Understanding Shoulder Pain
Why do I have shoulder pain? What are the possible causes?
A vast majority of chronic pain in the body is caused by dysfunction in the muscles. In other words, chronically tight or strained muscles that are stuck in patterns of compensation are frequently at the root of significant pain.
Left untreated, this type of chronic strain can lead to muscle tears which can become very painful.
Right shoulder and neck, front view.
Right shoulder and neck, back view
Also, failure to resolve patterns of muscular compensation through appropriate treatment can predispose the shoulder to further injury.
Sometimes a simple movement such as reaching behind you or above you can push the problem over the brink.
For example, let’s look at a very common shoulder problem: pain in the deltoid muscle (that’s the muscle on the outside of the shoulder).
The deltoid muscle often becomes strained and fatigued when the shoulder blade no longer moves freely. If the shoulder blade is stuck (what the layperson often calls "frozen shoulder"), then the deltoid must work 3-5 times as hard in order to perform the simple tasks such as lifting the phone, turning a doorknob, or reaching for something on a shelf.
All these movements, then, contribute to the mounting fatigue in the deltoid.
Right deltoid muscle, side view
Over time, the deltoid becomes ischemic, meaning it’s blood flow is significantly reduced. And then you have a muscle that’s working overtime, without an adequate supply of blood to nourish it. That’s a recipe for a painful shoulder and very specific therapy will be required for lasting shoulder pain relief.
The potential strain in the deltoid is just one example of a structural problem that could impact any number of muscles.
When the shoulder is stuck in internal rotation, the upper trapezius and deltoid muscles are forced to overwork.
What is frozen shoulder and what causes it?
Clinically speaking, frozen shoulder is the generic term used for adhesive capsulitis, a condition in which the joint capsule has literally become adhered to itself. Adhesive capsulitis can resolve itself with regular therapy though the time-frame can be in the range of 12-18 months for recovery. Sometimes surgical intervention may be required.
More commonly, however, any lack of movement in the shoulder blade may be called frozen shoulder. This type of frozen shoulder is typically the result of tight muscles and fascia that inhibit the easy sliding up and down of the shoulder blade. This inhibition of movement can be caused by a variety of things including:
1) Stress, which results in the unconscious bracing of the shoulder muscles.
2) Inactivity, resulting in the gradual tightening of the shoulder muscles.
3) Torsion in the pelvis and a functional leg-length difference, which can result in imbalances in the upper torso.
4) Repetitive movement patterns, which can allow the fascia to shorten up, thus inhibiting muscular movement.
5) A protective neuromuscular response in the body, which limits movement to avoid further pain or damage.
Shoulder pain relief in the case of frozen shoulder can often be achieved with very targeted therapy for the entire shoulder girdle. Often pain can be reduced by at least 75% in 4-6 treatments.
When the upper trapezius and deltoid muscles are overburdened, the deeper neck and shoulder muscles can be forced to compensate. This often results in strain and pain.
Why did I experience such sudden pain?
I didn’t "DO" anything.
Sudden onset of pain is often the result of muscular compensation that has been pushed over the edge. In other words, it’s common for muscular imbalances to build up in the body without any symptoms at first.
The body is extremely dynamic and will often adjust itself to numerous imbalances for long periods of time without there being any pain at all. But after a while, imbalances such as muscular compensation begin to announce themselves. Either enough time passes, or some small movement pushes the imbalance over the pain threshold.
For example, a shoulder could be set on a path toward becoming frozen by stress or inactivity, but wouldn’t necessarily be painful or present any symptoms at first. But with time, the shoulder becomes more and more stuck, and muscular compensation increases.
Over the course of days or weeks, there might be a gradual progression of discomfort that one doesn’t pay much attention to. Sometimes there’s no sensation whatsoever while compensations are increasing. But then one day, you reach for something and suddenly the muscles go into spasm and it seems like the pain came from nowhere.
The muscles of internal shoulder rotation are bigger and stronger than the muscles of external rotation. In the absence of adequate stretching and toning of ALL the muscles of the shoulder girdle, muscular imbalance can progress toward pain and dysfunction.
Are shoulder exercises recommended for shoulder pain?
Not at first. Shoulder exercises should be one of the last stages of rehabilitation, not the first. Exercises performed too soon merely force muscles that are in spasm to do work they’re not ready for.
For lasting shoulder pain relief, it’s essential to follow the stages of rehabilitation in the proper order:
1. Eliminate spasms and hypercontraction in the tissues (Manual therapy such a neuromuscular therapy, myofascial release, structural bodywork)
2. Restore proper biomechanics (Soft-tissue re-patterning, structural bodywork)
3. Restore flexibility to the tissues (Stretching, somatic movement, yoga)
4. Rebuild the strength of the injured tissues (Physical therapy exercises, strength training, weight-bearing exercise)
5. Build endurance (Aerobic exercise)
If rehabilitation is attempted without following this order, re-injury and setbacks to shoulder pain relief often occur. For example, attempting to resume weight training while muscles are still ischemic (muscles with insufficient blood flow) and hypercontracted may cause an injured muscle to spasm or become further strained.
What treatment is available and recommended?
If you have a achieved limited results with one or more modalities when seeking shoulder pain relief, it’s possible that the precise structural compensation pattern causing your pain may not have been identified.
While massage therapy, physical therapy, and chiropractic are excellent treatments for many problems, certain structural imbalances require a type of soft-tissue evaluation and treatment that is not their focus.
Many shoulder problems require a very specific two-pronged approach such as that employed by Neuromuscular Therapy or other manual therapies that follow a similar model.
First, it’s essential to correct the structural imbalances which set up compensating muscular patterns.
Second, it’s crucial to gently and thoroughly treat the painful areas themselves. Without manual precision, it’s easy to miss ischemic tissues which are the source of the greatest pain.
By following this protocol, it’s possible to get at the root of the problem and not simply treat the symptoms.
emergency care for an acute injury
If you get injured, be sure to see a qualified medical professional. In the meantime, follow this simple protocol to care for an acute injury.
R – REST
I – ICE
C – COMPRESSION
E – ELEVATION
When is surgery needed?
There are many conservative approaches available for treating a wide variety of shoulder problems prior to considering surgery.
However, in certain instances, surgery might be considered. For example, severe tears the rotator cuff or complete disruption of the acromio-clavicular ligaments are examples when surgery may be appropriate.
In these cases, manual therapy might bring a degree of shoulder pain relief, but not complete relief.