Painful shoulder, what can it be ?


Shoulder pain is common in the sports person, be it swimmers cyclist or runners. The persistence of
shoulder pain can significantly impede ones training regimen for an extended period. Historically,
identifying shoulder pathology posed a considerable diagnostic challenge. Physiotherapists
underwent extensive training in numerous specialized tests and intricate differential diagnoses to
discern the source of a patient’s shoulder pain. Fortunately, contemporary research has simplified
the process to the point where it is much more simple to diagnose shoulder pathology.

Shoulder pain can generally be divided into 4 categories. They are listed below from the most
common to the least common complaint.

1) The Overuse Shoulder
2) The Neck Related shoulder pain
3) The Stiff shoulder
4) The Unstable Shoulder

In order to diagnose your shoulder it is easiest to first rule out the less common categories of
shoulder pain.

The easiest category to rule out is the unstable shoulder. Unstable shoulders are most common in
patients who have dislocated their shoulder in the past or who have suffered for years from
subluxations or dislocations from having hypermobility syndromme. Does your shoulder feel like it is
going to come out of its socket when you lift it? If not, you don’t have an unstable shoulder.

The stiff shoulder is generally caused by 2 pathologies: The Frozen Shoulder and The Arthritic
Shoulder. True Frozen Shoulders have 2 main and very obvious symptoms. They are very painful and
they are very stiff. They usually happen via gradual onset for no reason at all and can take a very
long time to get better. Frozen shoulders usually present in the middle aged patient (ages 40-60).
Another common trait of frozen shoulders is that active movement and passive moment of the
shoulder are the same. That means that if you lift your shoulder (actively) or someone else lifts your
shoulder with you completely relaxed (passively), you get to the same range of movement.

The arthritic shoulder is more common in the older patient (60 and upward). Arthritic patients
usually have a history of arthritis and pain in other joints in their body. One way to differentiate
between a frozen shoulder and an arthritic shoulder is via X-ray. Frozen shoulders generally have a
normal xray (see reference) whereas arthritic shoulders have a reduced joint space seen on Xray.


Neck related shoulder pain are patients who present with shoulder pain, but the source of their pain
is actually their neck. There are many muscles that attach both to the neck and shoulder (or
shoulder blade) that can cause pain in the shoulder or down the arm. These patients often have
some neck stiffness or pain referral down the arm with palpation of muscles around the neck and
shoulder blade. They often present with almost full pain free range of movement of their shoulder
(although end of range shoulder movement can often elicit some pain)

The most common shoulder complaint (about 80% of patients) that physiotherapists see are the
category 1- The Overuse Shoulder patients. Other names for this shoulder pathology are Rotator
Cuff Tendinopathy, Subacromial Impingement Syndrome or more commonly nowadays -Rotator Cuff
Related Shoulder Pain.

These injuries usually come on after a period of overuse. This can be during sport, repetitive activity
or a new activity that a patient isn’t used to. Many of these patients cannot finger point the exact
time and place their pain started, as pain can often start slowly and gradually increase over time.
Common symptoms of overuse shoulder pathology include pain in the deltoid area, a painful arc of
movement when lifting the arm to the side, and pain sleeping on the shoulder.

Accurate diagnosis of shoulder pain is pivotal, providing essential insights for physiotherapists and
patients regarding prognosis and treatment strategies. This will form the basis for therapeutic
interventions, ensuring effective and targeted rehabilitation.

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