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A Guide to Physical Therapy for Shoulder Pain

Close up of woman's shoulder and arm

Introduction

The shoulder is an amazingly versatile joint. It has a greater range of motion than any other joint in the human body, allowing us the flexibility to climb mountains, do headstands, throw balls at over 100 miles per hour, paint beautiful murals, and embrace our loved ones. But this increased mobility can come at a cost. The shoulder is also one of the most easily injured joints.

Approximately 20% of the population is experiencing shoulder pain at any given a time.1 This doesn't mean you have to settle for being uncomfortable. Let's review the potential causes of your shoulder pain and what you can proactively do about it!

Table of Contents

The Complex Shoulder Joint

There are a lot of interconnected tissues in the shoulder joint, also known as the glenohumeral joint (GH joint) and shoulder complex, that help it function correctly.2

These include:

  • The humerus (upper arm bone)
  • The clavicle (collarbone)
  • The scapula (shoulder blade)
  • Rotator cuff muscles (infraspinatus, supraspinatus, teres minor, and subscapularis)
  • Acromioclavicular (AC) joint- where the shoulder blade and collarbone connect on the top of the shoulder
  • GH joint capsule and ligaments- the tissues and fluid that directly support and surround the joint
  • The biceps tendon
  • The triceps tendon
  • The pectoralis major and minor muscles/tendons
  • The deltoid muscle
  • Supporting scapular muscles (trapezius, levator, and rhomboids)
  • Surrounding blood vessels and nerves- including the brachial plexus
  • Bursae- fluid filled sacs that reduce friction between bones and tendons All of these structures work together to allow for a wide range of motion and function in the shoulder. When one area is out of balance or injured, it can lead to a plethora of issues that cause pain, as we will discuss below.

Is Physical Therapy Right for My Shoulder Pain?

Almost always, the answer is a resounding YES.

If you are experiencing shoulder pain, you may be wondering if physical therapy is the right treatment for you. Physical therapy (PT) is an effective way to manage shoulder pain and improve your overall quality of life in the long term.3 Plus, it can reduce your need for other interventions like medication or surgery.

We will discuss what physical therapy is, how it can help relieve shoulder pain, and some common exercises that you can do at home to improve your condition.

What Are Common Causes of Shoulder Pain?

The first step in recovery from shoulder pain is to understand what is causing it in the first place. Shoulder joint function is complicated since it requires a mix of mobility and stability to complete normal daily activities. Thus, there are many different causes of shoulder pain. They are broken up into two primary groups that we'll explore further: overuse and acute (sudden) injury.

Acute Injuries

A sudden, acute injury can occur from a fall, sports impact, or blow. Additionally, it can be a more subtle cause like twisting the shoulder, lifting something too heavy, or over-stretching local tissues. These can result in acute injuries, such as:

  • Joint capsule/labrum tear
  • Ligamentous sprain
  • Rotator cuff strain or tear
  • Muscle strain of other supporting muscles
  • Nerve injury from local compression, over-stretching, or dislocation
  • Fracture (broken bone, e.g. clavicle fracture)
  • Dislocation of the GH joint (shoulder) or AC joint (where the collar bone and shoulder meet)
  • Local contusion with bruising or swelling

These injuries lead to local swelling, heat, and activation of your body's pain receptors. Of course, more than one can occur at a time.

Overuse Injuries

Overuse injuries are the result of repetitive motions that put continued stress on the shoulder joint and surrounding tissues. These motions can be from work, sports, or daily activities and lead to a gradual onset of pain and dysfunction.

Bursitis

The bursae are small sacs of fluid that act as cushions between bones, tendons, and muscles. There are 8 bursae in the shoulder joint. When one of these becomes irritated or inflamed due to chronic friction (or sometimes trauma or infection), it is called bursitis.

