The Real Reason Your Shoulder Still Hurts — A Physiotherapist Explains

Does your shoulder bother you both at rest and in motion, leaving you wondering how on earth to fix this discomfort? You are not alone in this, and since quite a bunch of shoulder clients have come through the clinic lately, let's create a simple guide to early-stage rehabilitation of the shoulder, and also provide instructions on how to train the shoulder in the long run.

Rotator cuff syndrome is the most common disorder of the shoulder, and unfortunately the number of cases increases with age, with the prevalence of symptoms starting to rise after the age of 40. Symptoms are slightly more common in women compared to men. As the shoulder joint is the body's most mobile joint, it's also very vulnerable to various disorders. Anatomically the shoulder consists of three joints: the actual shoulder joint, the scapula-clavicle joint, and the clavicle-sternum joint. The sternum joint is the only point where the entire shoulder girdle receives bony support - otherwise the entire package is supported by muscles. There are also ligaments in the shoulder area, but their support alone is not enough to stabilize the joint - an essential part of the support comes from the muscles.

This is usually the place where things start to go wrong. Typically damage or inflammation occurs where the muscles supporting the shoulder - the rotator cuff tendons - attach to the insertion on the humerus. Over the years, degeneration weakens the strength of the tendon, and the healing of injury slows down slightly. However it's important to remember that everyone experiences this aging process, and just like facial wrinkles or gray hair, signs of aging are not always the reason for pain in certain areas. Repeated lifting and overhead positions contribute to tendon damage - through these actions minor changes may occur in the tendon, and as inflammation increases the tendon tissue swells and thickens, causing further constriction in the already tight shoulder region. This kind of chain of events happens when there is no underlying injury. Another scenario involves strains, for example during dog walking or other sprains, or a fall onto the upper limb or shoulder.

When we start to experience pain in the shoulder area, often our muscle function begins to change as a result of the pain. When pain disrupts shoulder function, the external rotators may often be neglected, causing challenges in shoulder function. When external rotators are not able to work properly at various shoulder joint angles, the upper arm can't be well positioned in the socket against the joint, and in these cases the shoulder joint constriction becomes a bigger problem.

So how do we get started? The function of the external rotators needs to be checked in a lower position. Place your elbow right next to your body and start externally rotating your shoulder. It's important that the amount of rotation increases, and when the movement becomes more difficult, increasing the amount of the body's rotation towards a wall can change the difficulty of this movement. The goal is that when your back is against the wall, your affected arm can still rotate the upper arm sufficiently backwards, so your knuckles come to touch the wall.

Sometimes when testing the movement with a client in the clinic, the movement is easier when you guide them to pull the shoulder blade back and down - this way the teres minor (the small muscle supporting the shoulder) and the latissimus dorsi (the wide back muscle) come to aid the shoulder movement. Through the activity of these muscles the shoulder position gets better, allowing the muscles to function better. Sometimes I might tape the shoulder blade with kinesio tape to slightly improve the position, making it easier for the client to feel the essence of the shoulder exercise.

Now that the shoulder is better positioned and the external rotators are activating, you should start performing larger shoulder abduction movements and ensure that the external rotators also function at other joint angles. Here it's important to perform external rotation so that the shoulder abduction and sufficient external rotation are present, and no intense pain occurs during these exercises, as the angle rises during the exercise gradually approaching the 90-degree angle. As the exercises progress it's always a matter of playing with either body rotation or shoulder abduction - each individual's story may be slightly different, but the end result should be the same for everyone: 90-degree shoulder abduction with sufficient external rotation so the knuckles touch the wall, and shoulder pain should stay away in this position.

So what's next from here? External rotators need to be kept in play when starting to perform shoulder presses, for example - in these exercises the elbow and the knuckles constantly remain against the wall. If the knuckles come away from the wall, then the external rotators are unable to work properly, and then the forearm is not vertically in line, and challenges may arise. If this doesn't help, then the likely bottleneck may be extremely stiff structures in the thoracic spine - check the video on thoracic spine mobility exercises for help with that. ---