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  Monday 4th April, 2022
  Author: Dr Graeme Blennerhassett

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

Doctor examining patient with shoulder pain
In this article we discuss the two common causes of shoulder pain doctors too often overlook
The problem

Shoulder pain is very common, yet most of the common treatments such as exercises, medications and other therapies do little more than temporarily relieve your pain. Doctors and therapists will give you a confident sounding diagnosis and advice, yet the reality is that the clinical trial results for those prescribed treatments are not encouraging, and according to a recent medical journal review of shoulder pain therapy (1)⁠ there is no agreement on how to control pain or any type of exercises to correct the problem.

Scientists have found the answer

If you have shoulder pain this is very bad news. However, there’s a light at the end of the tunnel. Scientists certainly understand why you get shoulder pain and what needs to be done, however, the information doctors receive is heavily filtered favouring information that helps sell drugs and medical services. In the case of shoulder pain medical journals usually omit the two main easily correctable causes of shoulder pain, and the fact that that it is virtually impossible for any exercise to fix a shoulder problem.

Dr Graeme's comments
The good news

The good news is that the solution to a lot of shoulder problems is often to just simply address those two overlooked causes, and to stop doing those exercises and therapies that don’t work. In this article we want to give you the best possible resource to help you fix your shoulder pain. We’ll start by sharing with you those three important issues that medical journals tend to omit, then give you a strategy to address these and hopefully get better. Please note that this is for general information only. For specific advice you need a professional familiar with your own needs.

Examples of medically filtered information about shoulder pain

The following section discusses the three critical pieces of information too often omitted from medical journals. This affects the advice you receive, whether it is from your GP or Physio, the Mayo Clinic, or Harvard Medical School.

Head forward posture
Head and shoulders forward posture: causes abnormal stress on your muscles and joints

Head forward posture causes shoulder pain

We found seven scientific studies that show that having a head and shoulder forward posture as shown in this diagram is a big cause of shoulder pain and impingement (2–8)⁠. This posture alters the angle of the joint, and places abnormal stress on the shoulder muscles and joint. In one trial where the posture was corrected this relieved shoulder pain (7)⁠. Despite being such an obvious issue confirmed by many scientific studies, medical journal articles written to instruct doctors on how to diagnose and treat shoulder pain generally make no mention of this. Instead they recommend using drugs and other therapies, oblivious to the cause (9–11)

(Myofascial) trigger point
Scientists found that these are a huge cause of shoulder pain

(myofascial) trigger points are a cause of shoulder pain

(Myofascial) trigger points are those tender lumps in your muscles massage therapists find. In a series of trials, highly credentialed scientists have found that they are are a major cause of shoulder pain, and that treating them gives excellent relief (12–18)⁠ . However, again this is not mentioned in those medical journals (9–11)⁠.

Exercises alone cannot correct a shoulder problems

Medical journals teach doctors that a major cause of shoulder pain is conditions such as impingement syndrome, which is where the shoulder joint functions abnormally causing it to “pinch”. The journals recommend that doctors correct this abnormal function by prescribing exercises (19).⁠ They do this in spite of the following.

  1. According to basic scientific principles it is impossible for exercises to correct this abnormal function.
  2. According to scientific studies where they have tried to correct abnormal function with exercise it doesn’t work (20)⁠.
  3. Trials where exercises alone have been used to relieve shoulder pain have only produced mediocre results (21–23)⁠.

The ironic thing is that as discussed in our article The real cause of shoulder impingement the two main causes of shoulder impingement are those two things the medical journals omit: head forward posture and (myofascial) trigger points. For further information on why exercises are inappropriate please see our articles:
Functional rehabilitation
Exercise shown to not correct abnormal muscle function

Your strategy to relieve shoulder pain

Dr Graeme's comments

Graeme’s comments

We wish to give you the best possible resource to help get rid of your shoulder pain. On one hand there are many possible causes of shoulder pain that need medical attention, but on the other hand the major issues are too often ignored and inappropriately treated. Another consideration is that with problems such as these usually the most effective and cost effective care is to have some professional advice, but be able to supplement their care with things you can do yourself. With this in mind, I’ll:

  • provide you with comprehensive yet easy to understand general information about these issues so you can choose a professional and discuss your care in an informed manner, and
  • provide the home advice we’d give if it were appropriate.

Major ignored cause one: head and shoulders forward posture

As mentioned, many scientific studies have confirmed that having a posture with your head and shoulders forward is a big cause of shoulder pain. There are two main reasons for this.

Balance example: leaning tower of Pisa
Leaning forward: no longer balanced

A head and shoulders forward posture affects balance

Your head and shoulders are designed to sit nicely balanced. With your head and shoulders forward they are no longer balanced, which causes extra tension on your muscles and pressure on the joints.

