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Method Health
Oct 299 min read

The Grumpy Shoulder

It used to be called shoulder “impingement.” It can now be called general or non-specific shoulder pain, a sprained shoulder, subacromial pain, or rotator cuff-related shoulder pain. Keep reading and I’ll explain why impingement is not a great thing to call this type of shoulder pain and why a Physio or Doctor can’t really be specific with a specific shoulder pain “generator”


As they should all be managed initially (and mostly entirely) non-surgically with very similar recovery principles, the title of a common grumpy shoulder or sprained shoulder groups the diagnosis of rotator cuff-related shoulder pain, bicep tendon pain, shoulder bursitis, sprained shoulder labrum, combined bicep, and labrum “tears” called a SLAP tear and shoulder osteoarthritis. Up to 65% of all causes of shoulder pain can be grouped in this category. A good chat with an evidence-based healthcare professional can increase confidence that more “specific” diagnoses aren’t warranted to improve management options or increase your optimistic recovery timeframes from the most common type of shoulder pain Shoulder pain: can one label satisfy everyone and everything? - PubMed (nih.gov) + Jeremy Lewis - Rotator Cuff Related Shoulder Pain & the athlete: Suggestions for management (youtube.com) + Diagnostic Labels for Rotator Cuff Disease Can Increase People's Perceived Need for Shoulder Surgery: An Online Randomized Controlled Trial - PubMed (nih.gov) 


Clues or common symptoms? 

Pain only around the top and side of the shoulder and down the arm when the arm is lifted any degree without the likelihood of these symptoms being caused by a more “specific” diagnosis. Specific diagnoses that have different management to general shoulder pain include a shoulder bony injury or dislocation with movement apprehension post a fall, sports injury or other traumatic event, frozen shoulder, nerve pain (pain spreads away from the shoulder in weird and wonderful ways), or other rare causes of shoulder pain like a joint infection or malignancy. Ok, we have ruled these out, Is there any other helpful test? If non-surgical management is being sought (as surgery will rarely be helpful), imaging is unnecessary and unhelpful in identifying changes in a “pain generator” in the shoulder or directing how to manage your symptoms. Also, movement tests cannot isolate a specific section of the shoulder that is hurting and many “special tests” produce mostly false positives. Be skeptical of one specific movement leading to a specific diagnosis. 


How common?

Around 15% of people will experience this type of general shoulder pain at least once during their lives so its the most common cause of shoulder pain


What is wrong? 

Simple and honestly: Something hurts in the shoulder. Movement tests you could perform can’t identify or isolate a specific irritated section of your shoulder. Most of the time, pain makes you feel weaker, which can feel like you have damaged something but it's better to think of your shoulder as having a headache or the flu - a temporary nuisance that will improve with time while you continue enjoyable activities without needing imaging, injection, or surgery. This might seem too simple or not very “specific” considering how much pain you may be experiencing, but is honest, evidence-based physiotherapy advice.


Often, long-term persistent symptoms are due to behavioural changes made after seeking medical advice and believing or being told tissue damage is causing pain, which in turn leads to a vicious cycle (see image below) that contributes to persistent pain. Tissue injury or damage is unlikely because 1) Imaging results often don't correlate with the severity of your symptoms - painful and non-painful shoulder images look similar, and 2) Imaging results don’t change while our symptoms improve.


So, shoulder “damage” is unlikely to be the important cause of your shoulder symptoms. If diagnoses have been ruled out such as traumatic bony or tendon injuries, or a frozen shoulder based on how your symptoms started, you can ignore perceived causes of your pain reported on imaging like “tears,” “degeneration,” or “bursitis” as these results can be found commonly in people without pain. What Imaging-Detected Pathologies Are Associated With Shoulder Symptoms and Their Persistence? A Systematic Literature Review - PubMed (nih.gov) Also, you are not a machine with degradable “parts” that age. You don’t need to worry about shoulder “impingement” being bad Rotator cuff related shoulder pain: An update of potential pathoaetiological factors (nzjp.org.nz) Most people can improve while “aging” without changing a specific part of their shoulder anyway. Optimistic and realistic mindfulness that shoulder pain is not caused by unrepairable damage or “impingement” is a mindset often observed in those who recover from shoulder pain faster than others.


Fear-Avoidance Model - an overview | ScienceDirect Topics Could be called the “pain-worry cycle”


Why me? 

