Ask a PT: what is causing my shoulder pain?

When your shoulder hurts, it can be difficult to tell exactly what's gone wrong. You've probably heard of pinched nerves and rotator cuff tears. Perhaps you've also heard about shoulders being 'impinged' or 'frozen.' It's not easy to keep these various shoulder conditions straight, especially when they all cause similar pain symptoms.

The first step towards fixing a problem is identifying it. This article, written by a team of Doctors of Physiotherapy, is designed to help you figure out what's causing your shoulder pain — so you can begin the process of healing it. We will dive into the five most common causes of shoulder pain and how to differentiate them.

What causes a pinched nerve (cervical radiculopathy)?

Cervical refers to the neck, and radiculopathy is pain that radiates to another body part. Hence, cervical radiculopathy: a pinched nerve in the neck, which can cause radiating pain affecting the shoulder. It occurs when the cervical spine becomes damaged due to sudden injury or degeneration over time, and squeezes or puts pressure on a nearby nerve.

You may have cervical radiculopathy if:

• You have sharp, burning, or radiating pain—typically only on one side of your body—in the areas supplied by the nerve (neck, back, shoulder, arm, and hand)
• You experience tingling or numbness in those areas—or the feeling that they've fallen asleep
• You feel weakness in those areas
• Your pain gets worse when you turn your head, cough, or sneeze
• Your pain is worse at night

What causes a rotator cuff injury?

The rotator cuff is the group of four muscles (plus tendons) that hold the shoulder joint in place and keep the arm in the shoulder socket. This is what allows you to safely rotate your shoulder and move your arm. Repetitive overhead motions or sudden injury can cause tears in the rotator cuff tendons. While most people develop small, asymptomatic tears in the rotator cuff as they age, larger tears can cause pain and impair function.

You may have a rotator cuff injury if:

• You have a dull ache in your shoulder
• It is painful to raise and lower your arm
• It is difficult to reach behind your back
• Your shoulder pops or clicks when you move it in certain positions
• You have weakness in your shoulder and arm
• Your pain is worse at night

What causes shoulder impingement syndrome?

Shoulder impingement—also known as swimmer's shoulder because it is common among swimmers, and others who repetitively use their arms overhead—is when the space between the rotator cuff and the bone on top of your shoulder (the acromion) becomes too narrow, causing irritation of the tendons.

You may have impingement syndrome if:

• You have mild pain at rest, and sharper pain when lifting or reaching overhead
• You have swelling and tenderness in the front of your shoulder
• You have pain radiating from the front of the shoulder to the side of the arm
• You have weakness in your shoulder and arm
• Your pain is worse at night

How does a shoulder labral tear occur?

The shoulder labrum is a piece of cartilage that lines the shoulder socket (the glenoid) where the head of the upper arm bone (the humerus) attaches, helping keep the joint stable. There are different types of shoulder labral tears, two of the most common being the SLAP (Superior Labral tear from Anterior to Posterior) tear and the Bankart tear.

A SLAP tear occurs where the biceps tendon attaches to the shoulder and is common among athletes who repeatedly engage in quick-snap motions overhead, such as pitching a baseball or hitting a volleyball. You may have a SLAP tear if:

• You feel pain at the front of the shoulder near the biceps tendon
• You feel a dull throbbing in the shoulder joint
• You hear popping or feel grinding in your shoulder as you move it
• It hurts to move your arm overhead or behind your back

A Bankart tear occurs in the lower rim of the labrum when the shoulder slips out of socket and pulls the labrum out of place with it. You may have a Bankart tear if:

• You feel as if your shoulder is slipping or may dislocate
• Your shoulder is dislocating repeatedly, and more easily over time
• You feel a dull ache in the shoulder and upper arm
• You feel a catching sensation in the shoulder joint

What causes frozen shoulder?

Frozen shoulder, also known as adhesive capsulitis, occurs when the tissue around the shoulder joint (the capsule) becomes inflamed and scarred. This causes the tissue to gradually tighten around the joint, making movement difficult and painful. Keeping the shoulder immobilized for a long period of time, such as post-injury or after a surgery, increases the risk of developing frozen shoulder.

The first stage of frozen shoulder is the 'freezing' stage, which can last from six weeks to nine months. Your shoulder may be freezing if:

• The pain in your shoulder is gradually increasing
• You are losing range of motion in your shoulder over time

The second stage of frozen shoulder is the 'frozen' stage, which can last from four months to a year. Your shoulder may be frozen if:

• Pain no longer increasing, it may even decrease during this stage
• Stiffness is increasing, using the shoulder at all becomes very difficult to impossible

As you can see, many common shoulder conditions result in similar symptoms, making it challenging to determine the culprit for your pain. While this article is meant to help you better understand your shoulder pain, it is not intended as a substitute for a professional opinion. Diagnosing some of these conditions requires medical imaging—such as MRI, CT scan, or arthroscopy—in addition to a physical examination. Please contact your health care provider for guidance.

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Physiotherapy for shoulder pain

The good news? All of the conditions listed above can be treated without surgery or other invasive procedures. Through physiotherapy techniques—such as strengthening specific muscles, range of motion enhancements, manual therapy, joint mobilisations, and more—you can reduce your shoulder pain and return to normal daily activities.

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