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Jul 20, 2023

Acute (recent pain onset or injury) Shoulder Pain

Updated: May 22

For information on persistent shoulder pain (longer than 6 months) read our Persistent Shoulder Pain post.



What can cause shoulder pain?

Newly developed shoulder pain can have many causes. Firstly, if it has a clear mechanism of injury (e.g., trauma) it could include dislocation, fracture, soft tissue injury. If there is no clear injury and pain has gradually increased it can be due to

  • Referred pain from the neck, mid-back, abdominal region or neural/vascular tissue (1).

  • Osteoarthritis (1). Read more on Redefining Osteoarthritis

  • Frozen shoulder (1).

  • Soft tissue (tendons, ligaments, bursa, muscle all have the ability to produce pain) (1).

  • Instability (1).

  • Local inflammation (2) or Rheumatic condition (2)

And very rarely due to more serious conditions such as:

  • Osteosarcoma (1,3)

  • Infection (3)

However, overall shoulder pain is quite a common phenomenon, with 67% of people experiencing shoulder pain at some point in their life (4). Most of these incidents resolve with time.



Do you need a scan for your shoulder pain?

Significant trauma (e.g., fall on shoulder from significant height) is a reasonable reason to have a scan. Another reason may be if a serious condition is suspected. Unfortunately, as with several other common pains (see low back pain blog) the usefulness of imaging (ultrasound, MRIs and others) is limited. ‘Abnormalities’ are often found in scans for people both with and ... without pain (5). In 80% of people over 80 years old with no shoulder pain rotator cuff tears are found (6). Another study found that in men with no shoulder symptoms, 96% had ‘abnormalities’ on scans (7). Additionally the severity of pain is also not related to image findings (8).



What happens if scans show no structures that are correlated with your pain

A few questions to ask, is the pain well localized or does it spread or move around? Is the pain random with no known trigger? Is the area of pain sensitive? These may indicate a phenomenon also known as central sensitisation (2). Central sensitisation is very complex however, overall it means that signals that may usually not cause pain cause pain and/or signals that do usually cause pain are amplified and now very painful (9). Overall, pain thresholds are lower, less stimulus or no stimulus is needed to experience pain (9,10).



Is posture related to shoulder pain?

Studies have not found associations between different postures and pain or structural damage (11). This is also found to be the case for shoulder pain (12). Postures such as rounded upper back (sometimes known as hunchback) were found in people with and without pain at an equal rate (12). Pain also does not change with “sitting up straight”. However, range of motion of the shoulder does seem to be greater in more upright positions/postures (12).



Are funky asymmetrical movements related to pain/injury of the shoulder?

Unlikely! A term that is commonly used in the rehab world is scapular dyskinesis (2,13), which received lots of attention as it was thought to be clinically significant (14). However, more recent studies have questioned its relevance. A study by Salahm (14) actually found that this phenomenon occurred in 48% of people with no pain (compared to 60% with pain). Remember, variation in movement between people is normal and is rarely related to pain or injury. We are humans, not cars or machines. We have the ability to adapt and recover without external assistance. A more accurate comparison is comparing people with plants (all credit goes to Nick Hannah for this analogy). These can grow back after being trimmed given the right environment, in our case movement, stress management, adequate quality sleep, quality nutrition.



What factors can amplify your shoulder pain?

Shoulder pain can be a result of excessive use and ... underuse (2,5). If the pain is potential due to overuse, a short period of rest and gradual return to normal duties is recommended. Underuse can lead to lower tissue tolerance, when trying to participate in activities your body is not used to, it can lead to ... (non threatening language).

  • Psychosocial factors/stressors (9,15) specifically Anxiety and Depression (9,15)

  • Poor sleep (15)

  • Metabolic health, diabetes (15)

  • Sensitisation (9,15)

  • Anger (9)



What does ‘impingement’ mean?

This term was created back in 1972 and indicated ‘impingement of rotator cuff tendons between structures’ (11,16). However, over the years studies found that this phenomenon also occurred in people with no pain at a nearly equal rate. Additionally, this term is seen as far too simplistic to describe the complex factors involved in shoulder pain. Surgeries that are developed to “correct” this phenomenon (subacromial decompression) have not shown to be more effective than exercises (1). Overall, the term shoulder impingement does not appear to be useful, it doesn’t explain a person’s pain and does not change treatment (2).



What is a ‘bursitis’?

There are 12 separate bursae in the shoulder joint with a significant number of nerve endings able to produce nociceptive signals (5,17). The bursa’s function is to reduce friction between different moving structures (5). The bursa can get inflamed and can cause nociceptive signals like other structures (17).



Tendon tears, now what?

