Shoulder pain is a frequent complaint for patients that can present in a number of different ways. For example, some patients experience significant limitations caused by their pain, others have low-grade discomfort that lingers across days, and still others experience more sporadic episodes of discomfort that come and go, but are no less limiting in their daily lives.
One of the reasons shoulders can create a number of different uncomfortable sensations is because it is a highly mobile joint. Lots of mobility in the shoulder is a good thing — in principle — but high mobility also creates high demands for control and stability of the joint as well. There is not much benefit to having a lot of mobility if you can’t control it!
With that said, today’s overview of the shoulder and shoulder pain provides a general perspective on what parts of the shoulder tend to hurt, and a quick note on what to make of imaging results (if you have those too). The next steps in the series will address getting the shoulder moving again, more specific range of motion activities, and finally strengthening and harnessing control of the mobile shoulder to avoid future discomfort.
One important note that applies to all of this series: there are so many unique ways shoulders can have issues that I strongly recommend getting an assessment from a health professional if you are going to address any lingering issues or painful complaints. The concepts addressed here are overviews of the most effective strategies for the most common issues — but individualization is nearly always required from basic recommendations when shoulders are involved.
What are the potential problem areas in shoulder pain?
Strictly speaking, the “shoulder” comprises the connection between the shoulder blade (scapula) and the arm bone (humerus) — called the glenohumeral joint. There are other connections that relate to the shoulder — more globally considered a “girdle” — which are important regionally (eg. scapulothoracic joint, acromioclavicular joint), but unless otherwise indicated this series is referring to the first mentioned glenohumeral joint.
When dealing with shoulder pain, you can consider three large categories that will capture most potential problem sources: muscles and tendons, joints and ligaments, and other soft tissue structures.
Most frequently, the rotator cuff is a group of muscles that provide stability support to the shoulder joint, making sure the shoulder both doesn’t move too much and when it does it is specifically controlled with co-ordinated contractions. This specific contraction mechanism of the rotator cuff is important since dislocation of the shoulder is relatively common due to the joint structures inclination towards more movement — but fortunately the rotator cuff is designed specifically to prevent events like this.
More common than dislocations, injuries to the rotator cuff develop into pain, weakness, and limited movement capacity of the shoulder. If the muscles and tendons are pinched, stuck, or squeezed during movement, pain can be the result of this “impingement”. If this type of strain on the structure continues, or it is exposed to too many demands in a short period of time without adequate healing, tears can also develop in the muscle or tendon.
Other structures that become involved in shoulder issues include the joint ligaments and capsules themselves, some of the passive support structures like the labrum, other muscles and tendons that attach in the area, or changes in bony structure (like calcium deposits or osteoarthritic changes). There are also other soft tissues that can become irritable or inflamed, like bursae, which can also limit movement and create discomfort.
Fortunately, conservative management (see: non-surgical) rates as similarly effective to having surgery on shoulder structures for these types of issues — so appropriate exercise, movement promotion, and functional restoration is a good option! We will get to that more specifically over the next few postings.
A quick note regarding advanced imaging
Since many patients end up getting advanced imaging when they are having shoulder pain (MRI, CT, ultrasound, x-ray), and many of those reports come back with some kind of positive finding, does that mean you need to have surgery?
Generally speaking, no. There are definitely findings that will make it more likely that surgery would be required, but there is frequently little agreement between the symptoms patients are experiencing and the findings that come from the imaging reports. Similarly, a great number of people with no symptoms at all also have positive findings when you take a form of advanced imaging of their joint!
This means that not all positive findings on your imaging have a direct link to the symptoms you are experiencing.
Dealing with what imaging results mean, and how they relate to the symptoms you have, is a complex topic that requires a dedicated post. But this hopefully relieves the idea that ALL positive findings mean surgical intervention is required.
In the next post, we’ll move into early strategies for management of shoulder pain.