Updated: Jun 14
Don't let bias and assumption steer you down the wrong path.
Shoulder pain is all too common. Usually people's minds go straight to the rotator cuff. While this perhaps isn't necessarily wrong, the reality is that multiple different tissues and structures, both in the immediate area of the upper arm/shoulder and nearby, can generate symptoms to what people will often refer to as the "shoulder". Here's a quick personal example of a family member.
A male in his early 50s awoke with pain along the top of his shoulder blade and in the upper arm in the area of the deltoid. He was able to use and move his arm, but he mentioned that his arm just ached all day. He did notice that checking his blind spot while driving really aggravated his pain, and lying flat on his back in bed also was quite painful for his arm. With some further questioning, it was revealed that moving his arm did not directly increase his pain – the only things that seemed to impact the arm pain was moving his neck. Upon seeing his primary care physician, he was diagnosed with a likely rotator cuff tear and referred to a shoulder surgeon. Ultimately, we were able to help steer him down a management pathway focused on his neck, and sure enough, his arm pain got better. This example, while fairly clear-cut, really underscores the importance of seeing an expert that will try to be thorough and examine all of the things that can potentially cause pain like this.
What can cause shoulder pain
There's more to your shoulder, and shoulder pain, than just your rotator cuff. Pain in the area of the shoulder can come from a nerve root irritation, irritated neck joint, the shoulder labrum, biceps tendon, rotator cuff (any or some combination of the 4 muscles that comprise the rotator cuff), the acromioclavicular (AC) joint, cardiac tissue... and that's not even a completely exhaustive list. Seeing a provider that will ask the right questions and perform the right exam procedures to try to confidently identify what may be causing your symptoms is imperative. Below, we'll dive into some of these different patterns we see clinically associated with shoulder pain.
Shoulder pain from the spine
Tendon-related shoulder pain
Shoulder pain from the neck and midback
As with the family anecdote above, the neck and upper thoracic spine can have a strong relevance to shoulder pain, whether your symptoms are being caused by these structures or influenced by these structures.
There is published evidence suggesting that midback mobility deficits can perpetuate shoulder pain. While this is somewhat different from directly causing pain, it is a common issue many people face, and addressing the limited mobility of the thoracic spine often can help people better manage their pain and better use their arm.
We routinely see what people call shoulder pain to come from the neck. When looking at
common pain referral patterns, pain along the top of the shoulder blade is more likely related to muscles attaching from the neck or from joints and tissues of the neck itself. Especially in cases where shoulder pain has been present for more than several weeks, it is necessary to at least try to rule out involvement from the neck, but even with acute pain it's appropriate for your provider to still perform an exam targeting the neck and nerves of the upper extremity. This means checking reflexes, testing your sensation side to side, and checking neuromuscular function of the upper extremity.
People often ask if this means a neck X-ray is needed – the short answer is probably not. There are well established guidelines (e.g., the Canadian C-spine rules) that help us determine when X-rays are necessary. More often than not when people come to see us, their shoulder pain seems to have come on out of the blue or after doing more activity than usual – these are not cases that suggest a need for an X-ray of the neck.
Often times, pain stemming from the neck can be fairly well managed by seeing our physical therapists. The big takeaway here, though, is that the neck must be examined. Certainly, sometimes assuming that the cause of symptoms is a rotator cuff issue or shoulder joint issue may end proving correct – but what if that assumption is wrong? We often see people deal with shoulder symptoms for months, if not years, simply because a thorough exam was not performed in the first place.
Shoulder tendon issues – The rotator cuff and more
The primary things we consider here are the four rotator cuff tendons and the biceps tendon.