Impingement Syndrome

Impingement occurs when the rotator cuff muscles and tendons become irritated or inflamed from rubbing against the shoulder blade or being compressed. The progressive inflammation can make the pain gradually worse and worse. There is currently mixed literature about the true cause of this type of shoulder pain.

Tendonitis

Tendonitis is an inflammation of the tendons surrounding the shoulder joint due to issues like poor posture or impaired biomechanics with daily activities, particularly overhead use. If left untreated, it can eventually lead to a partial or complete tendon tear.8

Tendinosis

Tendinosis is defined as structural changes to the tendons. This leads to a thickening of affected areas, pain, and general dysfunction. It can occur with chronic tendonitis or independently with chronic overuse.

Arthritis

There are many different types of arthritis, but the most common in the shoulder is osteoarthritis. It most often affects the GH joint (the main shoulder joint) and the AC joint (where the collar bone and shoulder meet). This is when the cartilage that provides cushioning within the joints wears down. While some wear is normal with aging, additional wear can cause inflammation, pain, stiffness, and altered mechanics.

Muscle Imbalances

When certain muscles become too tight or too weak (or both) they can lead to imbalances of the shoulder joint. This puts it at a biomechanical disadvantage placing excessive strain on local tissues, which can lead to irritation, inflammation, and pain. Strong back muscles and good chest mobility help to optimize the function of the shoulder to reduce the risk of pain and injury.

Frozen Shoulder

Also called adhesive capsulitis, this is a condition where the shoulder capsule (the connective tissue that surrounds the shoulder joint) becomes inflamed and stiff. It can be caused by an injury or idiopathic (unknown). Idiopathic theories involves hormone changes and correlate to metabolic diseases, such as diabetes.

All of these shoulder conditions aren't mutually exclusive. More than one issue is often going to occur at once. Plus, an overuse injury sometime starts as an acute injury that becomes chronic over time when not properly addressed.

Other Less Common or Indirect Causes of Shoulder Pain 5

  • Systemic inflammation due to chronic disease or poor health status
  • Calcium buildup (deposits or calcific tendinitis)
  • Herniated disc of the cervical spine causing radiating symptoms
  • Infection
  • Tumor (bone, muscles, etc.)
  • Chronic pain disorder
  • Fibromyalgia
  • Changes in shoulder function due to a neurological disorder, such as a stroke or multiple sclerosis

What Doctor to See for Shoulder Pain?

It's common to call your primary care physician when shoulder pain is present. However, please realize that physicians aren't muscle and joint specialists and aren't specially trained to address shoulder pain. Your physician may end up referring you to an expensive orthopedic specialist or they may prescribe general pain medications, which won't provide you with the answers or long-term relief you deserve.

Rather than losing time and money hopping from doctor to doctor, there is one specialist that will give you answers at the first visit — a licensed Doctor of Physical Therapy. They will then help you make continued progress from there, even if a referral to a surgeon is necessary in the end.

See a Trained Shoulder Specialist FIRST

As you now know, the best doctor to see for shoulder pain is a Doctor of Physical Therapy. Physical therapy can help you understand your shoulder pain and give you the tools to manage it in the long term.

Physical therapists are movement experts and are uniquely qualified to discover and treat the cause of your shoulder pain sustainably, often without having to resort to more invasive options. Plus, conservative treatment is considered adequate and satisfactory for most people suffering from shoulder pain.3 Additionally, many patients report that finding a good physical therapist is life-changing for feeling in control of pain.

Think you need a referral from your doctor to see a physical therapist for your shoulder? Many people don't realize they can directly call (or hop online) and schedule an appointment for PT without a referral in all fifty states. This can save you time, money, and unnecessary pain.6

What to Expect from Physical Therapy for Shoulder Pain

When you go to PT for your shoulder pain, the first thing your physical therapist will do is ask you questions. They'll want to know how your shoulder pain started, what makes it better or worse, your medical history and any other symptoms you're experiencing.

