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Why shoulder pain keeps coming back
If you suffer from shoulder pain that won't go away you're not alone. Studies show that only 21% of sufferers are better after 6 months. The reason shoulder pain won't go away is because as clinical trials show:
- the exercises and many of the things medics and physios do are not much help, and
- two major causes of pain and the treatment shown to work very well are ignored.
In this article we'll go over the causes and effective therapy that get overlooked. The main thing though is to provide the best possible resource to help you get better. To do this we'll give you some practical advice plus show you as much self therapy as possible. You may need some professional help though. If you do we’ll give you enough information to find a suitable professional and discuss things in an informed manner.
Overlooked cause one: (myofascial) trigger points
Overlooked cause two: head and shoulders forward posture
Overlooked effective therapy: trigger point therapy
What’s wrong with typical shoulder therapy
Practical advice to help your shoulder pain
Overlooked cause one: (myofascial) trigger points
The first overlooked cause of shoulder pain is (myofascial) trigger points, which are those tender lumps in your muscles that therapists find. As shown below, trigger points cause shoulder pain:
- directly by shooting referred pain, and
- indirectly by altering the biomechanics of your shoulder causing abnormal stress and impingement.
What are trigger points
Trigger points are those tender lumps in muscles that massage therapists find. For more info please see our article Trigger point basics, but the key issues are that trigger points:
- refer pain
- tighten muscles and inhibit them from functioning normally.
How trigger points cause pain directly
Trigger points directly cause shoulder pain by shooting referred pain. Scientists have mapped where trigger points refer pain to. This diagram is one of one of many muscles that shoot pain to the shoulder (1,2).
How trigger points cause pain indirectly
Trigger points indirectly cause shoulder pain by tightening muscles and stopping them working properly. This affects the movement of the shoulder joint, potentially causing abnormal stress and pinching (called “impingement syndrome”). Let's share how this happens.
As this picture shows your shoulder joint has a large rounded surface sitting in a shallow socket. As you lift your arm the large rounded surface needs to rotate and slide down so:
- there is a large even contact between the rounded surface and the socket, and
- so parts don’t get pinched
Muscular control of joint movement
With a large ball sitting in such a shallow socket it is fairly unstable, so without guidance it would easily slop around and cause damage. As this diagram shows you have a team of short muscles that hold the rounded surface in the best position. The key is that these muscles need to be able to work as a well coordinated team to keep the rounded surface exactly where it should be. However, as discussed in a separate article, with trigger points causing muscles to be abnormally tight and not work properly joint movement becomes coordinated, and this cause several problems.
Uncoordinated shoulder joint movement is the major cause of the commonly diagnosed “impingement syndrome”. When “sitting” normally there is plenty of space above the joint for the critical structures. However, if the position of the rounded part is moved just slightly it causes it to impinge on those structures.
Increased wear and arthritic changes
The pressure is no longer evenly spread across the joint surfaces so the joints wear faster. Long term this causes degenerative or arthritic changes that can be seen on x/ray.
Potential pain syndromes or injury
When your shoulder joint is moving abnormally parts often have to compensate or work in ways they were not designed to and become over-stressed. Over time these can become painful or are easily injured.
Overlooked cause two: a head forward posture
As shown by several studies (3-8), the second overlooked cause of shoulder pain is a head forward posture. This alters the angle that the arm hangs and the direction the shoulder joint moves, which puts a lot of abnormal strain on some parts, and causes others to jamb together when they otherwise would move freely.
The way a shoulder normally hangs
As shown in this diagram your arm usually hangs straight down roughly in line with your shoulder blade. This creates the best gap above for those sensitive structured discussed above, and also the best position for the supporting muscles and tissues.
Changes due to a head forward posture
This pic shows a diagram of head forward posture from one of the scientific studies. As the diagram next to it shows this cause the shoulder blade to be angled forward. With the arm still hanging straight down this alters the angle of the joint, placing unusual stress on the muscles and tissues and making structures more likely to pinch.
The overlooked treatment: trigger point therapy
Trigger points are a major overlooked cause of shoulder pain so it should come as no surprise that treating trigger points is a major overlooked therapy. Trigger point therapy is a very very effective therapy that has been successfully used in many clinical trials. Scientists agree, with one scientific review of 16 studies into shoulder pain stating that trigger points were the most common cause and their treatment should be the number one priority (9). Further, another researcher stated that if trigger points were not taken into consideration they could perpetuate and aggravate the problem, hindering diagnosis and making the applied treatments ineffective (10).
