Shoulder pain is a tough condition to live with. It restricts your quality of life, stops you from playing sport, or even just putting away the groceries. It’s often caused by irritation to the structures inside the shoulder joints. This leads to inflammation of the Tendons, Bursae (the fluid sac that lubricates the joint), or Capsules (the ligaments surround the joint).
Common causes of the pain include:
To understand what’s causing your shoulder pain, we have to first develop a deeper understanding of the shoulder complex.
The shoulder complex is made up of three bones: the Humerus (Upper Arm bone), Scapula (Shoulder Blade at the back), and Clavicle (Collar Bone at the front).
The shoulder joint is not a simple hinge: it can roll forward and back, as well as shift up and down in its socket. This allows a much greater range of movement for our arms.
These three bones connect to each other through different joints:
As you can see, the shoulder joint is very complex!
There are lots of muscles to move the arm in different directions. And as we mentioned earlier, the shoulder ball can also move up, down, forward, and back inside the joint to increase movement.
The main muscles that move the shoulder ball around are the Rotator Cuff Muscles.
These rotator cuff muscles extend from the top of the upper arm bone and attach to the Shoulder Blade. In order to make this work, the Rotator Cuff tendons have to pass through the joint itself (through the Subacromial space).
“Remember ‘Subacromial Space’ – it’s the key to your Shoulder Impingement!”
This Subacromial Space consists of a lubricating sac, known as Bursa, to allow smooth movements in the shoulder. If there’s any irritation or inflammation to the tendons and bursae, the space will shrink, which will cause sharp pain whenever you try to lift the shoulder.
Let’s look into the possible factors that worsen the impingement:
If you have shoulder pain, it’s best to look at posture first. Often posture will give hints about the cause of the pain, or might be the cause itself.
Some of the most common causes are having rounded shoulders and a Kyphotic trunk (an exaggerated curve in your upper back – a bit like a small forward ‘hunch’).
In the case of posture-related impingement, your shoulder ball is sitting in an unnatural position. This position constantly pushes and rubs on the structures around the shoulder ball. Over time, this puts stress on the Subacromial Space (the small hole in your shoulder joint, where the tendons run).
In particular, the shoulder ball tends to push up into the socket. This will worsen the condition as it compresses the space when you try to lift your arm up.
Now that you know rounded shoulders have its effect on worsening the impingement, there are also some other factors to add.
With your shoulders slouched for a long time, it will encourage the tightening in the muscles of the chest. The front of your chest has two muscles: the Pectoralis Major and the Pectoralis Minor. You probably know them as the ‘Pecs’.
As these muscles tighten overtime, they start to shorten. This shortening then encourages your shoulders to round even more. It’s a cycle that repeats itself: As a muscle becomes tighter, it’s also under tension almost all the time. This will lead to it being overworked and painful.
Aside from the two Pectoralis (chest) muscles, the Upper Trapezius (the triangle muscles between your neck and shoulders) are very likely to be tight as well. The same cycle will happen here too, with the only difference being the position where the muscles pull the shoulders.
With very tight Upper Trapezius, the shoulders are always stiff and raised towards the ears. This forces the shoulder ball upwards, enclosing the Subacromial Space further.
This condition is commonly combined with the poor posture we talked about above. If it gets worse, it may also lead to neck stiffness and tension headaches.
There are a lot of muscles that surround the shoulder blades to allow movements. This is because there are so many different movements our shoulder blades and arms can do:
When we sit slouched over, or walk with bad posture, our posture muscles get weak.
The posture muscles that are particularly essential to be strengthened are the Lower Trapezius (the muscles in the centre of your back below your shoulder blades). The Lower Trapezius pulls the shoulder blades down away from the ears.
The Rhomboids (muscles in between the shoulder blades), pull the shoulder blades backwards to keep them squeezed together. This prevents rounding of shoulders.
The final muscle is the Serratus Anterior. This muscle is difficult to explain, and even harder to look at in images. Essentially, it pulls your shoulder blades in towards your ribs, and stops them from ‘winging out’. This works with the other two sets of muscles to provide stabilization.
You may remember from cause number 1 that tight and high shoulders are a major cause of shoulder pain. Strengthening these three muscle groups helps to counter the tightness that is developed in the front of chest and top of the shoulders.
Imagine stretching out those tight muscles until they become loose. If there’s no muscle there to keep the muscles long and loose, the muscles will eventually return to their initial state and tighten up again. This makes strengthening these three back muscles extremely important in reducing shoulder pain.
Another cause of Shoulder Impingement Pain can be because of a stiff upper back. This limits your range of movement in the spine. As your shoulder is connected to the upper back through the Shoulder Blades on the back and the collar bone on the front, any stiffness in the back can translate into stiffness in the shoulder as well.
Imagine we start with our arms by our side, and then raise them out sideways slowly in a big arc until they are above our heads.
This motion doesn’t simply happen in the ball and socket joint – if it did, we’d crush all of the nerves and fibres inside it!
To increase our shoulder’s range of motion, we actually rotate through four different joints (the GH, ST, SC, and AC Joints mentioned earlier). What makes this even more complex is that they all rotate in different amounts during different parts of the shoulder lift. This is called the Scapulohumeral Rhythm.
As the arm moves, if any single joint is stiff or gets the timing wrong, you won’t be able to properly raise your arm without pain (this is similar to how Frozen Shoulder works).
Over time, any stiffness or bad joint-timing will cause irritation and swelling to the to the structures inside.
Now that you have an idea of what’s going on in the shoulder, it’s time to see what you can do to help your shoulders!
The good news is that there is already a very well-developed field that can help with Shoulder Pain. This field is called Clinical Pilates, and it’s an area that Physiotherapists can choose to Specialize in.
