What causes shoulder pain, and how physiotherapy treats it
Shoulder pain can affect sleep, dressing and reaching. An assessment can help separate stiffness, weakness, tendon-related pain and symptoms referred from the neck. Here is what is usually going on and what treatment involves.
Usually noticed in one specific movement
Reaching behind for a seatbelt. Getting a jumper over your head. Putting a plate on the top shelf. Most people can name the exact movement that first told them something was wrong, and often the pain is felt not at the top of the shoulder but in the outer upper arm.
Night pain is the other giveaway. Lying on that side becomes impossible, and a shoulder that felt manageable all day makes itself known at two in the morning. That is common with shoulder problems and it is one of the more wearing parts of them.
Some shoulders hurt. Others are simply stiff, losing range gradually over weeks until reaching or rotating is genuinely restricted. Some are weak rather than either, giving way when you lift something at arm's length. The assessment is largely about telling those apart.
A joint that trades stability for range
The shoulder moves further than any other joint in the body, and it manages that by relying on muscle control rather than on a deep socket. That is a good trade until something in the control system gets irritated or tired.
Most shoulder problems fall into a few broad groups. Tendon-related pain in the rotator cuff, usually after a change in load such as decorating a house, a new gym programme or a heavy month at work. Stiffness of the joint capsule, which comes on gradually and can restrict rotation markedly. Instability, more common in younger and more active people. Pain referred from the neck, which is why the neck usually gets examined too.
Age-related changes in the cuff tendons are extremely common and are found on scans in plenty of people with no pain whatsoever. A finding on an image and the reason your shoulder hurts are not automatically the same thing.
What happens across a course of treatment
Shoulders generally respond to loading the right structures at the right dose, alongside hands-on work to get comfortable movement back. It is rarely quick, and being told that at the start is more useful than being told it afterwards.
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Assessment
What movements provoke it, how it started, how you sleep, what your work and sport ask of the arm. Then testing range in each direction, strength through the rotator cuff, how the shoulder blade moves, and screening the neck as a possible source.
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Hands-on treatment
Soft tissue work and joint mobilisation to reduce irritation and free up movement, used where they help. For a stiff shoulder this is often about restoring range you can then use; for a painful tendon it is about settling things enough to start loading.
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Staged strength work
The part that holds the change. Rotator cuff and shoulder blade strength built gradually, starting at a level that does not flare the shoulder and progressing towards whatever you need it for, whether that is overhead work, swimming or lifting a grandchild.
Shoulder rehab is measured in weeks and months rather than days, particularly where a tendon or a stiff capsule is involved. The plan is written with a realistic timescale and reviewed as you go, and if it is not moving in the right direction that gets said rather than glossed over.
Sensible steps while you wait
Keep using the arm within comfortable limits. A shoulder that is completely rested tends to stiffen, and stiffness is harder to reverse than soreness. Ordinary daily use is usually fine even when it grumbles a little afterwards.
Step back from whatever provoked it rather than stopping everything. If overhead pressing at the gym started it, reduce or pause that while keeping the rest of your training going. Full rest from all activity rarely helps and often costs you strength you then have to rebuild.
For sleep, lying on the other side with a pillow supporting the sore arm in front of you is what most people find easiest. Heat or over-the-counter pain relief can take the edge off, and a pharmacist can advise on what suits you.
All general guidance. What loading is right for your shoulder depends on which of the broad groups above it belongs to.
Shoulder symptoms that need urgent care or a GP
- Call 999 if shoulder, arm or jaw pain comes on with chest tightness, breathlessness, sweating or nausea. Pain in the left arm or shoulder can come from the heart rather than the joint, and that is treated as an emergency rather than a physiotherapy question.
- Go to an urgent treatment centre or an emergency department after a fall or an accident if you cannot lift the arm at all, the shoulder looks an odd shape, or there is significant swelling or bruising. A fracture or a dislocation needs assessing before any rehabilitation starts.
- See a GP promptly if the shoulder is hot, red and swollen with a fever, or if pain comes with unexplained weight loss or with a history of cancer. Otherwise, most shoulder pain is exactly what it appears to be, and if an assessment here suggests otherwise you will be told plainly.
Book an assessment for your shoulder
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