Information omitted from medical journals
Apart from being completely obvious, as you can see in the appendix below, there is a massive amount of scientific research confirming these causes and that treating trigger points should be the first consideration. However, as shown in these three typical medical journal articles (11–13) medical journals usually fail to mention these issues . Instead doctors are advised to use drugs and therapies that don’t work. This omission is easy to understand when you appreciate that most sources of information for doctors rely on drug company funds. If you don’t get better they sell more drugs.
What you can get from this article
The main purpose of this article is to give you the best resource possible to help your shoulder get better. To do this we'll:
- Give you self help advice so you can do a lot yourself.
- If you need some professional help we’ll try and point you in the right direction and give you some things that they should be looking at.
- Unfortunately due to the amount of misinformation about shoulder pain that can be very misleading we need to start by making you aware of the major issues.
Major treatment error one: treating secondary problems
The issues that medics tend to look at such as inflammation, impingement and damage seen on scans are often secondary to the abnormal stresses from the functional and postural issues discussed above. However, these secondary effects are too often treated completely oblivious to their cause.
Major treatment error two: exercises don’t correct abnormal function
While exercises are often prescribed to help shoulder pain, studies show that they are of little help and can often worsen the problem. The reason is very simple. As discussed in our article functional rehabilitation and demonstrated in several studies of shoulder function, exercises cannot correct the abnormal function caused by trigger points or abnormal posture. When the exercises are done your body uses that same abnormal mechanics that causes the problem in the first place, and likely accelerates any damage.
Practical advice for your shoulder pain
Our goal is to give you the best possible resource to help your shoulder pain. We’ve made you aware of some common miss-information and potential pit falls. Now we’ll give you some positive steps. Please keep in mind that we cannot give specific information to those we have not personally examined so consider this as general information to be discussed with a professional familiar with your own needs.
Treat your trigger points
Trigger points were found to be a major cause of shoulder pain, and several clinical trials showed that treating the trigger points can give excellent relief (2,9,14–18). We have a comprehensive guide called Massage and trigger point therapy for shoulder pain: with self help options that gives:
- how to find trigger points
- several effective home therapy options
- a list of muscles that can be potentially involved, with specific instructions for each
Stop doing things that may be stirring up your shoulder.
If you know of any activities that are aggravating your condition stop doing them, at least temporarily while your shoulder settles down. This includes any exercises you may have been prescribed.
Head and shoulders forward posture
As discussed above a head and shoulder forward posture will create abnormal stress on your shoulder joints. If you have this condition it needs to be fixed. This diagram shows you what we mean by a head and shoulders forward posture. The person on the left has his head and shoulders forward, while on the right his head and shoulders are (almost) nicely balanced.
If you do have a head and shoulders forward posture, just like shoulder remedies a lot of the medical solutions such as exercises, taping, braces and advice are ill-conceived and ineffective. Please see this article for information about these spinal problems and how they are fixed.
There are often issues within the shoulder and other joints that inhibit them from working normally. The simplest way to think of these is as adhesions or restrictions stopping the joint surfaces from sliding across each other. Please see this article for more information about these and how they are treated.
There are many possible medical causes of shoulder pain that could be considered, especially if the pain is severe or not settling using conservative measures. Some are listed below. Please keep in mind that some may be secondary and will resolve once any abnormal stress is removed, but they may also be:
- primary resulting from something such as an injury
- secondary, but have developed into a problem in their own right.
Some possible medical causes of shoulder pain (11)
- Rotator cuff pathology (tendonitis, tears)
- Acromioclavicular pathology (sprains, instability)
- Labral tears
- Long-head biceps brachii pathology
- Adhesive capsulitis/stiff shoulder
- Scapular dyskinesis
- Cervical radiculopathy
Appendix: research support
We realise that the contents of this article are contrary to information provided by medical journals and respected professionals, so we conclude with documentation of the research papers and clinical trials that support the major points.
