Shoulder Pain really sucks. I mean you need your arms to perform most tasks in life. When a simple task like getting dressed and undressed becomes painful and scary, you know you have problems! I’m going to break this topic down for you so that you understand that there are simple and logical solutions for your shoulders.
Sometimes logic escapes people. It escapes them because they are too lazy to put a little effort into a topic. Logic requires that you think, question, and be open to being a little uncomfortable with some of the conclusions you make. When it comes to shoulder pain, there is much misunderstanding. Largely because of lazy therapists who refuse to put a little logic and effort into their thoughts and their work.
Shoulder pain is one of the most misunderstood conditions we see in the clinic. Diagnosing problems in the shoulder is not overly complicated. Not that we resort to imaging as a first response, but an MRI will pick up almost all the pain points in the shoulder. Symptoms are generally well understood. So when you combine symptom analysis, good testing, and even an MRI, most practitioners should be able to diagnose your shoulder pain with their eyes closed.
Treatment for shoulder pain, for some bizarre reason, seems to be way off the mark. From external rotation exercises, silly band work and ineffective cortisone injections, therapists have swallowed the bad rehab pill and you, the patient… you’re still suffering!
Now I have to take a minute here and mention that there are cases out there that are serious and require a referral, like labral tears, full rotator cuff tears, fractures and other traumatic injuries. There are even some serious pathologies, like heart conditions and tumor related illness that refer pain to the shoulder and need medical attention. These are not the topic of this article and should be addressed by the proper medical professional. What we are discussing today, is the shoulder pain that’s been hanging around for a few months that won’t go away, that seems to get worse with exercise and all the nasties have been considered and ruled out.
I’m a trained Osteopath. Osteopathy, compared to Physiotherapy and Chiropractic, is a fairly obscure profession. Being obscure, we usually see people at the end of the line. If you’re a shoulder pain sufferer, you usually see the doctor, physio, chiro, the specialist, the surgeon, the herbalist, the psychic. You’ve tried the rain dance… and then your colleague at work has told you – quite passionately – to come see an Osteopath.
So when we see a patient at the end of the line, they’ve tried everything and nothing has worked, you’re challenged to think differently and develop some tools that are somewhat “outside of the box.” And that’s fine with us, as our education actually encourages us to think deeply about the practical mechanics of a condition and its effects on your body.
Disclaimer: This is for Educational Purposes Only
Let me take a quick intercession to inform you as to the nature of our advice. We are experienced, healthcare clinicians. We wish to share our experience with you on topics to do with your health. We may be a little colourful in doing so, but at the heart of what we do is in-the-trenches experience. Whilst we have achieved academic success and understand the evidence, we are not solely evidence-based. We are, however, EVIDENCE INFORMED.
We find that the evidence is usually 10-15years (at minimum) behind what we are seeing in the clinic. We see real people, with real problems, and we’ve made a great living out of offering real solutions.
If all you’re after is the researched evidence, you can find some on Google Scholar, or you can very easily look for more on Google. We want to give you real-life advice, most of which you may not find in the research.
There is no way that this document can replicate or replace expert assessment and guidance given by a qualified registered healthcare practitioner who has seen you personally. I am sure you’re aware that I have no knowledge of your personal medical history or how you take care of your body. If you require care from a qualified practitioner, you would be best served by seeing someone who can empathise with your situation and treat you accordingly.
I’m sure you understand that I disclaim any and all responsibility for anything you do as a result of reading this document. And by reading this article, you accept 100% responsibility for the actions of you or anyone under your care.
Moving forward, a little anatomy is important.The Shoulder Complex is made up of three joints:
- The Gleno-Humeral Joint (GH joint), which is the ball and socket joint between your arm (ball) and the glenoid (socket) . It has ligaments around it that create a capsule around the joint, much like the hip joint.
- The Acromio-Clavicular Joint, commonly referred to as the the AC joint, connects your collarbone to the forward bony part of your shoulder blade called the Acromion.
- The Scapulo-Thoracic (ST) Joint. This is psuedo joint in that it’s not made up of two bony ends. This joint is more like a floating joint of tissues that bind the shoulder blade (scapula) to the spine (thoracics).
In combination, these joints allow you to fully rotate your arm around with a lot of mobility, very much like a softball pitcher would when throwing a softball. Although the shoulder joint is similar to the hip joint in it’s make up, but different to the hip, in that it gives up a lot of stability for mobility, hence why it can be susceptible to many injuries and can be affected by injuries to closer structures, like the spine and ribs.
There are many important muscles affecting the Shoulder Complex. The most talked about are the rotator cuff group of muscles. These are the 4 muscles where we usually either find tearing or inflammation when people present to us with shoulder pain. They are called the rotator cuff because they all help rotate the ball within the socket.
- Supraspinatus: This muscle starts from the top of the shoulder blade, wraps around the back of the shoulder and attaches onto the top of the arm. It begins the first part of the movement when raising your arm to the side, like a pulley.
- Infraspinatus: This muscle starts from the large midsection of the shoulder blade, wraps around the back of the shoulder and attaches onto the top of the arm. It externally (outwardly) rotates the arm.
- Subscapularis: This muscle starts from the front side of the shoulder blade, wraps in front of the shoulder and attaches on the top of the arm, underneath the supra/infra muscles. It internally (inwardly) rotates the arm.