With tendon issues, the preferred diagnostic label is "tendinopathy". Historically, people used to refer to "tendinitis" as the diagnostic term for pain related to a tendon; however, research has demonstrated that the processes associated with tendon issues really exist along a continuum and are not a cut-and-dry, black-and-white state of being irritated or not irritated. Over time, things like overload (be it prolonged exposure to physical stresses) or acute overload (think of the middle-aged father who begins throwing around with their son or daughter every night after not throwing a ball much for a couple of decades) can lead to an acute, reactive state of tendinopathy. This is often more consistent with what we used to call "tendinitis" – things are hot and bothered acutely, and loaded activity often is quite bothersome. Tendinopathy can also exist in a less irritable but still limiting chronic state – this might manifest with having a degree of shoulder pain perhaps during but especially afterward, and any attempt to do more than normal often is met with symptoms being aggravated.
Conservative management for rotator cuff tendinopathy should include some combination of progressive resistance exercise that is matched directly to your present tolerance and capacity, as well as some combination of manual therapy and mobility exercise to address related impairments (e.g., thoracic mobility, as mentioned above). But what about outright rotator cuff tears?
Believe it or not, there is some evidence to suggest that especially with what are deemed "degenerative" rotator cuff tears, people can often manage pain and regain function without having to have surgery. Even people with traumatic rotator cuff tears can sometimes avoid surgery, although our clinical experience would suggest that this group often does fairly well with surgical management. We tend to see a much higher percentage of people with diagnosed rotator cuff tears having gradual, over-time histories associated – the big thing here is to know that conservative management should not cause harm or damage, and avoiding 4-6 (or more) weeks in a sling is always nice.
In addition to the rotator cuff tendons, we also have the biceps tendon. Pain often will behave similarly when the biceps is involved. There can be subtle differences, however, from your history and physical exam that may point to this being involved. Ultimately, your provider needs to try to explore these things in order to try to rule it out. Ignoring or overlooking is another way to potentially miss the boat, so to speak, when it comes to diagnosis.
What else can cause shoulder pain?
People are often quick to think rotator cuff, but what else non-tendinous can be associated? Bursitis is also a common diagnosis that people will get. While there are a couple of different bursae (a bursa is a fluid-filled sac or structure that often surrounds soft tissues/joints and serve to reduce friction) to consider in the shoulder, the reality is that these often are present with some other primary issue (like a tendon disorder).
We also need to consider the joints in the area. First, you have what you likely think of as the shoulder – the glenohumeral joint. In younger individuals especially, the glenoid labrum can be source of issue, often after a direct trauma, a dislocation, or with certain repetitive sports movements (e.g., baseball pitchers). The glenohumeral joint itself can also be a source of issue. Some people may deal with instability associated with pain, be it from a prior dislocation or trauma or whether it's from someone having a systemic hypermobility disorder (e.g., Ehlers-Danlos Syndrome). Additionally, an arthritic glenohumeral joint can also pose issues. Some of the same logic applies to the acromioclavicular (AC) joint.
Adhesive capsulitis, more commonly known as "frozen shoulder", is another fairly common issue we see that is a cause of shoulder and upper arm pain. This commonly stage-like diagnosis often will present like a rotator cuff issue early on; however, progressive stiffness and loss of mobility are characteristic. As with all of these other diagnoses, the management and treatment is quite different from an isolated rotator cuff issue.
While less common, it's also still prudent to consider some of the non-musculoskeletal causes of shoulder pain. Within the last six weeks of writing this post, our office has seen two people with shoulder and arm pain referred by another physician wherein we helped to catch things like cardiac arrhythmias and helped facilitate referrals to cardiology that caught things like coronary artery stenosis (which can lead to reduced blood perfusion to the tissues of the heart). With these cases, the medical treatment of their cardiac issues eliminated the shoulder and arm pain. Again, these instances are far less common than the above issues – but they still do happen, and they will not be caught if your provider doesn't try to rule them out.
Understanding your shoulder pain
So why does this information matter? It definitely matters for you and your healthcare experience. Your shoulder pain is likely very different from someone else's. A five to ten-minute office visit with three or four questions and a couple of quick movements is not sufficient to truly gain an understanding of what may be going on, and understanding what is likely the primary reason for your shoulder pain is the best way to get on the right track to feeling better as quickly as possible. When dealing with shoulder pain, be sure to seek out a provider who can take the time to do a thorough exam, talk to you about the findings, and offer a well thought-out plan to address these issues.