There is significant research that has shown that tendon tears found on scans are not correlated to pain (11). Roughly 40% of people over 60 years old have rotator cuff tears (18). A study has shown that for 2⁄3 of people with no pain, rotator cuff tears can be found (19). Besides pain, there also seems to be limited evidence to suggest physical function (18). Furthermore, physical activity does not further enlarge the tear (18). Overall, tendon tears that are not a result of trauma can be seen as a normal part of aging, not related to pain or shoulder function (think wrinkles of skin).


Do you need a diagnosis for shoulder pain?

Potentially, serious conditions, significant trauma, frozen shoulder, nerve injuries, instability are a few exceptions of shoulder conditions that will likely change treatment directions (2). However, treatment should always depend on the person, their age, goals, fitness level, sensitivity, comorbidities, life circumstances, etc.. In other words, treatment should be individualized to the person and not the diagnosis. Additionally, as outlined above, with a few exceptions, we do not have means to identify the exact structure that is responsible for your pain (1,5,19,20). “Special tests” done at your doctors, physio or chiro clinic are not so special as they have shown very little use in the exact diagnosis of structures responsible for pain (1,5,19,20). It is not possible to isolate different structures with certain movements (5,19). This means that you are likely to receive a different inaccurate diagnosis when you visit different healthcare professionals or from your scan. A term more commonly used and more accurate is rotator cuff related shoulder pain.



Exercise vs other treatments, should you delay surgery?

A well structured exercise rehab program for rotator cuff related shoulder pain has been shown to have similar results to the shoulder in both the short and long term (22). Of course exercise has many positives (think of general health). However, this method does require significant and consistent engagement, Of course there are occasions where surgery is indicated. Medications for shoulder pain act to reduce pain to allow for more movement, this may be needed in the short term. In the long-term commonly used medications (e.g., Panadol, anti-inflammatories) are not recommended. Another option to reduce pain is injections, which again shows similar results to exercise (22). Platelet rich plasma injections do not seem to outperform exercise (22).



But exercise makes my pain worse?

This is not uncommon (19,21) which may seem to indicate that it isn’t working. It is important to know that pain with movement is not always indicating further damage (8) and often does not impact recovery (19). Think about the consequences of not moving the shoulder due to pain (or fear of pain). This can lead to de-conditioning, lower pain threshold, reduced function and eventually disability (8). However, there is the other side of the coin, too much movement and not providing enough recovery time. This is when the exercise itself is not the problem but instead the load; how much and how often you are performing it. Think about finding a happy medium, not too much and certainly not too little. This is where professionals such as physiotherapists and exercise physiologists can assist.



Final Note

Important note, pain is always subjective and always unique. Two people with the same injury or disease will have a completely different pain experience and recovery. Therefore, it is so important to have treatment tailored to you specifically.



References

  1. Lewis J. (2016). Rotator cuff related shoulder pain: Assessment, management and uncertainties. Manual therapy, 23, 57–68. https://doi.org/10.1016/j.math.2016.03.009

  2. Lo, C. N., Van Griensven, H., & Lewis, J. (2023). Rotator cuff related shoulder pain: An update of potential pathoaetiological factors. New Zealand Journal of Physiotherapy, 50(2). https://doi.org/10.15619/nzjp/50.2.05

  3. Hind, J., Sidhu, G. A. S., Arealis, G., Khadabadi, N. A., & Ashwood, N. (2022). An algorithmic approach to shoulder pathology. Journal of family medicine and primary care, 11(9), 5510–5515. https://doi.org/10.4103/jfmpc.jfmpc_475_21

  4. Salamh PA, Hanney WJ, Boles T, et al. Is it Time to Normalize Scapular Dyskinesis? The Incidence of Scapular Dyskinesis in Those With and Without Symptoms: a Systematic Review of the Literature. IJSPT. 2023;V18(3):558-576. https://doi.org/10.26603/001c.74388

  5. Lewis, J., McCreesh, K., Roy, J. S., & Ginn, K. (2015). Rotator Cuff Tendinopathy: Navigating the Diagnosis-Management Conundrum. The Journal of orthopaedic and sports physical therapy, 45(11), 923–937. https://doi.org/10.2519/jospt.2015.5941

  6. Milgrom, C., Schaffler, M., Gilbert, S., & van Holsbeeck, M. (1995). Rotator-cuff changes in asymptomatic adults. The effect of age, hand dominance and gender. The Journal of bone and joint surgery. British volume, 77(2), 296–298.