Clinical Pilates is all about creating personally-tailored exercise programmes that strengthen specific muscles, while lengthening and loosening others. The exercises are very specific and can work on very targeted areas.
Clinical pilates is always a good idea to cope with pains in the body as it incorporates low-impact workouts planned by a professional physiotherapist or practitioner, with or without equipment.
For Shoulder Impingement Pain, the things that you want to work on are:
Here are some of the exercises that you can kick start with to help your shoulders:
Your Pecs pull your shoulder ball forward in its socket. Loosen up your tight chest muscles so that your shoulders can sit further back in the shoulder socket.
Stand in a doorway facing forward, with the side of your body next to the door frame. Raise your arm so that your upper arm is horizontal with your shoulders. Bend your elbow so that your forearm is pointing towards the ceiling.
Place your entire forearm and upper arm against the wall on one side of the doorway. If you’re unable to reach, just adjust your body angle a bit and work with what you can do.
From there, gently twist your upper body and head away from the wall to feel the stretch along your chest to your upper arm.
Don’t overdo it! This is Clinical stretching for pain-relief – not ballet. Gentle stretches are far more effective than aggressive stretching.
Stop when you feel a gentle pull in in your chest region. Hold for 30 seconds. Release and repeat twice.
“When stretching, we want to feel it in the chest – not the shoulder ball. If your shoulder ball pushes forward, it’s possible to feel the stretch in the joint. This will not help your shoulder pain, and will actually destabilize your joint. Ease back, set your shoulder back in the joint, and try again.”
Unlike the Pec Major, the pec minor Rotates the shoulder ball over in the joint. This muscle gets very tight if you have rounded shoulders. Stretch it out to get your shoulder joint back to centre.
To stretch out the pectoralis minor, set yourself up exactly as per the previous stretch.
This time, however, we ward to raise the upper arm slightly above shoulder height so that your palm is higher than your head.
Now rotate your body gently away to feel a stretch. The stretch should now feel higher up in the pecs – just below your collar bone.
If a stiff upper back is the cause of your shoulder pain, you can increase your spinal mobility by flexing your spine forwards, and then extending it backwards. This exercise helps you to get the motion in your upper back instead of your lower back.
Kneel down on a mat or blanket, sitting on your heels.
Place your palms on the floor slightly forward to the knees with gentle pressure towards the ground.
Inhale first. As you exhale, start to sink the belly down towards the floor, gently arch the upper back up, look upwards. (This is the ‘cow’ pose)
Inhale. As you exhale, start to tuck the belly inwards, tuck everything in away from the floor, and round the upper back up, head looking down, look into the belly button. (Now you’re an angry cat!).
Repeat the whole cycle five times.
“The purpose of this exercise is to get mobility in your upper spine. Take it slow and try to feel that movement in your upper body. It’s difficult for most people. If you rush this movement, you will only flex your lower back – the area that is already very mobile.”
While the previous exercise focused on forward and backward flexion of your upper spine, you also need to rotate the upper spine to improve your mobility. Increasing upper spine mobility will reduce shoulder pain.
Just as with the Cat Cow pose, sit in a kneeling position again, and then place your hands on the ground.
From here, take one hand and touch your palm to the back of your head.
Inhale first, and as you exhale, start to twist your upper body and slowly point your elbow towards the ceiling.
Open through the front of the chest. Inhale at the top, as you exhale, reverse the motion until your elbow is pointing towards the ground.
Repeat for five times. And then change sides.
“When you’re pointing your elbow towards the ground, make sure that it’s your spine that’s rotating – not your arm! If you’re just rotating your arm, you’re doing the chicken dance, and not getting any shoulder pain relief.”
Sit sideways on a stool (no chair back) in front of a mirror for better view of your posture.
Look at the position of your shoulder joint as well as your collar bone. Are there a lot of wrinkles in your shirt at the front of the shoulder? If there are, your shoulders are hunched forward.
If your shoulders are rounded, you need to strengthen through your shoulder blades to bring the backwards and downwards.
Think of having a glass chopstick in between your shoulder blades behind you. Squeeze the glass chopstick so that it does not fall down to the floor. If you release, the chopstick will drop and break.
As you do this, focus on getting the squeeze in your between your shoulder blades (in the Rhomboids and Lower Trapezius).
Don’t forget to keep the shoulders down, away from the ears.
Hold the squeeze for 10 seconds, release slowly. And repeat for five repetitions.
Practice this whenever possible to start correcting your sitting posture.
“Your shoulder position matters when you’re squeezing your shoulder blades. If you shrug your shoulders up near your ears, all of the squeeze goes through your Upper Trapezius (The triangle muscles between your neck and shoulders). Do you remember “Shoulder Impingement Cause 2”? That’s right! Tight Upper Trapezius! So doing this exercise correctly will help, while doing it incorrectly will actually worsen your shoulder pain.”
Hopefully by this point, you can start to understand just how complex shoulder pain can be. If you’re serious about getting real Shoulder Pain Relief in the long term, then it’s time to come and see a professional Physiotherapist.
Specifically, you want to see a Physiotherapist who specializes in Chronic Pain relief, and has a Clinical Pilates Studio.
This type of Physiotherapist is very different from a Sports Physio. They deal exclusively with clients who have nagging shoulder, neck, and knee issues, and they have different equipment to suit these conditions.
No condition is too small to address. It’s common for clients to have pain and wait 5, 10, even 20 years before they finally say ‘enough is enough’. You can seek treatment today and solve your body issues quickly and effectively.
So please do book in to see a Physiotherapist to get the right diagnosis and programme for your shoulder pain relief.