Trigger points as a cause of shoulder pain and trigger point therapy as a treatment
- Basic trigger point research showing what they are and what they do (19–23)
- Trigger points highly prevalent in shoulder pain sufferers (9,24,25)
- Those trigger points refer pain to the shoulder (2,10,25)
- Trigger points effect shoulder function and can cause damage or injury (26–28)
- Trigger point therapy relieves shoulder pain (2,9,14,16–18,29)
Head and shoulder forward posture as a cause of shoulder pain
- This posture as a cause (3–8,30)
- Correcting this posture relieves shoulder pain (8)
Medical journals ignore this information
- Examples (11–13)
Medical are procedures ineffective for shoulder pain
- Analgesics, NSAIDS, corticosteroids and physiotherapy (31,32)
Exercises are unlikely to help shoulder pain
- Clinical trial results (29,31,33,34)
- Exercises cannot correct key functional problems (35–37)
- Bron C. High prevalence of shoulder girdle muscles with myofascial trigger points in patients with shoulder pain. BMC Musculoskelet Disord . 2011;12.
- Bron C, De Gast A, Dommerholt J, Stegenga B, Wensing M, Oostendorp RAB. Treatment of myofascial trigger points in patients with chronic shoulder pain: A randomized, controlled trial. BMC Med. 2011;9.
- Jcu R, Sakthi D. Clinical assessment of subacromial impingement-which factors differ from asymptomatic population. Musculoskeltal Sci Pract. 2017;27:49–56.
- Alizadehkhaiyat O, Roebuck MM, Makki AT, Frostick SP. Postural alterations in patients with subacromial impingement syndrome. Int J Sports Phys Ther. 2017;12(7):1111–20.
- Skolimowskil J, Barczyk K, Dudek K, Skolimowska B, Demczuk-Włodarczyk E, Anwajler J. Posture in people with shoulder impingement syndrome. Ortop Traumatol Rehabil. 2007;9(5):484–48498.
- Otoshi K, Takegami M, Sekiguchi M, Onishi Y, Yamazaki S, Otani K, et al. Association between kyphosis and subacromial impingement syndrome: LOHAS study. J Shoulder Elb Surg . 2014;23(12):e300–7.
- Hunter DJ, Rivett DA, McKeirnan S, Smith L, Snodgrass SJ. Relationship between Shoulder Impingement Syndrome and Thoracic Posture. Phys Ther. 2020;100(4):677–86.
- Lewis JS, Wright C, Green A. Subacromial impingement syndrome: The effect of changing posture on shoulder range of movement. J Orthop Sports Phys Ther. 2005;35(2):72–87.
- Sergienko S, Kalichman L. Myofascial origin of shoulder pain: A literature review. J Bodyw Mov Ther . 2015;19(1):91–101.
- Perez-Palomares S, Oliván-Blázquez B, Arnal-Burró AM, Mayoral-Del Moral O, Gaspar-Calvo E, De-La-Torre-Beldarraín ML, et al. Contributions of myofascial pain in diagnosis and treatment of shoulder pain. A randomized control trial. BMC Musculoskelet Disord. 2009;10(1):1–7.
- Holmes RE, Barfield WR, Woolf SK. Clinical evaluation of nonarthritic shoulder pain: Diagnosis and treatment. Phys Sportsmed. 2015;43(3):262–8.
- Burbank KM, Stevenson JH, Czarnecki GR, Dorfman J. Chronic shoulder pain: Part I. Evaluation and diagnosis. Am Fam Physician. 2008;77(4):453–60.
- Burbank KM, Stevenson JH, Czarneck GR, Dorfman J. Chronic shoulder pain: Part II. Treatment. Am Fam Physician. 2008;77(4):493–7.
- Gordon CM, Andrasik F, Schleip R, Birbaumer N, Rea M. Myofascial triggerpoint release (MTR) for treating chronic shoulder pain: A novel approach. J Bodyw Mov Ther . 2016;20(3):614–22.
- D. Bang. Comparison of supervised exercise with ans without manual physical therapy for patients with shoulder impingement syndrome. J Orthop Sport Phys Ther. 2000;30(3):126–37.
- Shih YF, Liao PW, Lee CS. The immediate effect of muscle release intervention on muscle activity and shoulder kinematics in patients with frozen shoulder: A cross-sectional, exploratory study. BMC Musculoskelet Disord. 2017;18(1):1–10.
- Van Den Dolder PA, Ferreira PH, Refshauge KM. Effectiveness of soft tissue massage and exercise for the treatment of non-specific shoulder pain: A systematic review with meta-analysis. Br J Sports Med. 2014;48(16):1216–26.
- Hains G, Descarreaux M, Hains F. Chronic Shoulder Pain of Myofascial Origin: A Randomized Clinical Trial Using Ischemic Compression Therapy. J Manipulative Physiol Ther . 2010;33(5):362–9.