  7. Frost, P., Andersen, J. H., & Lundorf, E. (1999). Is supraspinatus pathology as defined by magnetic resonance imaging associated with clinical sign of shoulder impingement?. Journal of shoulder and elbow surgery, 8(6), 565–568. https://doi.org/10.1016/s1058-2746(99)90090-3

  8. Alaiti, R. K., Caneiro, J. P., Gasparin, J. T., Chaves, T. C., Malavolta, E. A., Gracitelli, M. E. C., Meulders, A., & da Costa, M. F. (2021). Shoulder pain across more movements is not related to more rotator cuff tendon findings in people with chronic shoulder pain diagnosed with subacromial pain syndrome. Pain reports, 6(4), e980. https://doi.org/10.1097/PR9.0000000000000980

  9. Bilika, P., Nijs, J., Fandridis, E., Dimitriadis, Z., Strimpakos, N., & Kapreli, E. (2022). In the Shoulder or in the Brain? Behavioral, Psychosocial and Cognitive Characteristics of Unilateral Chronic Shoulder Pain with Symptoms of Central Sensitization. Healthcare (Basel, Switzerland), 10(9), 1658. https://doi.org/10.3390/healthcare10091658

  10. Previtali, D., Bordoni, V., Filardo, G., Marchettini, P., Guerra, E., & Candrian, C. (2021). High Rate of Pain Sensitization in Musculoskeletal Shoulder Diseases: A Systematic Review and Meta-analysis. The Clinical journal of pain, 37(3), 237–248. https://doi.org/10.1097/AJP.0000000000000914

  11. McFarland, E. G., Maffulli, N., Del Buono, A., Murrell, G. A., Garzon-Muvdi, J., & Petersen, S. A. (2013). Impingement is not impingement: the case for calling it "Rotator Cuff Disease". Muscles, ligaments and tendons journal, 3(3), 196–200.

  12. Barrett, E., O'Keeffe, M., O'Sullivan, K., Lewis, J., & McCreesh, K. (2016). Is thoracic spine posture associated with shoulder pain, range of motion and function? A systematic review. Manual therapy, 26, 38–46. https://doi.org/10.1016/j.math.2016.07.008

  13. McQuade, K. J., Borstad, J., & de Oliveira, A. S. (2016). Critical and Theoretical Perspective on Scapular Stabilization: What Does It Really Mean, and Are We on the Right Track?. Physical therapy, 96(8), 1162–1169. https://doi.org/10.2522/ptj.20140230

  14. Salamh, P. A., Hanney, W. J., Boles, T., Holmes, D., McMillan, A., Wagner, A., & Kolber, M. J. (2023). Is it Time to Normalize Scapular Dyskinesis? The Incidence of Scapular Dyskinesis in Those With and Without Symptoms: a Systematic Review of the Literature. International journal of sports physical therapy, V18(3), 558–576. https://doi.org/10.26603/001c.74388

  15. Maestroni, L., Marelli, M., Gritti, M., Civera, F., & Rabey, M. (2020). Is rotator cuff related shoulder pain a multidimensional disorder? An exploratory study. Scandinavian journal of pain, 20(2), 297–305. https://doi.org/10.1515/sjpain-2019-0108

  16. Lo, C. N., Leung, B. P., Sanders, G., Li, M. W., & Ngai, S. P. (2022). The major pain source of rotator cuff‐related shoulder pain: A narrative review on current evidence. Musculoskeletal Care, 21(2), 285–293. https://doi.org/10.1002/msc.1719

  17. Lanham, N. S., Swindell, H. W., & Levine, W. N. (2021). The Subacromial Bursa: Current Concepts Review. JBJS reviews, 9(11), 10.2106/JBJS.RVW.21.00110. https://doi.org/10.2106/JBJS.RVW.21.00110

  18. Lawrence, R. L., Moutzouros, V., & Bey, M. J. (2019). Asymptomatic Rotator Cuff Tears. JBJS reviews, 7(6), e9. https://doi.org/10.2106/JBJS.RVW.18.00149

  19. Ristori, D., Miele, S., Rossettini, G., Monaldi, E., Arceri, D., & Testa, M. (2018). Towards an integrated clinical framework for patient with shoulder pain. Archives of physiotherapy, 8, 7. https://doi.org/10.1186/s40945-018-0050-3

  20. Lange, T., Matthijs, O., Jain, N. B., Schmitt, J., Lützner, J., & Kopkow, C. (2017). Reliability of specific physical examination tests for the diagnosis of shoulder pathologies: a systematic review and meta-analysis. British journal of sports medicine, 51(6), 511–518. https://doi.org/10.1136/bjsports-2016-096558

  21. Ulack, C., Suarez, J., Brown, L., Ring, D., Wallace, S., & Teisberg, E. (2022). What are People That Seek Care for Rotator Cuff Tendinopathy Experiencing in Their Daily Life?. Journal of patient experience, 9, 23743735211069811. https://doi.org/10.1177/23743735211069811

  22. Powell, J. K., Lewis, J., Schram, B., & Hing, W. (2024). Is exercise therapy the right treatment for rotator cuff-related shoulder pain? Uncertainties, theory, and practice. Musculoskeletal care, 22(2), e1879. https://doi.org/10.1002/msc.1879




This blog was written by Samuel Bulten





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