- Teres Minor: This muscle starts from the upper outside edge of the shoulder blade, wraps around the back of the shoulder and attaches to the top of the arm. It also rotates the arm outwards.
There are a few other muscles that are key in understanding shoulder injury. Serratus Anterior, Rhomboids, Deltoids to name a few. But there is, in my opinion, a King Maker in the shoulder pain puzzle. A smaller muscle that tends to underpin many unresolved shoulder injuries. This would be the Pec Minor.
The Pec Minor starts from the front pointing bone of the shoulder blade (called the coracoid process) and attaches to the front part of ribs 3-5. It’s function is to shift the entire Shoulder Complex forward. It doesn’t take a genius to figure out that shoulder blade movement forward and outwards, what we generally call protraction, has more to do with Pec Minor tension than it has to do with any weakness in rotator cuff or posterior shoulder blade muscles. It’s this tension in Pec Minor and the subsequent forward movement of the whole shoulder complex that locks your problem in, without improvement! The reason for this…is well, simple. As humans, we almost always work with our arms out in front of us.
The Shoulder area is a relatively small space. There are 4 tendons, many ligaments, bones and muscles that all need to move together. These structures are lubricated in their movement by small structures called bursa. A bursa is basically a fluid filled sack sitting in areas where friction between two structures can be problematic. They help with movement. These bursa can also get inflamed, giving us Bursitis. There are two major bursa in the Shoulder Complex, the Subdeltoid Bursa and the Subacromial Bursa.
Now that we have gotten the anatomy out of the way, let me provide an explanation as to why you’re not getting any better. The standard Physiotherapy, Exercise Physiology, and dare I say evidence based approach to shoulder pain is to strengthen the rotator cuffs and the posterior muscles affecting the shoulder blade. The idea behind this is to improve stability in the joint, and pull the shoulder blades back into position. External rotation exercises are given along with band pulls to try and stabilise the shoulder. This doesn’t work and in most cases, will actually make you worse! Let me explain why.
As I mentioned earlier, most of our work is done in front of our bodies. Most observations of the shoulder blade in people with shoulder pain see the position as being forward and outwards, as in rounded shoulders. The Pec Minor is the major player in this rounded shoulder position. This turns the whole shoulder complex inwards. Now, you can’t operate a mouse with shoulders turned in, you can’t hold a hammer, write with a pen, or chop with a knife. So to balance yourself back to a position where you can function, you subconsciously over time turn your arms outwards. This is what the body does, it compensates to allow for your everyday function. So now, you have shoulders rolled in,and arms turned out. Your shoulders pretty much look rounded. Your GH joint is in an external (outwardly) rotated position, and at least 3 of those rotator cuff muscles are inflamed trying to do this for you.
Once those tendons are inflamed you have less space in that shoulder area and you get pinching at the top of an overhead movement and pain with movements behind your back. That’s why you get a pinch when reaching for a cup, can’t put your jacket on or unclip your bra without pain. This change in function will eventually affect the structure of the joint. The capsule and ligaments of the shoulder change their integrity to allow for external rotation and restrict internal rotation. I’m not even going to mention the myriad of changes to the spine.
And that is why external rotation exercises don’t work. Because they are taking the shoulder into a position that it’s already suffering in. If anything, they’re making you worse. Why would you work a muscle that’s already hyper inflamed?! Why would you encourage positional changes that are already causing structural problems?! The therapists that give these exercises, are lazy and don’t think. The use of logic somehow seems too painful and arduous for these people. It’s easier to just give you exercises, then blame you for not getting better because you didn’t do them correctly.
As a therapist, once you understand shoulder pain and it’s origins, you then come to the conclusion that not only is thought required, but also some hard work and responsibility. You have to help the patient unwind some of the compensations that have built up over time. There needs to be work done on muscles, ligaments and joints. You’ll need to help them reduce inflammation and manage their movement so as not to create more inflammation. The therapist must take responsibility in helping you achieve a decent night’s sleep and needs to have developed some strategies for inflammation management. You also need a plan for correct strengthening work, that strengthens the whole structure, once it’s ready for it.
Ok, so what are some things you can do to try and reverse this condition?
- You need to manage inflammation, especially at night. If you’re not sleeping because of shoulder pain, then you’re not recovering. Simple as that. Icing can help. Check out our icing video in the resources section. Place the ice pack under a tight skins shirt about 1-2hrs before you sleep. Fish Oils, Magnesium and Curcumin may also be helpful with inflammation.
- Perform a Sleeper Stretch on your affected shoulder. This will begin to unwind the shoulder capsule so you can get your arm behind your back.
- Open up your Thoracic spine and Rib Cage. This will make sure that your shoulder isn’t placed under undue stress due to poor spinal mechanics. It will also ease tension on the Pec Minor.
- See a therapist that can explain to you, logically, what they’re doing and why they’re doing it. If they just give you a bunch of exercises and don’t get their hands wet treating you, they’ll fail and ultimately blame you for not doing things right.
As painful as Shoulders can get, the frustration people feel when they just can’t get them right is an overwhelming emotion. But the shoulder isn’t any more special a problem than other parts of the body. It can, and does improve, given that it’s treated with logic, thought and the hard work and responsibility that goes with that. If you have suffered from this injury for many months, even years, there is a solution out there for you. Find someone who believes there is a solution for you and is willing to put the work in to find it.