The effect of posture on shoulder joint position
Your arm hangs straight down, so a head forward posture changes the angles of your shoulder joint

A head and shoulders forward posture affects joint mechanics

Having a head and shoulders forward posture changes the angle of pull on the shoulder joint and the way it moves. One of the main medical diagnosis for shoulder pain is shoulder impingement, which is abnormal shoulder joint movement causing pinching. As discussed in our article The real cause of shoulder impingement having a head and shoulder forward posture is a main cause of this abnormal movement.

Doctors try and correct this abnormal function using shoulder exercises. However, I hope you can see that as long as the posture remains abnormal gravity will pull on the joint abnormally. Shoulder excercises cannot correct this. Worse still, if you exercise with your posture this way the exercises will be doing the same "pinching" movement, just doing more damage.

Addressing the issue of head and shoulder forward posture

In one trial scientists used tape to normalise the posture and found that it relieved the shoulder pain (7)⁠ , which confirms the logical idea that if you straighten your posture the tension and pressure will come off the muscles and joints, and your arm will hang straight down normalising the mechanics. Using tape in a clinical trial to prove a point is great, but it is not an appropriate way to make proper long term changes to your posture. If you have head and shoulders forward posture we recommend that you see out article What is a misaligned vertebrae for advice on proper correction.

Major ignored cause: (myofascial) trigger points

As mentioned, the second major overlooked cause of shoulder pain is (myofascial) trigger points. They are those tender lumps in muscles that massage therapists find. Scientists have done a series of studies that prove conclusively that they are a major cause of shoulder pain (12-18), and can do so either directly or indirectly.

Trigger point chart
Scientists have found that many many trigger points refer pain to your shoulder

How trigger points cause shoulder pain directly

When they are smaller trigger points only shoot pain when someone presses on them. However, as they grow larger they shoot pain without being provoked. Scientists have found that a large number of these can shoot pain to your shoulder. For details and a list of these muscles please see this article.

Trigger points cause shoulder pain indirectly

Trigger points have been shown to cause shoulder joints to work abnormally (24,25)⁠, and as discussed this can cause abnormal stress and “pinching” within your shoulder joint. The way trigger points to this is by altering the way your muscles work, and muscles control the movement of your shoulder. Even if not causing pain directly, when a muscle contains trigger points it:

  • tightens abnormally
  • has reduced strength
  • quickly fatigues, and
  • responds slowly

How to check for and treat your shoulder trigger points

We have an excellent guide on finding and treating trigger points which may be causing shoulder pain. It is called Massage And Trigger Point Therapy For Shoulder Pain, With Self Help Options.

Dr Graeme's comments

Thank you very much for reading this. It is most appreciated. If you have any questions or comments please don't hesitate to email.

Graeme :-)

Appendix: medical causes of shoulder pain

The following table is a list of possible causes of shoulder pain as given in a medical journal (11)⁠. Although the major causes are missing the potential problems listed are real, and must be considered by any professional addressing shoulder pain.

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. Greenberg DL. Evaluation and treatment of shoulder pain. Med Clin North Am. 2014;98(3):487–504.
  2. Jcu R, Sakthi D. Clinical assessment of subacromial impingement-which factors differ from asymptomatic population. Musculoskeltal Sci Pract. 2017;27:49–56.
  3. 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.
  4. 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.
  5. 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
  6. 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.
  7. 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.
  8. Land H. Clinical assessment of subacromial shoulder impingement – which factors differ from the asymptomatic population? Musculoskeltal Sci Pract. 2017;70:429–40.
  9. Burbank KM, Stevenson JH, Czarnecki GR, Dorfman J. Chronic shoulder pain: Part I. Evaluation and diagnosis. Am Fam Physician. 2008;77(4):453–60.
  10. Burbank KM, Stevenson JH, Czarneck GR, Dorfman J. Chronic shoulder pain: Part II. Treatment. Am Fam Physician. 2008;77(4):493–7.
  11. Holmes RE, Barfield WR, Woolf SK. Clinical evaluation of nonarthritic shoulder pain: Diagnosis and treatment. Phys Sportsmed. 2015;43(3):262–8.
  12. 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.
  13. Sergienko S, Kalichman L. Myofascial origin of shoulder pain: A literature review. J Bodyw Mov Ther. 2015;19(1):91–101.
  14. 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.
  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.
  19. 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.
  20. 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.
  21. 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.
  22. 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.
  23. 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;
  24. 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.
  25. Kim HA. Comparison of shoulder strength in males with and without myofascial trigger points in upper trapezius. Clin Biomech. 2017;49:134–8.

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Dr Graeme

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