Shoulder Pain Management

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What is Shoulder Pain?

The structure of the shoulder is complex. It is composed of two joints and three intersecting bones: the scapula (shoulder blade), clavicle (collarbone), and humerus (the long bone in the upper arm). Four tendons (connective tissue that attaches muscle to bone), three ligaments (connective tissue that attaches bone to bone), and numerous muscles give the shoulders a broad range of movement. Cartilage protects the bones from rubbing against each other, and synovial fluid keeps the joints lubricated. All of these elements help make the shoulder the most flexible joint in the body.

Many people experience shoulder pain throughout their lives. Estimates suggest that more than 1 out of every 100 people experiences shoulder pain. Furthermore, it is estimated that 40-50% of individuals with shoulder pain experience recurrent or persistent pain (otherwise known as chronic pain).

Individuals with shoulder joint pain may find it painful to move their arms in front of their body, behind their back, or above their head. Their shoulder pain may also be accompanied by pain in the neck, arm, and/or hand.

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Causes of Shoulder Pain

Medical professionals often rely on x-rays, MRIs, ultrasounds, and CT scans in order to identify the cause of shoulder pain. The problem with these tests is that they are poor predictors of pain. These tests are important tools for ruling out serious medical concerns, such as broken bones, dislocations, and tumors. However, they should not be used to diagnose the cause of shoulder pain.

Why? Because most routine shoulder “issues”, including bursal thickening, osteoarthritis, tendinosis, labral and rotator cuff lesions/tears, and labral abnormalities are present in asymptomatic shoulders (i.e. shoulders with no pain). In fact, one study found shoulder abnormalities in 96% of asymptomatic shoulders! Furthermore, many people with pain in one shoulder have the same structural issues in the other shoulder. In other words, most structural abnormalities are not indicators of pain. And conversely, many people have excruciating, persistent shoulder pain, but there is no obvious structural cause.

If most shoulder pain is not caused by structural issues, then what is causing the pain? The answer is that in most cases, shoulder pain is partly or fully caused by Primary Pain (sometimes called Central Sensitization). Click here and here if you are interested in learning about research on the link between central sensitization and shoulder pain. Primary Pain refers to pain that is driven by the central nervous system (CNS), rather than a structural issue.

Ultimately there are two main types of shoulder pain: Primary pain (driven by sensitization of the nervous system), and Secondary pain (driven by a structural issue in the shoulder). Shoulder pain can also be caused by a combination of Primary and Secondary pain. So, how can you determine what type of shoulder pain you have?

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Primary Pain indicators:

• Your shoulder pain has lasted for more than 6 months
• Pain onset was not caused by an obvious injury (i.e. a sports accident, a car accident, a fall)
• Pain started during a time of stress or change
• You have experienced similar shoulder pain before
• Your neck pain is inconsistent: it moves around your shoulder/body; arises only during certain activities or times of day; grows stronger during times of stress; and/or grows more manageable during times of calm or enjoyment.

Remember, even if you have received a structural diagnosis (such as arthritis, rotator cuff tear, labral tear, bursal thickening, or tendinosis), if your pain fits the characteristics of Primary Pain listed above, it is very likely that your pain is Primary. This has important implications for finding the treatment that will truly relieve your pain.

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Secondary Pain indicators:

• Pain onset was caused by an obvious injury (i.e. a car or sports accident, a fall, an impact)
• The injury happened less than 6 months ago
• You have consistent pain that is always present in a specific part of your shoulder
• Your symptoms behave predictably and you can consistently reproduce them

Secondary shoulder pain is most commonly present in the acute (less than six weeks following injury) and subacute phases (six weeks to three months following injury) of pain. Pain of this kind is generally not reflective of a dangerous injury and resolved on its own relatively quickly.

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Shoulder Pain Treatment

If you’re currently dealing with either acute or chronic pain in your shoulder, you might be wondering how to treat shoulder pain. When it comes to shoulder pain management, it is important that you have a correct diagnosis to receive the proper treatment. In this section, we’ll cover the best treatments for Primary and Secondary pain.

First of all, any of the following symptoms may be signs that your shoulder injury requires medical attention.

• Catching or locking of the shoulder joint
• instability, dislocation, and/or frequent subluxation (partial dislocation) of the shoulder
• excessive scapular winging
• consistent numbness and/or tingling in a particular part of the arm or hand
• atrophy of specific shoulder muscles and significant weakness
• significant swelling or bruising
• changes in vision, balance, or concentration/focus
• Loss of motor control
• Fever
• Sudden weight loss

These symptoms are considered “red flags”. If your shoulder pain fits with these symptoms, seek medical care to identify and treat any dangerous injuries or conditions. If your shoulder pain is not consistent with these symptoms (as is the case for most shoulder pain), good news! Your pain is not indicative of a dangerous injury or condition.

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What treatments are recommended for Primary Pain?

