Why shoulder pain keeps coming back- and what you can do about it

CONTENTS

The medical treatments that do not work
The causes doctors are not told about
Shoulder pain treatment summary

Please note that this is for general information only. For specific advice you need a professional familiar with your own needs.

The medical treatments that do not work

In this section:

• Primary treatments
• “Impingement syndrome”
• Exercises

Primary treatments

As discussed in the following quote from the Journal of Shoulder and Elbow Surgery (1),⁠ there is no evidence the common medical treatments for shoulder pain work.

“The primary care treatment of this problem is not evidence based. Analgesia, nonsteroidal anti-inflammatory drugs (NSAIDS), corticosteroid injections, and physiotherapy modalities are all used for shoulder pain in the primary care setting. Clearly, shoulder pain is a symptom, not a diagnosis, but many studies have aimed at finding the best initial treatment for this symptom without success. Thus, trials of various interventions for shoulder pain have been performed but have been criticized for their lack of population definition and the heterogeneity of the outcome measures used.”

Impingement syndrome

Although “impingement syndrome” is the most common diagnosis made by doctors for shoulder pain, as discussed in the following quote from BMC Musculoskeletal Disorders Journal (3)⁠ this is a major error.

Although subacromial impingement is often suggested to be a potential source of shoulder pain [7,8], solid evidence is lacking. In fact, calcifications, acromion spurs, subacromial fluid, or signs of tendon degeneration are equally prevalent in healthy subjects and in patients with shoulder pain [9-12]. Furthermore, physical examination tests of subacromial impingement are not reliable [13-15], and the results of imaging diagnostics do not correlate well with pain [9,10,16,17]. In addition, interventions targeting subacromial problems are, at most, only moderately effective at treating shoulder complaints [18-24] (3)⁠.

Corrective exercises do not help

While exercises are a worthwhile part of rehabilitation, commonly prescribed “corrective exercises” do not work and can possibly make the problem worse. For more information please see our article Do exercises help shoulder pain .

The causes doctors are not told about

In the previous section we discussed that doctors are told to make incorrect diagnoses and prescribe treatment that does not work. In the following section we will discuss the two major causes of shoulder pain that:

• are supported by a large amount of research,
• treatment has been proven to be effective.

Despite being backed by a large amount of research this information is omitted from most medical journals (eg. (4,5)⁠) This is because such information is heavily influenced by drug company funding. This affects the advice you receive, whether it is from your GP or Physio, the Mayo Clinic, or Harvard Medical School.

The causes:

1. A head and shouldered forward posture
2. (Myofascial) trigger points

How trigger points indirectly cause shoulder pain

Shoulder function relies on muscle control

As shown in the diagram below your shoulder has a large ball sitting in a shallow socket. This allows your shoulder to move a long way, but is very unstable. Because of this your body has the muscles around the joint work as a team to keep the ball sitting correctly in place.

Trigger points impair muscle control

As discussed in our Your Complete Guide To (Myofascial) Trigger Points , trigger point prevent muscles from working normally. When this happens the ball does not sit in the socket correctly so:

• pressure on the bearing surfaces is uneven
• parts of the joint can be pinched or overstressed.

This can result in:

• pain
• an increased risk of injury
• increased wear (long term arthritic changes)

Shoulder pain treatment summary

Please note that this is for general information only, and no substitute for advice for advice from a professional familiar with your specific needs.

1. First do no harm
2. Assessment of posture
3. Trigger point assessment
4. Sensible use of exercises
5. Medical conditions

First do no harm

The first step is to evaluate and if necessary discontinue any treatment that may be unhelpful or even harmful. For example:

• As discussed in our article Do exercises help shoulder pain , “corrective exercises” often do more harm than good.
• Analgesics may mask the pain that acts as a warning to prevent further damage.

Assessment of posture

If you have a head forward posture your shoulders will continue to suffer from abnormal stress. In one clinical trial researchers used tape to help normalise posture, however, this is not a permanent solution. There is usually a reason for this posture other than poor habits, so consciously “straightening” or doing exercises are usually not solutions either.

For more information on the common cause of poor posture please see our article on the cause of back pain. To deal with this you will likely need help from a qualified person such as a Chiropractor, Osteopath, or Physiotherapist with special post graduate qualifications.

Trigger point assessment

Please see the following article for a step by step guide on how to find and treat the trigger points that cause shoulder pain.
Massage and trigger point therapy for shoulder pain

Sensible use of exercises

So called “corrective exercises” cannot correct abnormal shoulder function are are likely to cause harm. However, once function is corrected exercises are very useful for rehabilitation. For more information please see Do exercises help shoulder pain .

Medical causes of shoulder pain

Although medical journals promote drugs and exclude other things there are some potential medical causes that can be considered. The following list is from one of the example articles that completely omitted the two major causes (4)⁠.

Potential causes of nonarthritic shoulder pain

• Rotator cuff pathology (tendonitis, tears)
• Bursitis
• Impingement
• Acromioclavicular pathology (sprains, instability)
• Labral tears
• Long-head biceps brachii pathology
• Instability
• Adhesive capsulitis/stiff shoulder
• Scapular dyskinesis
• Fracture
• Cervical radiculopathy

References

1. 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.).
2. 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.
3. Bron C. High prevalence of shoulder girdle muscles with myofascial trigger points in patients with shoulder pain. BMC Musculoskelet Disord 2011;12.
4. Holmes RE, Barfield WR, Woolf SK. Clinical evaluation of nonarthritic shoulder pain: Diagnosis and treatment. Phys Sportsmed. 2015;43(3):262–8.
5. Burbank KM, Stevenson JH, Czarnecki GR, Dorfman J. Chronic shoulder pain: Part I. Evaluation and diagnosis. Am Fam Physician. 2008;77(4):453–60.
6. Jcu R, Sakthi D. Clinical assessment of subacromial impingement-which factors differ from asymptomatic population. Musculoskeltal Sci Pract. 2017;27:49–56.
7. 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.
8. 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.
9. 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 [Internet]. 2014;23(12):e300–7. Available from: http://dx.doi.org/10.1016/j.jse.2014.04.010
10. 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.
11. 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.
12. Land H. Clinical assessment of subacromial shoulder impingement – which factors differ from the asymptomatic population? Musculoskeltal Sci Pract. 2017;70:429–40.
13. 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.
14. Sergienko S, Kalichman L. Myofascial origin of shoulder pain: A literature review. J Bodyw Mov Ther. 2015;19(1):91–101.
15. Fernández-de-las-peñas AHC, Arendt-nielsen CAHGL, Arroyo-morales M. Muscle trigger points and pressure pain hyperalgesia in the shoulder muscles in patients with unilateral shoulder impingement : A blinded , controlled study . 2010;Experimental Brain Research 202(4):915-25
16. Van Den Dolder PA, Roberts DL. A trial into the effectiveness of soft tissue massage in the treatment of shoulder pain. Aust J Physiother . 2003;49(3):183–8.
17. 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.
18. 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.