In a metaphorical context, the shoulder often is associated with carrying great weight—for example, “shouldering the blame” or “crying on someone’s shoulder.” But while the shoulder is not an inherently weight-bearing joint, it is one of the most commonly injured structures in the human body.
Luckily, physical therapy is highly effective in treating most shoulder conditions and injuries. But before we go into depth about various treatments for shoulder pain, let’s go over the basic anatomy of this famous connective structure.
The Anatomy of the Shoulder
Often compared to a ball and socket, the shoulder connects the upper arm with the upper torso. Specifically, it holds together the humerus (i.e., the upper-arm bone), the scapula (i.e., the shoulder blade), and the clavicle (i.e., the collar bone). Soft-tissue elements of the shoulder include numerous ligaments and muscular attachments that support the joint and allow for movement.
While most people think of the shoulder as a single joint, it actually is a combination of three separate joints. They are:
- The glenohumeral (GH) joint, in which the rounded end of the humerus sits inside of the slightly cupped surface of the glenoid.
- The acromioclavicular (AC) joint, which joins the scapula to the clavicle.
- The scapulothoracic (ST) joint, which is the area in which the scapula lies over the back of the rib cage, also known as the thorax.
Another anatomical structure contained within the shoulder—and often affected by injury—is the rotator cuff. The rotator cuff is made up of four muscles that wrap around, and help stabilize, the shoulder joint. Various tendons attach the muscles to the shoulder bones. Bursa sacs—small, fluid-filled membranes—help cushion the shoulder joints and minimize friction.
The shoulder is one of the most mobile parts of the human body, featuring a larger, more varied range of motion than any other joint. However, this extraordinary flexibility comes at a cost: instability. Because of that instability, the shoulder is prone to many problems. While some shoulder issues respond well to good old-fashioned rest, many require medical attention. And physical therapy has proven highly effective in the treatment of shoulder injuries.
Shoulder Problems and Causes
Generally, shoulder problems develop as the result of one or more of these factors:
- Aging: As the body gets older, the tissue around the shoulder joint becomes less resilient, thus increasing the risk for injury. Also, as people become less active, disuse and atrophy lead to stiffness and weakness—two more injury risk factors.
- Strain and overuse: These often are associated with repetitive motion and/or fatigue resulting from certain athletic activities (e.g., pitching a baseball) or job functions (e.g., lifting heaving objects, especially above the head).
- Trauma: These types of injuries most commonly result from sports contact (e.g., football tackling) or accidents (e.g., falling on the shoulder). There are two types of trauma:
- Macrotrauma occurs as the result of strong, violent force and often involves fractures, major tears, or dislocation.
- Microtrauma is less severe and usually occurs as a consequence of non-violent strain, often resulting from everyday activities such as dragging a heavy piece of furniture or reaching for a box on the top shelf of the kitchen cabinet.
Common Shoulder Conditions
Pain or decreased mobility in the shoulder often result from one of the following issues:
- Rotator cuff tendonitis: The tendons in the rotator cuff sometimes get pinched underneath a bony prominence on the shoulder blade. When this happens, the tendons can become inflamed and painful.
- Biceps tendonitis: The biceps tendon connects the biceps muscle in the upper arm to the front portion of the shoulder. It basically serves as a fifth rotator cuff tendon, providing additional stability to the front of the joint. Pain and inflammation can develop if the tendon gets pinched by the shoulder blade or by the ligaments connecting the collarbone and the shoulder blade.
- Bursitis: If the bursa sacs in the shoulder joint become inflamed, they can thicken and impede movement in the joint. This results in pain and stiffness.
- Osteoarthritis: This condition occurs when the cartilage in the shoulder deteriorates, thus increasing friction within the joint. It can result from several factors, including wear-and-tear over time, disease, infection, or injury. In addition to being painful, arthritis leads to stiffness that can impede full movement of the joint.
- Subluxation: Sometimes referred to as a “partial” dislocation of the shoulder joint, this condition occurs when the bones in the joint quickly pop out and in. Most common among people who are 14-30 years old, subluxation often occurs while playing sports that require overhead motion (e.g., tennis or swimming). While it may not cause a lot of trouble at first, subluxation can develop into other, more serious conditions over time.
- Dislocation: Whereas subluxation is a relatively minor injury, dislocation is far more serious and debilitating. This injury occurs when the bones separate from the shoulder joint but do not pop back in; it also usually involves strain, tearing, or other damage to the soft tissues in the joint.
- Impingement: This condition occurs when the shoulder joint does not have enough room to function properly, either due to an existing structural issue (e.g., a bone spur) or an environmental issue (e.g., poor posture).
- Adhesive capsulitis: Often called “frozen shoulder,” this condition is characterized by gradual loss of motion, which can last up to a year and a half.
- Fracture: Shoulder fractures—involving the clavicle, the scapula, the humerus, or a combination of all three—typically result from significant trauma to the joint and its surrounding structures.
Treatment for Shoulder Pain
If your shoulder pain is the result of a trauma event—such as a fall or auto accident—you should seek medical attention immediately following the incident. Similarly, if you have had shoulder pain for more than two or three weeks—even if it was not the result of trauma—then it’s time to see a healthcare provider (e.g., a physical therapist). That way, you can prevent the issue from compounding and potentially developing into a more serious condition.
With most shoulder injuries, you should rest the joint for at least two to three days, icing it periodically. During this time, you can move the shoulder gently to maintain mobility if you are able. After a few days, you can begin exercising the joint to strengthen the muscles around it and improve range of motion. If the pain persists, you should seek professional medical treatment. While surgery may be necessary to repair damage caused by certain conditions, many problems are treatable with physical therapy alone. Your physical therapist (PT) can evaluate your pain and provide you with an appropriate diagnosis and a personalized treatment plan. When you first begin physical therapy, your PT will conduct a variety of tests and assessments to gain as much knowledge as possible about your specific shoulder condition. These include:
- Using a goniometer to measure the strength and range of motion of the shoulder as well as the quality and coordination of the motion
- Evaluating your posture
- Performing upper extremity screening tools to pinpoint the specific area of injury
After completing your evaluation, your PT will develop a rehabilitation program—also called a plan of care—to rehabilitate your injury and reduce your pain. This program will include a variety of exercises specifically designed to improve strength, mobility, and flexibility as well as eliminate any deficiencies in those areas, thereby preventing the development of any chronic, ongoing shoulder issues. These activities may include:
- Water exercises (e.g., arm circles or shoulder rolls)
- Proprioception training (i.e., exercises designed to increase awareness of shoulder position, movement, and orientation)
- Agility and endurance exercises
Your PT also will provide you with a home exercise program, which is a set of exercises—along with recommended frequencies and durations—that you are responsible for completing at home. Additionally, your PT may use passive treatment methods such as ultrasound, hot-cold therapy, or electrical stimulation to relieve pain and swelling and increase blood flow. In many instances, manual therapy (i.e., hands-on manipulation, mobilization, or massage) may be appropriate.
The length of your treatment and the frequency of your therapy sessions will both depend on your specific condition, its severity, and whether you underwent reparative surgery. Rehabilitation could take anywhere from several weeks to several months. That said, remember that the duration of your overall therapy treatment is greatly affected by your commitment to your plan of care. Therefore, it’s imperative that you follow your PT’s plan—especially your home exercise regimen—as closely you can. That way, you’ll be able to resume your normal routine—and eliminate your shoulder pain—as quickly as possible.