If you like to lift weights and stay active, then constant and limiting shoulder pain is the worst thing that can happen to your training!
Let's start by getting 1 thing straight- there can be so many causes for how shoulder pain might have developed, but there are a few typical culprits we can look to. Now I do want to take a second to clarify that this information is not meant to help you diagnose any condition you might be dealing with, but think of it as an informative overview of the common things we see patients dealing with, so you can maybe determine "Hey, I think I might have this".
This article will NOT be covering ways to specifically assess or treat these conditions, but I have linked other articles we have that cover those EXACT topics so you can start getting the relief you deserve!
Ok... now back to the good stuff!
While there are some common areas of the shoulder typically involved, the cause behind why those structures are affected comes down to one overarching reason. That reason being-there was more load (or stress) placed on that structure than it could handle causing some dysfunction, injury, and/or pain.
This can be developed over time or happen in one acute episode. It can also happen for many reasons-such as using too much weight during an exercise, using poor form consistently, moving too fast throughout your range of motion, and having an imbalance of muscle stability to name a few. This may sound like vague reasoning, but trying to predict what exactly happened that caused an injury after it already happened is usually pretty difficult. But that is exactly what we're trained as PT's to determine, so we can help you manage these injuries!
Plus, no one can completely protect themselves from an injury, nor can a pain or injury be completely avoided, but with a careful assessment and thorough application of a treatment plan we can help you recover and help to prevent a re-injury!
The shoulder joint is a very complex setup. The ball and socket joint of the shoulder itself is not a very "stable" joint, which just means that the joint can be very mobile but it gets much of its stability from the surrounding muscles. We also have to consider the complex nature of the scapula (shoulder blade) and how it is completely supported by muscles, but also serves as the foundation of the shoulder joint. With these less "stable" joints, we leave more room for dysfunction developing and pain being present.
Here are 5 of the most common structures we see involved in shoulder injuries and with patients having pain in the shoulder, and how to differentiate them on your own!
1) Rotator Cuff
Probably the most well known "cause" of shoulder pain is the rotator cuff. You see these words thrown around whenever anyone has ANY sort of pain in the shoulder. Before we get into the weeds, it helps to understand what the rotator cuff (RTC) is, and is not.
The RTC is a group of 4 muscles that surround the shoulder like a supportive sling. The muscles are the supraspinatus, infraspinatus, teres minor, and subscapularis and their primary roll is promoting smooth movement of the ball of the humerus (arm bone) in the socket of the scapula (shoulder blade). These are smaller muscles muscles compared to many around the shoulder, but they have an important job.
The RTC is often implicated in shoulder pain because of the movements that hurt with shoulder pain and it's isolated connections within the shoulder. And since these are smaller muscles groups they are often found to be torn in later stage injury (which may or may not even be the cause of pain-but now is not the time for that topic).
A simple way to screen if your rotator cuff may be involved in your pain is with some active arm movements. But disclaimer here- these will not tell you for sure if the RTC is the cause of your pain but merely alert you to the possibility of it.
If you have pain with one or all of these movements, getting some further assessment will be necessary to really pinpoint the true cause of your pain and the best way to make sure it goes away for good.
We have another article that goes into some of our favorite exercises we use with patients dealing with rotator cuff pain- click the link below to get the exact movements we use with many of our patients!
How to fix your Rotator Cuff Pain!
2) Labrum
The labrum of the shoulder is a type of cartilage that helps to provide additional support and padding within the joint. The bony parts of the shoulder joint are very shallow-think a golf ball sitting on a golf tee. The labrum is some extra support on the "golf tee" socket to give the ball of the humerus (upper arm bone) some additional cushion.
This structure is not as commonly injured as other areas of the shoulder such as the rotator cuff but it can be injured in a variety of ways. Most commonly we see this with dislocations and severe sudden trauma to the shoulder such as falling on the arm or mishandling something heavy when lifting and you drop it. In cases like this we tend to see more significant and sharp pain, but with tears that are more chronic and degenerative the pain will be less intense and more achy.
While symptoms can be similar to other structures, there are some key differences from other injuries.
Labrum injuries are overall less frequent, and rarely need surgery unless mobility or function is very limited. But we can not ignore the contribution of this structure to the presence of shoulder pain.
There are also many different types of tears that can happen, and each has a different prognosis on how well it can recover.
Most commonly we see a "SLAP" tear, meaning the top of the labrum (think the 12 o clock position if you're referencing the picture below) is torn to either side and can form its own little flap or "bucket handle" tear. Usually this also pulls the bicep muscle off the bone because that's where it also inserts!
Surgery for this type of tear requires suturing the labrum together and helping reattach the bicep muscle and can be a long recovery. If symptoms are minor and depending on other factors such as age, activity level, stability of the joint, and how clean the tear is, surgery might not even be warranted.
3) Bicep
The bicep is often an overlooked cause for shoulder pain, but it plays a bigger role than many understand.