If you have Primary shoulder pain, you will have the best results by adopting a brain-first approach targeting the central nervous system. Treatments such as Pain Reprocessing Therapy (PRT), Emotional Awareness and Expression Therapy (EAET), and Pain Neuroscience Education have been shown to significantly reduce Primary Pain. These techniques utilize education and exposure to help the nervous system process pain as non-dangerous, ultimately reducing pain levels in measurable and lasting ways.

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What treatments are recommended for Secondary Pain?

As noted previously, Secondary shoulder pain is most commonly acute or subacute. This type of pain is generally not indicative of dangerous bodily damage, and will resolve naturally on its own.

If you have sustained an acute shoulder injury, it is recommended that you allow your shoulder to rest for 24-48 hours following the injury. Rest, Ice, Compression, and Elevation (RICE) can be helpful during the period immediately following an injury. The same is true in the few days following shoulder surgery.

After the first 24-48 hours, it is highly recommended to stay active and exercise (while avoiding movements that trigger too much pain). Gentle movement and stretching is almost universally helpful in speeding up the body’s natural healing process.

Regardless of whether your shoulder pain is Primary or Secondary, certain factors are beneficial across-the-board for reducing shoulder pain. These include:

• Movement: movement is crucial for keeping down pain levels. In fact, inactivity can cause deconditioning (bodily changes that result from low activity levels), which can cause pain levels to increase.
• Stress and fear reduction: stress, anxiety, and fear can amplify pain sensations in the body.  This is important because pain is directly related to fear, regardless of the pain’s cause. Identifying sources of stress and fear, and working to minimize them, help drive down pain levels.

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Other traditional and holistic pain management options:

Various other treatments and techniques may be helpful for reducing shoulder pain in the short term, as long-term treatment of the underlying pain mechanism(s) is underway. These include:

• Physical therapy - A physical therapist can set you up with an exercise program that can strengthen and improve the flexibility of your shoulder.
• Medication - Nonsteroidal anti-inflammatory drugs (NSAIDs) like ibuprofen and naproxen and other pain medications prescribed by your physician can relieve pain and lessen inflammation.
• Injections - Your doctor may inject steroids (corticosteroid) or numbing medication into your shoulder to temporarily alleviate the pain you’re experiencing. In some cases, steroids can be taken orally instead.
• Surgery - Most patients respond to other shoulder pain treatments without needing to resort to surgery. In the cases of torn rotator cuffs and recurring dislocations, surgery is a viable option that doctors usually recommend early on.
• Regenerative medicine - There are innovative, cutting-edge medical technologies available that are being used to treat shoulder pain as well. One example is plasma and stem cell therapy which involves inserting cells into injured tissue to initiate growth, regeneration of damaged tissue, and anti-inflammatory properties (1).
• Light resistance training - Lifting light dumbbells boosts blood flow to the rotator cuff muscles, which can speed up the healing process. This is usually done after a few days of rest followed by a few days of gentle stretching.
• Daily exercises - There are numerous exercises and stretches that you can do at home to manage your shoulder pain and increase your flexibility (2).
• Heating pad - Heat can temporarily alleviate the discomfort you feel in your shoulder.
• Epsom salt bath - Like a heating pad, taking a warm bath can be soothing and make you feel more comfortable.
• Massage - There are many benefits to massage, including increased circulation, a reduction in muscle tension and stress hormones, and improved joint mobility. In addition, it is relaxing and has been found to hasten the healing process for soft tissue injuries (3).
• Acupuncture - An ancient Chinese practice, acupuncture involves inserting thin needles into certain areas of the body to promote well-being and healing (4).
• Natural pain relievers - Turmeric, willow bark, and cloves have all been found to work as natural remedies for shoulder joint pain.
• Menthol rub or essential oils - Applying these (arnica cream is another alternative (5)) to the spot that hurts can provide some temporary relief.
• Osteopathy - Osteopathy combines both traditional medicine and osteopathic manipulative medicine (which concentrates on reducing pain and musculoskeletal tension) to help with shoulder pain.
• Rolfing - Similar to a deep tissue massage, rolfing involves manipulating muscles and fascia to assist the body in regaining its structural balance.
• Chiropractic adjustments - Another holistic treatment for shoulder pain involves visiting a chiropractor who can help you increase your shoulder’s range of motion, boost flexibility, reduce pain, and restore function.

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Do home remedies for shoulder pain actually work?

You may be questioning if performing home therapy for shoulder pain is effective or not. The answer is that home therapies can be helpful during the healing process of acute shoulder injuries. However, for chronic shoulder pain, it is important to address the root cause of the pain, whether it be Central Sensitization or something else, in order to find lasting relief. Pain management options such as the ones listed in the previous section (including massage, physical therapy, and medication) can be helpful in the short-term for keeping chronic shoulder pain at bay. However, they should not be relied on for long-term relief, and neither should they be the primary means of chronic shoulder pain treatment.