. bursa and tendons), causing impingement leading to swelling or tears. Typically signs of abnormal scapulohumeral rhythm include shoulder pain, instability and clicking. Researchers have identified abnormal scapulohumeral rhythm as a major cause of rotator cuff impingement.
Your shoulder physiotherapist is an expert in the assessment of scapulohumeral rhythm. They will observe your shoulder motion and perform strength and control tests to assist their diagnosis. X-rays, MRIs, ultrasound scans and CT scans cannot determine scapulohumeral rhythm dysfunction.
Why is Scapulohumeral Rhythm Important?
Poor scapula stability usually results in tipping and downward rotation of your scapula. The downward posture causes your shoulder (tip of acromion) to pinch down on the subacromial structures. Rotator cuff impingement, shoulder bursitis or rotator cuff tears result from subacromial impingement.
Normal shoulder blade-shoulder movement - (scapulohumeral rhythm) - is required for a pain-free and powerful shoulder function. Luckily, abnormal scapulohumeral rhythm can be retrained by an experienced shoulder physiotherapist.
Scapulohumeral Rhythm Correction
Your skilled physiotherapist can assess and correct your scapulohumeral rhythm. Any deficiencies will be an essential component of your rehabilitation. Among other treatment options, teaching you how to control your shoulder blade via scapular stabilisation muscles is crucial for a successful recovery.
Your physiotherapist will be able to guide you in the appropriate exercises for your shoulder.
Restore Normal Neck-Scapulo-Thoracic-Shoulder Function
You may find it challenging to comprehend that your neck and upper back (thoracic spine) are essential in treating shoulder pain and injury. Neck or spine dysfunction can not only refer to pain directly to your shoulder but can affect a nerve's electrical energy supply to your muscles, causing weakness.
Plus, painful spinal structures from poor posture or injury don't provide your shoulder, or scapular muscles, with a solid pain-free base. In most cases, especially chronic shoulders, some treatment directed at your neck or upper back may ease your pain, improve your shoulder movement and stop pain or injury from returning.
For more information, please consult your shoulder physiotherapist.
What is Dry Needling?
Dry needling is an effective and efficient technique for the treatment of muscular pain and myofascial dysfunction. Dry needling or intramuscular stimulation (IMS) is a technique that Dr Chan Gunn developed. Dry needling is a beneficial method to relax overactive muscles.
In simple terms, the treatment involves the needling of a muscle's trigger points without injecting any substance. Western anatomical and neurophysiological principles are the basis of dry needling. It should not be confused with the Traditional Chinese Medicine (TCM) technique of acupuncture. However, since both dry needling and acupuncture utilise the same filament needles, the confusion is understandable.
In his IMS approach, Dr Chan Gunn and Dr Fischer, in his segmental approach to Dry Needling, strongly advocate the importance of clearing trigger points in both peripheral and spinal areas.
Dry needling trained health practitioners use dry needling daily for the treatment of muscular pain and dysfunction.
What Conditions Could Acupuncture or Dry Needling Help?
Acupuncture or dry needling may be considered by your healthcare professional after their thorough assessment in the following conditions:
Private Health Fund Rebates
Most private health funds offer rebates on acupuncture or dry needling treatments as a component of your physiotherapy or acupuncture consultation.
Why is Post-Operative Physiotherapy Beneficial?
The success of your surgery doesn't finish the moment you leave the operating theatre. A famous quote: "The only place 'success' comes before 'work' is in the dictionary." Vidal Sassoon.
Your surgeon will have skillfully performed a surgical procedure that is the initial step towards your successful outcome. However, you'll have to do some work in the form of exercises to optimise your results.
Your physiotherapist will provide you with simple exercises to minimise chest infection or DVT complications when in the hospital. They may prescribe some early strengthening or range of motion exercises. Once discharged, you'll usually require re-assessment and checking of your progress.
Post-orthopaedic surgery, you'll almost certainly require exercise progression to regain your strength, flexibility, and function fully. Optimise your prompt return to life by consulting an experienced physiotherapist. Based on their assessment, they'll prescribe the most appropriate exercise for you and discuss your post-operative treatment.
At PhysioWorks, we'll happily assist you in your post-operative care. We are familiar with the treatment protocols prescribed by most Orthopaedic Surgeons. We'll happily liaise with your surgeon to determine any specific requirements based on your surgery.
Common Surgeries Requiring Post-Operative Care
Wrist & Hand
Carpal Tunnel Release, Fracture, Tendon Repairs
Achilles Tendon Repairs, Fasciotomy
Ankle & Foot
Ankle Reconstruction, Ligament Repairs, Arthroscope, Fracture, Spur Removal, Bunionectomy
Spine (Neck & Back)
Discectomy, Micro-discectomy, Laminectomy, Spinal Fusion/Stabilisation
Individualised Post-Operative Physiotherapy
At PhysioWorks, we'll work with you to develop a tailor-made rehabilitation program to ensure you make the best possible recovery in the quickest time. Whatever your needs, we'll get you back to your work, sport or day to day activities ASAP.