Most commonly, you might wake up with or develop shoulder pain over a couple of days. This is not because of sleeping wrong.  Increased risk of developing shoulder pain overnight comes on randomly or from increased shoulder use in the last couple days to weeks (like spending a weekend painting the house or playing a tennis tournament) with a background of reduced tolerance to stress either due to persistent social stress (family stress or death of a close one) or work dissatisfaction, reduced sleep, reduced previous physical activity, being overweight, smoking or a recent illness. Is there an association between metabolic syndrome and rotator cuff-related shoulder pain? A systematic review - PubMed (nih.gov) Pain might make you weak or move with less motion, but peak strength, flexibility, or movement technique are not predictive of developing shoulder pain. Everyone goes through these periods of life that predispose them to reduced tolerance to shoulder movements so don’t blame your past self. 


What can I do about it?

The goal of management is to modify your valued activities so that you can tolerate continuing them. It is essential to keep completing the activities that are important to you that might be impacted by your irritable shoulder right now, as these activities can help you recover An Open Letter to You, a Unique Individual Living with Shoulder Pain - PubMed (nih.gov) 


Each day you complete the shoulder tasks you enjoy, the body's immune and nervous systems does its thing, reducing pain around the shoulder over time. Most of the time, the best management strategy is a short-term period of reduced shoulder use followed by progressively using your shoulder more during activities you enjoy, which are or are not sensitive to shoulder movements. Modify your physical activity to ensure you continue meeting Australian activity guidelines for your active hobbies and general health.


Suppose you wish to improve your function and strength. In that case, you might benefit from adding upper body strength, power, or valued activity-specific exercises to improve tolerance to the activities impacted by shoulder pain. Don’t be too worried about finding the “best exercise.” You can’t isolate all the RC muscles, labrum, or shoulder ligament with one movement anyway. The progressive movement that involves any amount of pushing, pulling and lifting your arms to the side strengthens all of the shoulders. 


A general shoulder strength routine will “isolate” the shoulder muscles as much as any fancy shoulder exercise Specific versus general exercise program in adults with subacromial impingement syndrome: a randomised controlled trial - PubMed (nih.gov). When your shoulder is grumpy, pain during arm use is safe, but wise to keep to tolerable pain levels to avoid sleep deprivation or entry into the pain worry cycle. Remember, this type of shoulder pain is not caused by measurable tissue change, and more pain does not equal more change. But, while in a sensitive state, your immune and nervous systems are more sensitive or “ready to go,” and the threshold for a flare-up is lower which can affect sleep and negative thoughts during shoulder movement. Stay optimistic in your recovery and educate yourself on the risk factors for increasing the persistence of your shoulder pain by asking us for validated, up-to-date information as there is lots of unhelpful physio fluff is out there and modify the risk factors you can. 


Surgery to reduce “impingement” or “fix” atraumtic shoulder pain is hardly ever more likely to be more helpful than a well-informed (modern, evidence-based) non-surgical management. Surgery can be helpful for some in specific contexts for disabling shoulder OA (don’t worry that is not inevitable for all with shoulder OA), first-time shoulder dislocation, and traumatic rotator cuff injuries. Often, any other surgery is no better than a sham/fake surgery. Injections are becoming less recommended for general shoulder pain as it is likely impossible to find the “pain generator” to inject. Movement optimism and patience are the best management strategies for this most common type of shoulder pain. 


Busting Myths


How long will it take? 

If you are optimistic, have clear expectations and education about what shoulder pain means (more shoulder pain does not equal more shoulder damage), and follow realistic, up-to-date advice, many can feel much better within 2 weeks to three months. Sometimes, it takes more than 12 months to feel better. Role of physiotherapy in the treatment of subacromial impingement syndrome: a prospective study - ScienceDirect Don’t be too concerned; just having symptoms for longer does not mean you will not improve when following good advice. Just keep doing the things that are helpful for your tendon health, like improving your general health (sleep, physical activity, stress coping). You can live well with this common form of shoulder pain. 


What can Physiotherapy or Exercise Physiology at MH offer? 

  • We can offer individual advice to help you modify your activities to tolerate keeping up with life with shoulder pain. Shoulder pain should not stop you from doing the things you love. This might involve adding some strength exercises for your shoulder and upper body to your weekly routine, which we can coach you through or help support you in getting back to the activities you enjoy and might have reduced or avoided due to your beliefs about what will help your shoulder pain. 

  • We can be your support crew to encourage lifestyle changes that can improve your general health, such as coaching you on sleep, guiding you through ways to reduce stress, or adding things to your life to better cope with stress. 

  •  If you have had persistent shoulder pain and are very confused about the “specific” diagnostic labels you have been given that might be unhelpful, including shoulder “degeneration,” “tears,” “bursitis,” or “impingement,” and why you still have shoulder pain persistence, we can help you make sense of the pain, highlight areas of management to prioritise or be more optimistic about, and give you individual guidance to assist in managing and resolving it. 

  • Exercise physiology and physiotherapy can offer high-quality exercise-based management for general shoulder pain.

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