The bicep consists of 2 heads, with the "short head" attaching onto the coracoid process (not shown below) and the "long head" attaching onto the top of the glenoid fossa- AKA the top of the shoulder socket. This head of the bicep also attaches onto the top portion of the shoulder labrum, which we JUST talked about.
The muscle can get torn due to trauma, or from a long duration of repetitive wearing down. More often than not, the biceps pain takes a long time to develop, and is the result of gradual friction and irritation overloading the bicep tendon more than it can tolerate. This can lead to the tendon itself becoming weaker, and potentially tearing. Symptoms can start with tightness and mild pain and range all the way to severe sharp pain and inability to lift the arm and preventing you from exercising.
Differentiating pain from other structures is tough, due to the proximity to other potential causes of pain, and the similar movements that will be aggravating to each, but here is what we see in patients with biceps pain.
The type of exercise you do will determine if an issue like this will develop. If you are doing lots of high volume shoulder and overhead exercises, it is more likely you will develop a bicep pain issue than someone who predominantly trains cardio such as running, rowing, biking, etc. But if I have learned ANYTHING in my years as a PT, it's that no one is safe from developing shoulder issues, even if you don't even do any shoulder or overhead exercises!
4) Neck/Cervical Spine
Alright, now this is my favorite one here. The number of times I have seen someone with shoulder pain that is caused by on contributed by the cervical spine (neck) is TOO DAMN HIGH! It can be debilitating, which makes understanding the cause and how to treat it even more important!
You might also hear the term "Cervical Radiculopathy" which means the neck (cervical) is causing irritation to the nerve and subsequent symptoms (radiculopathy).
This is a harder concept to grasp, as the location of pain or symptoms isn't always the location causing those symptoms. And it's an even harder condition to properly identify and treat. Many PTs and doctors don't even fully appreciate how involved the structures of the cervical spine can be in the presence of shoulder pain.
But here is how it works.
In the neck, the spinal cord has nerves that branch off at different levels of the spine-if you need a visual then check out the picture below. These branches then form into individual nerves that go into the shoulder and down the arm. Overall, we have a very detailed understanding of exactly where these nerves go, and what structures of the shoulder they supply, both the muscle function and skin sensation.
When a nerve is irritated or pinched, it will let us know by causing sensations such as pain, numbness or tingling, cramping, burning, throbbing, swollen sensations, tenderness, and in severe cases muscle weakness and inhibition.
The pain can range anywhere from a mild tightness, to uncomfortable throbbing, to searing burning pain and anything in between.
Here is the tricky part though; the location and behavior of symptoms can be wildly variable. One person with C5 level cervical radiculopathy will present with completely different symptoms than another.
You might have pain in one small area or it can be widespread in the shoulder or arm. It can change locations without warning. It can be severe one day then gone the next.
When we're dealing with symptoms from a nerve, there are many possibilities under the sun. Which unfortunately makes detecting them a little more difficult.
The hard part is understanding the symptoms you're having and determining if it is because of the neck, or it can be attributed to one of the other shoulder structures. But once you have that figured out, it makes the treatment so much easier AND effective!
Here is a list of the most common symptoms you can see if your shoulder pain is caused by the neck.
While these symptoms can be widely variable, it usually takes a thorough physical assessment to determine how they can bet treated. And once you have that assessment done, it's time to listen to your PT and trust the process, because these cervical spine issues can take a while to resolve!
5) Upper Back/Thoracic Spine
The 5th and final culprit for shoulder pain is the upper back, or the thoracic spine. This has less direct influence on the shoulder than other areas mentioned, but issues here can affect how the shoulder moves, which can cause pain and dysfunction.
This area has much less movement when comparing it to the shoulder joint, but the 12 thoracic vertebrae and their corresponding ribs encompass a large area and need to be moving well into both extension and rotation when referencing it to shoulder movements.
Since this has a secondary influence on shoulder pain/movement, there are no consistent symptoms that you see with thoracic spine dysfunction. Honestly, the symptoms can mimic just about any other issue, because a restricted thoracic spine will affect how EVERYTHING else moves and your body will find a way to compensate.
What you might notice is a general lack of stability or strength in the shoulder at first, or the development of tight or achy discomfort on one side.
If you are doing overhead lifting, pain in between the shoulder blades might be present on the side you are having shoulder issues.
If you're looking for more ways to assess and treat your potential thoracic spine dysfunction and see how it relates to your shoulder pain, check out our article! This is a great jumping off point to determine if your stiff and weak thoracic spine is contributing to your shoulder symptoms.
If you've been dealing with shoulder pain, we hope this cleared some things up and gave you some clarity.
And if you're still just as confused as you were before, never fear!
The reality is that pain and injury is a complex thing to deal with, and lucky for you that is exactly what we help solve every single day in the clinic!
If you're in the Columbus, Ohio area and have been dealing with pain or injury preventing you from working out like you want, hit us up and schedule a free phone consultation with Dr. Taylor to see how we can help you!