What Causes Shoulder Pain

Shoulder Pain & Poor Posture

Using dental pain as an example, there are many tooth cavity-related issues that can occur within any of your teeth, yet they ALL relate to the consumption of sugar. Similarly, when it comes to shoulder pain, there are many different issues that can occur, and they virtually ALL have their root cause in our postural habits. 

When our posture is good our shoulders are shoulder, all the muscles work in unison, all the tendons do their job unimpeded, the ball and socket stays well located and free of strain to its cartilage. This the secret of people who lead long active lives with zero shoulder pain, they do exist!! Shoulder problems are virtually unheard of in children partly for this reason, they have great posture. 

When you have a persistent postural issue, it’s usually made up of bad habits, excessively tight muscles at the front of the body, muscle wasting behind the shoulder, and unhealthy adaptation of the spine’s connective tissue. This situation causes chronic strain and impingement within the connective tissues of the shoulder, eventually, this often means pain and injuries. The nature of your genes, occupation and lifestyle will dictate where, when and how bad that pain proves to be.

Shoulder Pain & Rib Issues

If you have stubborn knots inside your shoulder blade it is very likely that your upper ribs have locked up on you, where they attach to your spine. The area inside the shoulder blade is a major focus of postural strain in the human body, it is heavily predisposed to locking of the small rib joints where they meet the spine. 

Your spinal column is made up of a series of bones, these bones move and flex because of the discs and small joints that connect them. Throughout the middle section of your back (thoracic spine) the bones also articulate with your ribs to form your rib cage. This is where your rib (costovertebral) joints come in.

The area just inside the shoulder blade is an area where large numbers of people get pain at one time or another. Pain and knots in this area often feel muscular but are in fact being caused by a rib that has locked where it attaches to the spine. Many people with this issue feel like they want a massage but find that it brings unsatisfactory levels of relief. 

Shoulder Pain & Scar Tissue

It is common knowledge that scar tissue can develop after significant traumatic injuries. It is far less well known that there are forms of scar tissue that build up in response to stubborn lifestyle related strain in the body. Although you may not be familiar with the concept of this scar tissue you will definitely have seen its effects.

Picture the average long standing (or rather sitting) office worker with poor posture, you may have noticed that they kind of change shape over time. If we sit hunched, ultimately we become hunched, and eventually, we can’t sit up straight even if we try, because we have changed shape. A big part of this change is a fibrous build up of scar tissue in the spine and shoulders. This fibrous change is a major factor in many cases of stubborn shoulder pain. Once scar tissue has established itself in the shoulder and spine, it can make it very hard for the shoulder tissues to perform their roles without excessive pressure and irritation. 

Desk work is a particularly excellent way to develop scar tissue in the shoulder and spine. Many other of life’s tasks and activities can however contribute to the build up of scar tissue also.

Shoulder Pain & Muscle Issues

Your shoulder is the most highly mobile joint in your body, it’s range of motion is far greater than any other joint in the body. Having caused by a large range of motion is very useful but it makes for a far less stable joint, the more a joint moves the more opportunities there are for something to go wrong. 

The secret to all this movement combined with the relative infrequency of shoulder injuries is our shoulders stabilising muscles. The action of the rotator cuff combined with additional support from the muscles of the back and chest is what enables a large range of movements without frequent injury

Having a joint that is heavily dependent on muscles for support means that there is a high volume of muscle tissue, and that muscle tissue is always working hard. This is a recipe for muscle pain, and sure enough, a very significant number of shoulder pain cases are in fact muscle pain. It is worth remembering that all rotator cuff issues come under this heading because the rotator cuff is made up of muscles. 

Most shoulders with persistent pain are full of ‘pressure points’ or ‘myofascial trigger points (the sore spots you feel in muscles) and muscle groups in spasm. In many of these cases releasing these points is key to achieving pain relief and restoring movement. While using exercises to bring the muscles back to full health is the key to successful longer term outcomes. 

Shoulder Pain & Bursitis / Bursa Impingement

Bursae are small, fluid-filled sacs that are placed throughout the body in places where there is a great deal of friction. They act as lubricated pads between bones and soft tissues and help reduce friction during movement between the shifting muscle tendon and bone.

Bursitis is a condition where the bursa becomes inflamed due to excessive pressures being placed upon it. Bursitis can lead to shoulder pain and limitation of pain free movement in the shoulder.