If you have been a surgical patient, it is always beneficial to inform your surgeon that you would like to return for post-operative care at PhysioWorks.
You can make an appointment with PhysioWorks at any stage. Seek their advice if you believe you are not making satisfactory progress in your recovery or if your mobility is compromised.
When Should Diagnostic Tests Be Performed?
If your symptoms persist despite treatment, it is appropriate to return to your physiotherapist or doctor for further evaluation.
It would be best to consider other causes of pain, and perhaps X-rays or other studies (MRI, CT scan, bone scan, or pathology studies) may be needed to make an accurate diagnosis.
Can Your Physiotherapist Refer for X-Rays and Scans?
Yes. Physiotherapists can refer you for many medical investigations, including X-Rays, Ultrasound Scans and MRI scans.
The full Medicare rebate applies to most X-rays ordered by physiotherapists. Not all Radiology clinics bulk bill, so out of pocket expenses may be payable.
Medicare uses item numbers and limits specific investigations. Different referral rights are depending on whether your referrer is a GP, Medical Specialist or Physiotherapist.
Your physiotherapist is happy to discuss with you the pros and cons of specific tests.
Arm Pain Causes
Arm pain and injuries are widespread. The causes can be related to sports injuries, work injuries or simply everyday arm use. Arm pain can occur due to either sudden, traumatic or repetitive overuse.
Causes of Arm Pain by Region
Causes of Arm Pain by Structure
Neck-Related Arm Pain
Shoulder-Related Arm Pain
- AC Joint Injury
- Biceps Tendinopathy
- Broken Shoulder - Fractured Humerus
- Bursitis Shoulder
- Dislocated Shoulder
- Frozen Shoulder
- Rotator Cuff Calcific Tendinopathy
- Rotator Cuff Syndrome
- Rotator Cuff Tear
- Shoulder Arthritis
- Shoulder Impingement
- Shoulder Tendonitis
- Swimmer's Shoulder
Elbow-Related Arm Pain
Wrist-Related Arm Pain
Hand-Related Arm Pain
Muscle-Related Arm Pain
- DOMS - Delayed Onset Muscle Soreness
- Muscle Strain (Muscle Pain)
- RSI - Repetitive Strain Injury
- Overuse Injuries
Other Sources of Arm Pain
Common Causes of Arm Pain
- Your rotator cuff or frozen shoulder most commonly causes shoulder pain.
- Elbow pain is commonly caused by tennis elbow or golfers elbow.
- Wrist & hand pain can be related to carpal tunnel, wrist arthritis or even a thumb tendon condition known as de Quervain's tenosynovitis.
Referred Arm Pain
Cervical radiculopathy is a common source of referred arm pain. As mentioned earlier, your neck can refer to arm pain from another source. Cervical radiculopathy will respond positively to treatment at the source of the injury (e.g. your neck joints).
Professional assessment from a health practitioner skilled in diagnosing both spinal-origin and local-origin (muscle and joint) injuries (e.g. your physiotherapist) is recommended to ensure an accurate diagnosis and prompt treatment directed at the arm pain source.
Arm Pain has Diverse Causes.
The causes of your arm pain can be extensive and varied. Due to this diversity, your arm pain should be assessed by a suitably qualified health practitioner to attain an accurate diagnosis, treatment plan and implementation specific to your arm pain.
What Arm Pain is Associated with a Heart Attack?
Left-arm pain can be an early sign of a life-threatening cardiac issue. A professional medical assessment that involves an accurate history, symptom analysis, physical examination and diagnostic tests to exclude a potential heart attack is essential to exclude this potentially life-threatening source of arm pain.
Please consult with your health practitioner, call an ambulance on 000, or visit a hospital emergency department to put your mind at ease.
Most Arm Pain is NOT Life-Threatening.
Luckily, life-threatening arm pain is far less likely than a local musculoskeletal injury. Before commencing treatment, your health practitioner should assess and confirm arm pain caused by a localised arm muscle, tendon or joint damage.
Arm Pain Prognosis
The good news is that arm pain and injury will typically respond very favourably to medical or physiotherapy intervention when early professional assessment and treatment are sought. Please do not delay in consulting your healthcare practitioner if you experience arm pain.
Common Arm Pain Treatments
With accurate assessment and early treatment, most arm injuries respond extremely quickly to physiotherapy or medical care, allowing you to quickly resume pain-free and normal activities of daily living.
Please ask your physiotherapist for their professional treatment advice.