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  Tuesday 26th September, 2023
  Author: Dr Graeme Blennerhassett

Do exercises help shoulder pain

Neck and shoulder exercises
Do these actually help shoulder pain

If you suffer from shoulder pain you will likely be given some analgesics to relieve the pain and some exercises to “correct” the problem. However, according to the Journal of Shoulder and Elbow Surgery 79% of people with shoulder pain are still suffering after six months (1)⁠. So, do the exercises work, or are they even a good idea?

When we reviewed the clinical trials and other scientific information we found that using exercises like this is unlikely to correct shoulder problems and has even been shown to cause harm. However, “more enlightened” medics and other professionals do use exercises very successfully as part of correction and rehabilitation programs. In this article we will explain why the first approach will not work, then how others use exercises successfully.

An overview of shoulder problems

The key issue

The key issue is that for your shoulder to be able to move such a long way the joint has to be complex and relatively unstable. This requires a complex mechanism to keep the joint surfaces aligned properly as you move. When something affects this mechanism the joint will move abnormally, causing it to pinch, wear fast and become damaged. To correct your shoulder you need to correct what’s affecting the control mechanism. If you just exercise the shoulder will continue to move abnormally and be further damaged.

The issue in more detail

Hip and shoulder joint movement
Your shoulder joint has to move further, so is more complex and less stable

The unstable anatomy of your shoulder

To understand this lets compare your hip and shoulder joints. Looking at your hip joint first it doesn’t have to move so far so it has a ball sitting snugly in a socket with strong bands holding it in place. Looking at your shoulder for comparison it has a large ball sitting in a shallow socket. That lets the joint move much further, but as you can see there’s not that snug fit in the socket stopping it move up and down, or even pull out for that matter. To keep that ball sitting snugly where is should be we have a complex control mechanism involving balance and the muscles around your shoulder. Lets look at how this works.

Upwards shoulder movement

How your shoulder moves

Your shoulder need to move in all different directions, but I’ll just use one as an example. As your arm lifts up the ball slides down in the socket.

Faulty shoulder joint movement

Lets look at what happens if it doesn’t do that properly. We can see it’s pinching at the top. Also, instead of the load being spread out over a big area there’s a lot of pressure in one spot, and the gap at the bottom is much bigger so it’s stretching things and a lot less stable.

The key to most shoulder pain

This is the key to most shoulder pain and shoulder problems. If everything is working as it should your shoulder joint moves around nicely and is very happy, but if something is not right such as the balance being upset or some of the muscles not working properly you’ll get that abnormal movement in the joint causing pinching, uneven pressure and abnormal stress.

Impingement syndrome medical

Impingement syndrome

Doctors call this impingement syndrome, and here is an example showing the ball pinching the structures at the top of the joint.
If you leave it for long enough some of those parts becoming damaged or worn. Doctors like to show you things like that on scans and x-rays saying they’ve found the problem. The trouble is yes they might be a problem, but they are secondary damage caused by real problem,

Why analgesics and exercises will not fix the problem

Understanding that, let look at why the analgesics and exercises will never fix the problem.
The abnormal movement in the joint will have some underlying cause(s) such as a postural imbalance or muscles not doing what they need to. If you exercise the shoulder with those issues remaining that joint will still move around abnormally causing damage. If anything it will accelerate the damage, and that’s what scientists have found. They’ve found that exercises can’t fix these problems (2–5)⁠, they won’t fix the shoulder pain, and in many cases make the pain worse (6)⁠.

The better solution to shoulder problems

I mentioned that there were medics and other professionals who were using exercises differently and being very successful. Their approach is very logical. They identify and fix the issues that cause the joint to work abnormally. The joint is then able to move normally and exercises are used to help rehabilitation.
With that we’ll make the rest of this article the best resource we can to help you understand the issues and get your shoulder looked after properly. We will be covering:

  1. some things you need to be careful of
  2. the main issues that cause shoulders to work abnormally
  3. how the successful professionals do it

Some issues to be careful of

We have already seen that the common medical approach to shoulder pain is illogical, but according to their own medical journals:

  • the evidence does not support the use of analgesics, anti-inflammatory drugs, corticosteroids, physiotherapy or exercises, and
  • after six months 79% of shoulder pain is un-resolved (1)

Ironically, the major issues we are about to discuss usually do not rate a mention.

The main issues that cause shoulder joins to work abnormally

There are three main issues that cause shoulder joints to work abnormally. We discuss these in our article Why shoulder pain keeps coming back and what you can do about it , but will summarise them here.

  1. Head forward postures
  2. (Myofascial trigger points)
  3. Joint adhesions, nerve interferences and other issues that need a professional to help with
Head forward posture
Having a head forward posture is a major cause of shoulder pain, but this is largely omitted from medical journals

Head forward shoulder posture

Postures like shown in this diagram alter the angles and balance of shoulder structures placing them under abnormal stress. Several studies have found this to be a major cause of shoulder impingement (7–13)⁠, while one found that if this posture was corrected it relieved shoulder pain (13)⁠. As said before though, the medical journals doctors read usually do not mention this (14,15)⁠.

Teres major muscle, points and pain
Teres major muscle, points and pain

(Myofascial) trigger points

(Myofascial) trigger points, or “trigger points” for short are those tender lumps in your muscles that massage therapists find. They actually cause shoulder pain three ways.