The conventional explanation for bursitis, which you will find all over the internet, is that straightforward ‘overuse’ is what causes shoulder bursitis. The reality is though that there are always a million other humans overusing their shoulders, and not getting bursitis. This is the case because the true cause of bursitis is postural imbalances and poor movement habits that put excessive compression on your bursa.. 

The other commonly observed myth about bursitis is that if you have an enlarged bursa on your ultrasound scan that must be the cause of your pain. The far more complex and nuanced truth is that many people with enlarged bursae in their shoulders do not have bursa pain, the bursa is enlarged but it’s soft tissue pain that they are experiencing. The fact is hinted at by the extremely hit & miss nature of those highly toxic injections into the bursa. 

Shoulder Pain & Tendinosis

If you have shoulder pain that prevents you from lifting your arm easily without pain, but you do still basically have reasonable use of the shoulder, a highly likely cause of this is tendinosis. 

A tendon is a flexible cord that enables muscle to attach to bone. In reality, your tendons are not separate structures to your muscles, we just talk about them like that, they are in a sense the ends of the muscle itself. It would be hard to put into words how strong and durable your shoulder tendons are, but like all tissues, they do have their limits. It is in pushing the limits of what the shoulder tendons can handle that creates tendinosis.

The most common tendons to be affected by tendinosis in the shoulder are the four rotator cuff tendons and the biceps tendons. The rotator cuff is made up of several small muscles and their tendons that cover the head of your humerus (arm bone) and hold it in the shoulder socket. Your rotator cuff helps provide safe, fluid shoulder motion and stability. The bicep tendon assists with bending the elbow by anchoring the bicep muscle to the front of your shoulder. 

In a nutshell, there is a better than 95% type of probability that your shoulder tendinosis is largely caused by long standing postural change in your body. The other perhaps 5% of cases happen purely due to extreme overuse like tennis serves or painting ceilings.

When your posture becomes slightly ‘round shouldered’, it reduces the already small space (between the bones) that your rotator cuff tendons have to work within. In other words, poor posture causes pinching of the tendons. When combined with many hours spent each day with bent elbows, poor posture can also cause shortening and irritation of the biceps tendon. Postural alterations in combination with the normal activities of life are what lead to the majority of tendon tears in the shoulder. 

Shoulder Pain & Tendon Tears

Tendons are flexible cords that attach muscle to bone and enable movement. Your tendons are not really separate structures from your muscles, we just talk about them like that. Tendons are in a sense the ends of the muscle itself. Shoulder tendons are extremely strong and durable, but like all tissues, they do have their limits. It is in pushing the limits of what the shoulder tendons can handle that creates tears.

Tendon tears vary greatly in severity, partial tears thankfully are far more common than complete tears. Partial tears involve a discrete portion of the tendon while in most complete tears, the tendon is pulled away from its attachment to the bone. Rotator cuff and biceps tendon injuries are by far the most common tendons to rupture…

Tendon tears in the rotator cuff can result from acute injury where the movement or force is so extreme that a completely healthy tendon partially ruptures. Far more commonly tendon tears are caused by underlying degenerative changes in the tendon and weakened over a long period of time. 

The happy news about tendon tears is that they don’t always require surgery and they don’t always amount to a ‘pain sentence’. It is quite normal for many tears to be able to stabilise the shoulder with exercises and live completely pain free. In other cases, modern shoulder surgery techniques are minimally invasive and often extremely effective. 

Shoulder Pain & Labrum Tears

Your labrum is a connective tissue ring that helps fix your shoulder ball and socket joint (glenohumeral joint) in place. The margins of the labrum are attached to the bone with tiny ligaments that run the circumference of the labrum.

If you have chronic postural issues in combination with an active lifestyle, or if you have some significant cartilage degeneration in your shoulder, you may at some point experience a labrum tear. Labrum tears are detachments of the margins of the labrum. Sometimes these happen in the context of extreme physical activity like a classic injury, other times they happen more quietly without you realising. 

Labrum tears are hard to treat and diagnose. If your shoulder pain is resistant to treatments that usually work for others and feels ‘catchy’ and unpredictably painful with movement you may have a tear in your labrum.