- Dommerholt J, Bron C, Franssen J. Myofascial Trigger Points: An Evidence-Informed Review. J Man Manip Ther. 2006;14(4):203–21.
- Jafri MS. Mechanisms of Myofascial Pain. Int Sch Res Not. 2014;2014:1–16.
- Zhuang XQ, Tan SS, Huang QM. Understanding of myofascial trigger points. Chin Med J (Engl). 2014;127(24):4271–7.
- Shah J et al. Myofascial Trigger Points Then and Now: A Historical and Scientific Perspective. HHS Public Access. 2015;7(7):746–61.
- Celik D, Mutlu EK. Clinical implication of latent myofascial trigger point topical collection on myofascial pain. Curr Pain Headache Rep. 2013;17(8).
- Lucas KR, Rich PA, Polus BI. How common are latent myofascial trigger points in the scapular positioning muscles? J Musculoskelet Pain. 2008;16(4):279–86.
- Hidalgo-Lozano A. Muscle trigger points and pressure pain hyperalgesia in shoulder muscles in patients with unilateral shoulder inpingement: a blinded controlled study. Exp Brain Res. 2010;202:915–25.
- Lucas KR, Polus BI, Rich PA. Latent myofascial trigger points: Their effects on muscle activation and movement efficiency. J Bodyw Mov Ther. 2004;8(3):160–6.
- Phadke V, Ludewig PM. Study of the scapular muscle latency and deactivation time in people with and without shoulder impingement. J Electromyogr Kinesiol. 2013;23(2):469–75.
- Bohlooli N, Ahmadi A, Maroufi N, Sarrafzadeh J, Jaberzadeh S. Differential activation of scapular muscles, during arm elevation, with and without trigger points. J Bodyw Mov Ther . 2016;20(1):26–34.
- Bang MD, Deyle GD. Comparison of supervised exercise with and without manual physical therapy for patients with shoulder impingement syndrome. J Orthop Sports Phys Ther. 2000;
- Land H. Clinical assessment of subacromial shoulder impingement – which factors differ from the asymptomatic population? Musculoskeltal Sci Pract. 2017;70:429–40.
- Gleyze P, Georges T, Flurin PH, Laprelle E, Katz D, Clavert P, et al. Comparison and critical evaluation of rehabilitation and home-based exercises for treating shoulder stiffness: Prospective, multicenter study with 148 cases. Orthop Traumatol Surg Res. 2011;97(8 SUPPL.).
- Cloke DJ, Watson H, Purdy S, Steen IN, Williams JR. A pilot randomized, controlled trial of treatment for painful arc of the shoulder. J Shoulder Elb Surg. 2008;17(1 SUPPL.).
- Senbursa G, Baltacı G, Atay A. Comparison of conservative treatment with and without manual physical therapy for patients with shoulder impingement syndrome: A prospective, randomized clinical trial. Knee Surgery, Sport Traumatol Arthrosc. 2007;15(7):915–21.
- Yemul SR. COMPARISON OF SUPERVISED EXERCISE WITH AND WITHOUT MANUAL PHYSICAL THERAPY FOR PATIENTS WITH SHOULDER IMPINGEMENT SYNDROME. J Cur Res Rev . 2013;05(05):5.
- Camargo PR, Alburquerque-Sendín F, Avila MA, Haik MN, Vieira A, Salvini TF. Effects of stretching and strengthening exercises, with and without manual therapy, on scapular kinematics, function, and pain in individuals with shoulder impingement: A randomized controlled trial. J Orthop Sports Phys Ther. 2015;45(12):984–97.
- De Mey K, Danneels L, Cagnie B, Cools AM. Scapular muscle rehabilitation exercises in overhead athletes with impingement symptoms: Effect of a 6-week training program on muscle recruitment and functional outcome. Am J Sports Med. 2012;40(8):1906–15.
- Falla D, Jull G, Hodges P. Training the cervical muscles with prescribed motor tasks does not change muscle activation during a functional activity. Man Ther. 2008;13(6):507–12.
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About Dr Graeme
Several years ago Dr Graeme, a Chiropractor practicing in Victoria, Australia was looking for a serious hand held massager his patients could use at home to get the extra quality massage they needed. The ones he found in the shops and on-line for home use looked nice but were not serious, and... read more
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