  1. They inhibit muscles making them unable to maintain the shoulder joint in it’s correct position.
  2. They refer pain directly like it shows in these charts.
  3. They can contribute to postural issues
Key research findings about trigger points and shoulder pain
  1. One researcher found that when the shoulder muscles contained trigger points they were unable to control the joint properly, but when the trigger points were treated the control went back to normal (16)⁠
  2. Other researchers found that compared with non-sufferers the muscles of shoulder pain sufferers contain large numbers of trigger points, and treating these trigger points relieves shoulder pain (17,18)⁠

As before, this information does not appear in the medical journals doctors read (these journals rely on drug company advertising).

Joint adhesions, nerve interferences and other issues that need a professional to help with

Shoulder joints are very complex so there can be a host of other issues affect the control of their movement. These need to be investigated and taken care of by a properly qualified professional such as a Chiropractor, Osteopath, or a Physiotherapist with special post graduate qualifications. We recommend that you have someone like this check you, especially if your shoulder is not improving.

How the successful professionals do it

The successful (and logical) way to help these problems is to correct or eliminate any issues that are causing your shoulder to work abnormally, then use exercises to help rehabilitation. There are professionals who do this well, so lets look at some examples.

  1. Trigger points: the universal problem
  2. Examples in clinical trials
  3. The (USA) National Association of Sports Medicine guide
Recommendations

If you have shoulder pain we recommend that you seek the help of a professional who follows similar practices to those described below.

Trigger points: the universal problem with shoulder pain

Trigger points are almost universally present in shoulder pain sufferers (18)⁠, and can cause pain 1) directly by referred pain, 2) by preventing the muscles that control movement from working normally, and 3) by altering posture. We have seen that treating trigger points alone is very effective in relieving shoulder pain.

What happens is by treating trigger points you take care of a lot of potential causes of shoulder pain. Unless there are serious issues, if you remove the issues that prevent normal shoulder function your nervous system will be able to use your shoulder normally again. Normal movements and activities can take care of any rehabilitation. For more information about how to take care of these trigger points please see our article Massage and trigger point therapy for shoulder pain .

Examples in clinical trials

There have been several studies of shoulder pain where exercises alone have been compared with exercises plus physical therapies such joint manipulation (freeing up restricted joints) and soft tissue therapy (massage and trigger point therapy) (19–22)⁠. In each case the results were way better when using the therapies. In these cases professionals have used various physical therapies to help take care of the issues inhibiting normal joint function, then the joints can exercise functioning more normally for rehabilitation.

National Academy of Sports Medicine: Essentials of corrective exercise training
National Academy of Sports Medicine advises to restore functional elements as part of any corrective exercise program

(USA) National Academy of Sports Medicine guidelines

The National Academy of Sports Medicine (NASM) produces a 400+ page guide called “NASM Essentials of Corrective Exercise Training" (23)⁠. It advises that before doing “corrective” exercises several issues including those muscular problems we’ve mention need to be addressed.

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. Worsley P et. al. Motor control retraining exercises for shoulder impingement: effects on function, muscle activation and biomechanics in young adults. J Shoulder Elb Surg. 2013;22(4):e11–9.
  3. Moraes GFS, Faria CDCM, Teixeira-Salmela LF. Scapular muscle recruitment patterns and isokinetic strength ratios of the shoulder rotator muscles in individuals with and without impingement syndrome. J Shoulder Elb Surg. 2008;17(1 SUPPL.):48–53.
  4. 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.
  5. 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.
  6. 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.).
  7. Jcu R, Sakthi D. Clinical assessment of subacromial impingement-which factors differ from asymptomatic population. Musculoskeltal Sci Pract. 2017;27:49–56.
  8. 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.
  9. 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.
  10. 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.
  11. 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.
  12. Land H. Clinical assessment of subacromial shoulder impingement – which factors differ from the asymptomatic population Musculoskeltal Sci Pract. 2017;70:429–40.
  13. 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.
  14. Burbank KM, Stevenson JH, Czarnecki GR, Dorfman J. Chronic shoulder pain: Part I. Evaluation and diagnosis. Am Fam Physician. 2008;77(4):453–60.
  15. Holmes RE, Barfield WR, Woolf SK. Clinical evaluation of nonarthritic shoulder pain: Diagnosis and treatment. Phys Sportsmed. 2015;43(3):262–8.
  16. Lucas KR, Rich PA, Polus BI. The Effects of Latent Myofascial Trigger Points on Muscle Activation Patterns During Scapular Plane Elevation. Jclb . 2007;25(8):765–70.
  17. 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.
  18. Bron C. High prevalence of shoulder girdle muscles with myofascial trigger points in patients with shoulder pain. BMC Musculoskelet Disord . 2011;12.
  19. 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
  20. Bae YH, Lee GC, Shin WS, Kim TH, Lee SM. Effect of motor control and strengthening exercises on pain, function, strength and the range of motion of patients with shoulder impingement syndrome. J Phys Ther Sci. 2011;23(4):687–92.
  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. Clark MA, Lucett SC. NASM Essentials of Corrective Exercise Training. Lippincott Williams & Wilkins; 2011.

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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



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