Shoulder Pain & Joint Instability

Shoulder instability occurs when the support structures of the shoulder joint fail. The primary fail is usually within the muscles that stabilise the shoulder. The majority of us have some degree of weakness and muscle wasting behind the shoulder that has been imposed on us by our modern lifestyles. If these muscles become sufficiently weakened the shoulder joint can become unstable, because these muscles hold the ball and socket in place. 

The most dramatically obvious way that shoulder instability presents itself is in sudden shoulder dislocations, and in partial dislocations (subluxations). These events are what happens when the ball and socket literally separate from one another. These are majorly and seriously acute painful events. Shoulder dislocations often happen with dynamic overhead movements of the arm.

There is a far more slow burning and insidious legacy that can arise from chronic shoulder disability. That is the development of osteoarthritis and advanced muscle wasting. Repeat dislocations and chronic mild day-to-day instability can cause the joint cartilage to break down and the already weakened muscles to waste further over time. 

The primary answer to shoulder instability is a long term commitment to restoring strength to the muscles of the shoulder. And a commitment to breaking down scar tissue using shockwave therapy. Many people find dramatic improvements in their dislocation issues with these interventions. The secondary answer to cases of shoulder instability is sometimes surgical repair of the connective tissues in the shoulder if they are ‘too far gone.

Shoulder Pain & Frozen Shoulder

Frozen shoulder is a somewhat mysterious condition where the fibrous capsule that holds the shoulder joint in place spontaneously thickens. This thickening of the capsule dramatically reduces the movement of the shoulder and can also cause a certain amount of pain.

The first and most obvious difference between a frozen shoulder and most other shoulder issues is that it involves less pain but a lot more stiffness. Many sufferers of frozen shoulders can barely move their shoulder joint above waist height and yet they often don’t have much pain. 

Most cases of frozen shoulder resolve within 6-12 months while some do go on a lot longer. While the frozen shoulder is notoriously hard to treat you should make every effort to find physical therapies that ease it. 

At Featherston St Pain Clinic we find that we can reduce the duration of the average frozen shoulder down to less than 3 months max using Focused Extracorporeal Shockwave Therapy. This is the same treatment doctors use to break up kidney stones, we use it to break down capsule adhesions.

Shoulder Pain & Arthritis

Shoulder pain may in some instances be caused by arthritic conditions. There are many varieties of arthritis with contrasting underlying causes. The most common form of arthritis to affects the shoulder is osteoarthritis. Osteoarthritis is the common ‘wear & tear’ form of arthritis. There are other less common instances where inflammatory/auto-immune forms of arthritis can affect the shoulder joint also.  

Osteoarthritis is a complex condition and is most definitely not ‘just old age. Genetics, lifestyle, general fitness, posture, and diet all have a part to play in shoulder osteoarthritis. 

Inflammatory forms of arthritis are also complex conditions that simultaneously call for high quality medical interventions, and a serious approach to addressing underlying lifestyle, dietary, and sometimes even emotional issues. 

From our perspective, if you have been diagnosed with shoulder arthritis you should view it as an opportunity to heal yourself, and do so with a good dose of optimism because there are many, many effective ways of positively impacting chronic pain of all kinds. 

Shoulder Pain & Fractures

Fracture is the technical term we reserve for broken bones. Fractures within the shoulder complex commonly involve the clavicle (collarbone), the scapula (shoulder blade), and humerus (upper arm bone). It takes a huge amount of force to fracture any of these bones if they are healthy, they are very strong. Sports like rugby offer many rich and diverse opportunities to fracture these bones. The elderly sometimes fracture their shoulder bones in far more simple trips and falls due to their bones having lost some structural density.

If you have the slightest suspicion of a fracture in your shoulder you will obviously need to seek some medical assistance as a matter of urgency. The secret to good long term outcomes after shoulder fractures is a very serious approach to rehab and strengthening. Most people suffer from bad muscle wasting in the shoulder after a fracture, you don’t want to carry that weakness with you long term. 

Shoulder Pain & Infections & Serious Health Issues

Bone and joint infections can cause shoulder pain in rare instances. Tumors can also manifest in the shoulder and cause shoulder pain. There are also instances where serious issues in the spinal column and organs can create referred shoulder pain. While all these shoulder pain causes are relatively rare, they do serve as a reminder that pain is not meant to be ignored.

 If you have stubborn shoulder pain get it checked out by someone who is professionally trained to diagnose these issues. Especially if you have any other undiagnosed/unchecked  medical symptoms.

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