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For information on recent shoulder pain or injury read our other blog Acute Shoulder Pain post.
Why has my pain not improved with surgery, medication and/or other treatments?
There can be numerous reasons. However, one explanation which has become more plausible is central sensitisation (1). Central sensitisation is a phenomenon that results in the nervous system essentially being on high alert; lower pain threshold and less stimulus is needed to cause pain (1).
Majority of healthcare professionals are able to pick up conditions that may change the course of treatment. However, it could be worth asking if less common conditions have been considered in their reasoning:
Frozen shoulder. Higher risk if you have diabetes or a thyroid condition. This condition can take 5-26 months (2).
Polymyalgia rheumatica
Rheumatoid arthritis
Nerve injuries including brachial plexus injury, supraspinal nerve neuropathy
Why has shoulder pain persisted far beyond expected?
There could be many reasons for this that include physiological, psychological, social factors and how these interact with one another.
Should movements that cause shoulder pain be avoided?
This is the million dollar question and the answer is not very simple. If the explanation for the pain is most likely central (or even peripheral) sensitisation, pain is not a signal that indicates damage and movement often does not impact recovery (3). 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 (4). 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.
Why do treatments that claim they work or fix things not work for me?
As discussed earlier, pain is a unique experience and many factors play a role. Shoulder pain that persists past healing times may be due to central sensitisation. When central sensitisation is present, “conventional” treatments are usually ineffective (1,5).
Can persistent shoulder pain improve?
Yes, but if your pain has persisted for many years being completely pain free may not be attainable. However, people can still live a meaningful and happy life and reduce how much the pain impacts their life. Some key strategies are:
Understand your condition and the underlying mechanism. A healthcare professional should be able to help you with this. Another great resource is the Explain Pain book:https://www.noigroup.com/product/explain-pain-second-edition/
Taking an active approach to your management/recovery. It is unlikely you will find a “quick fix” as there likely isn't an “simple” explanation for your pain. You will need to put in effort and time, but it will be worth it.
Having less fear of pain and working toward accepting that pain signals are no longer a signal of damage. Once pain is not seen as a signal of damage we can start working on living a normal life again independent of pain.
Find a healthcare professional that is able to identify possible contributing factors to your pain and recovery and provide you with knowledge and a plan to address these. If you are given a simple explanation for your pain that has persisted for many many years and you are provided with a “quick fix” solution that involves you laying on a treatment table ..... Run (you and your bank account will thank you for it).
References
Borstad, J., & Woeste, C. (2015). The role of sensitization in musculoskeletal shoulder pain. Brazilian journal of physical therapy, 19(4), 251–257. https://doi.org/10.1590/bjpt-rbf.2014.0100
de Sire, A., Agostini, F., Bernetti, A., Mangone, M., Ruggiero, M., Dinatale, S., Chiappetta, A., Paoloni, M., Ammendolia, A., & Paolucci, T. (2022). Non-Surgical and Rehabilitative Interventions in Patients with Frozen Shoulder: Umbrella Review of Systematic Reviews. Journal of pain research, 15, 2449–2464.https://doi.org/10.2147/JPR.S371513
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
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
Noten, S., Struyf, F., Lluch, E., D'Hoore, M., Van Looveren, E., & Meeus, M. (2017). Central Pain Processing in Patients with Shoulder Pain: A Review of the Literature. Pain practice : the official journal of World Institute of Pain, 17(2), 267–280. https://doi.org/10.1111/papr.12502
This blog was written by Samuel Bulten
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