Shoulder pain is a common issue for many people, whether you’re an athlete, an office worker, or just living an active life. But it’s more complex than just feeling discomfort in one of your body’s most mobile joints. This post will break down the different types of shoulder pain, what could be causing it, and how physiotherapy and osteopathy can help in assessing, diagnosing, and treating your shoulder pain.

Different Types of Shoulder Pain

Shoulder pain can be caused by a variety of factors, and the pain itself can feel different depending on the underlying issue. Broadly, shoulder pain can be categorised into three types based on the pain mechanisms:

1. Nociceptive Pain: This is the most common type of pain, where a specific injury or issue (like a torn muscle or inflammation) triggers the pain. It's usually localized, and once the injury heals, the pain subsides.

2. Nociplastic Pain: Here, the pain isn’t directly tied to tissue damage but rather changes in the way your nervous system processes pain. You might feel pain in your shoulder even when there's no active injury. This might be associated with long standing pain, or when you have recurrent flares of pain.

3. Neuropathic Pain: This type of pain occurs when nerves are irritated or extra sensitive. It can be sharp, shooting, or burning and may radiate down the arm.

Common Shoulder Pathologies

Several shoulder conditions can cause pain, each presenting its unique challenges.

1. Rotator Cuff-Related Shoulder Pain (RCRSP)

RCRSP is an umbrella term for a group of conditions affecting the rotator cuff (a group of muscles and tendons surrounding the shoulder joint). It replaces previously used terms such as “impingement syndrome” and encompasses rotator cuff strains and tendon injuries. It may begin with an acute inciting event, a change in load on the shoulder or gradually develop over time. It may be constantly sore with specific movements, or it may warm up with movement and then cause pain as you cool down. Generally we can reproduce your pain doing specific orthopaedic tests and movements in the clinic. Overhead movements are typically difficult.

2. Frozen Shoulder (Adhesive Capsulitis)

Frozen shoulder is when the connective tissue around the shoulder joint thickens and tightens, restricting movement. It often comes on gradually and can be intensely painful, limiting your ability to move your arm without discomfort. People with diabetes, or those who’ve had recent surgery or immobilisation, are more prone to developing this condition, and women are more likely than men. We see a progressive loss of both active and passive range of motion, meaning your shoulder feels like it gets stiffer and stiffer.

3. Osteoarthritis

Just like any joint in our body, osteoarthritis can affect the shoulder. The specific joints that commonly contribute to shoulder pain are the glenohumeral (GH) joint, sternoclavicular (SC) joint and the acromioclavicular (AC) joint. We can often confirm this joint stiffness via imaging.

4. Shoulder Instability

The shoulder can be described as a “golf ball on a tee”. It is an inherently mobile joint with a large range of motion and sometimes a lack of stability. Dislocations or subluxations can be problematic for athletes and require careful management to avoid ongoing future shoulder issues.

5. Referred Pain

Sometimes, shoulder pain is not directly related to the shoulder joint or its structures. It can be referred from other areas of the body, such as the neck or upper back. For instance, an irritated nerve in your cervical spine (neck) or heart conditions like angina can cause pain that radiates to the shoulder. In these cases, treating the underlying condition, rather than the shoulder, is key to finding relief. This is why we always take a thorough medical history and examine the structures surrounding your area of pain, to ensure that we have an accurate diagnosis and can treat your pain effectively.

Diagnosing Shoulder Pain: Physiotherapy and Osteopathy

When it comes to diagnosing shoulder pain, both physiotherapists and osteopaths play a vital role. Here's what you can expect from our approach:

• A detailed history: your clinician will listen carefully to you and ask specific questions about what might be aggravating or helping your shoulder pain. We combine this with a medical history in order to rule out any ‘red flags’ and to narrow down our diagnosis.

• A thorough examination: physical examination includes us watching to see how you move your shoulder, strength tests and specific orthopaedic tests, combined with testing your passive range of motion (us moving your shoulder for you). We will also examine other parts of your body that may be contributing to your pain, particularly your back, neck, ribs and arm.

• A variety of treatment options: all of our clinicians are skilled in a variety of treatment techniques. Your previous experiences and preferences as well as our knowledge of evidence based approaches, help us to make the decision together on how to treat your shoulder pain. It might include massage, joint mobilisation, strength exercises, stretching or dry needling among many others.

Treatment Options for Shoulder Pain

Depending on the type of shoulder pain you’re experiencing, treatments can vary. Some of the most effective options include:

1. Exercise Therapy: Strengthening exercises for the rotator cuff and shoulder stabilisers can help reduce pain and improve function, especially for conditions like RCRSP and tendon injuries.

2. Manual Therapy: Both physiotherapists and osteopaths use hands-on techniques like joint mobilisation and soft tissue release to improve mobility and reduce pain.

3. Education and Pain Management: Understanding the cause of your pain and learning strategies to manage it (such as heat/ice application and activity modification) are crucial parts of the recovery process. Adhesive Capsulitis has a particularly long recovery time, having a clear understanding of your prognosis and goals of treatment is really important to us.

The Bottom Line

Shoulder pain is complex and can stem from many different causes, ranging from direct injuries like strains and tendonitis to more complicated issues like frozen shoulder and referred pain. Whether it’s nociceptive, nociplastic, or neuropathic pain, having a thorough assessment by a healthcare professional like a physiotherapist, osteopath or exercise physiologist is essential for diagnosing the problem and creating an effective treatment plan. If you’d like to book in with one of our clinicians, click here

References:

• Lewis, J. (2016). Rotator cuff-related shoulder pain: Assessment, management, and uncertainties. Manual Therapy, 23, 57-68.

• Bunker, T. D. (2011). Frozen shoulder: unravelling the enigma. Annals of the Royal College of Surgeons of England, 93(5), 343-348.

• Woolf, C. J. (2011). Central sensitization: Implications for the diagnosis and treatment of pain. Pain, 152(3 Suppl), S2-15.