Pain is interesting. It doesn’t always tell us what caused the pain. And to make if even more complicated, the onset of pain can be delayed by several days and even weeks from the initial injury. This can make it super frustrating to figure out what is wrong, how to fix it, and how to prevent it from happening again.
Let me try to tell a common story about shoulder pain that seems to come from nowhere. We will call the patient Bill. Bill noticed a slight ache in the top side of his shoulder that steadily increased over the last few weeks. He didn’t recall doing anything that could have caused the pain. We chatted a little more, and I asked about any arm activities in the last 2 months. He did say several weeks prior he had done a little more yardwork that required some overhead activity. He said it was fatiguing, but he didn’t notice any pain. This is a common history with shoulders. We do something a little more strenuous overhead that we don’t do on a regular basis, and then a few days to a few weeks later we notice an ache that gets worse.
Why does this happen? Let me try to explain it. The shoulder is a very mobile joint with approximately 18 muscles that influence the shoulder and shoulder blade. The shoulder joint has four key muscles called the rotator cuff that provide key shoulder stability at shoulder height and above. Unfortunately, the design of the rotator cuff has a poor blood supply to the tendon portion, and this gets worse as we age. This part of the rotator cuff often gets “pinched” in the shoulder when working at shoulder height or above. This pinch can happen for various reasons, but it is most common when muscles are tight in certain areas of our chest. Those tight muscles tend to pull our shoulders – and posture – forwards. How does this happen?
If you do not stretch and maintain shoulder, thoracic spine (upper back) and chest mobility, you will have limited range of motion in the shoulder. This creates an opportunity for pinching the tendon when working at shoulder height and above. Tightness can also develop over time from poor posture habits. Another cause can be a bone spur from arthritis. The bone spur combined with shoulder, chest, upper back tightness does not leave enough room in the shoulder joint. When moving in certain combinations this “pinch” creates rubbing/friction on the tendon and sometimes the bursa. Repeated friction and pinching on the tendon can cause gradual tearing over time. Hopefully you can see how important the correct stretching routine is. If you do the wrong exercises/stretches, you could make this situation worse and cause a tear.
Back to Bill’s story. Once we evaluated his movements, joint stiffness, muscle flexibility, strength and ruled out that his pain was not coming from his neck (special orthopedic tests,) we found he had tightness in the chest, thoracic spine, neck and shoulders. He needed some hands on mobilizations and release of the stiffness from us. Then he was given ways to work on those at home without causing joint pain or worsening of symptoms. His medical diagnosis was “impingement” and “rotator cuff strain,” but we outlined all the muscles involved and what he could do to fix the problem and prevent it from coming back. Bill’s first 4-6 visits focused on pain “relief.”
The next 4-6 visits were focused on “restore,” which involved more aggressive range of motion, stretching, and also improving the strength and coordination of the rotator cuff and shoulder blade muscles. We also covered lifting and reaching in ways that would not irritate the shoulder as much and emphasized long-term success and prevention.
I hope you can see that even when you think you haven’t done anything harmful lately, you may need to go back in time. Also, really look at your posture, your flexibility, and understand how the shoulder is often irritated easily from overhead activities. The rotator cuff needs special TLC and the right exercises to keep it working for life. We are happy to help!
The author, Jennifer Penrose, is a Physical Therapist and owner of Penrose Physical Therapy. If you have any questions about neck and shoulder pain, you can call (360) 456-1444 or email email@example.com.