Plus, if they follow the biopsychosocial model like CityPT Clinicians do, they will ask about your mental state, social interactions, and other lifestyle factors that may be affecting your general health and pain. This information will help them start to build a picture of what is going on with your shoulder.

Putting All The Pieces Together for a Comprehensive Plan

After these questions are answered, they will do a physical examination. This will involve:

  • Assessing your range of motion
  • Strength assessment
  • Special tests to determine the involvement of specific tissue
  • Checking for any areas of tenderness

They will also observe how you move your shoulder and look for any movement compensations you may have developed to avoid pain (or that are causing pain). All of this will help them come up with a working diagnosis of your shoulder condition.

Finally, they can then develop a personalized program that will address the underlying issue and help you get on track with recovery sustainably.

Treatment Options for Shoulder Pain

There are many different treatment options available for shoulder pain. Physical therapy is almost always the best place to start since it's a conservative, and non-invasive, option. Physical therapy can help to improve range of motion, strength, and function while also reducing pain. PT may also be used in conjunction with other treatment options.

PT Treatment Options

What combination of treatment recommendations is right for you will depend on your unique injury, preferences, and needs. They will include one or more of the following:

  • Education: This is the most valuable treatment your physical therapist will offer. They will provide education that helps you feel empowered. Topics will include what to expect during the healing process, understanding the cause of your pain (and how lifestyle choices affect it), posture and biomechanics optimization and relevant activity modification.
  • Exercise prescription: A personalized program will be designed to reduce pain acutely and promote better biomechanics for long term pain relief. This will include stretches, range of motion, coordination, and strengthening exercises.
  • Biomechanical training: To reduce shoulder strain with your daily activities.
  • Ergonomics training: For better postures with sleeping and sitting; and better habits when working at the computer, in the kitchen, or in the garage.
  • Manual therapy: Sometime hands-on therapy is needed. For example, your physical therapist can provide soft tissue mobilization (expertly guided and focused massage), joint mobilization, trigger point dry needling, highly focalized stretching, myofascial release and guided range of motion.
  • Physical modalities: These are used for short term pain relief and include things like ice, heat, electrical stimulation, vibration guns, class IV laser and ultrasound.
  • Other tools: Your physical therapist may utilize other tools to promote tissue healing, such as kinesiology taping, dry needling, cupping, scraping, etc.

The ultimate goal with treatment is to get pain relief as soon as possible, restore tissue balance to promote healing, and to feel your best.

Invasive Options

If physical therapy isn't working, if affected tissues aren't healing well or are severely damaged, other options are available. These include:

  • Surgery
  • Injections
  • Medications

Pain relief with injections or medications can be a great short-term strategy to help you get on track with a comprehensive program as discussed above. This is particularly true with long term or difficult issues that need extra help. Reduced inflammation can help with pain relief and tolerance for movement.

Even if surgery is required, physical therapy is an excellent pre-operative treatment to maximize your functional outcomes. Plus, if you are trying conservative care first, your physical therapist can help you decide if surgery might be necessary after the first 4 to 5 visits.

Other short-term pain relief treatment options might include massage therapy, chiropractic, and acupuncture. If surgery is indicated, you should see a physical therapist for recovery as well.

Home Treatment Options

If your shoulder pain is mild or sporadic (off and on), you may not feel ready to seek treatment. Thankfully, there are also many things you can do at home to help with your shoulder pain. However, it's important to remember that anything you do on your own is not personalized. This means you run the risk of making your pain worse or not getting adequate relief (putting you at risk for chronic pain). Read more about the dangers of DIY PT here.

Home Remedies Might Include:

For acute pain

  • RICE (rest, ice, compression, elevation)
  • Gentle exercise
  • Topical pain relieving creams

For chronic pain

  • Alternating ice and heat
  • Topical pain relieving creams
  • Massage
  • Exercise

Home Exercises for Shoulder Pain

Below are 7 exercises to try at home to promote blood flow (aka healing), tissue extensibility, good posture, and muscular balance. Never force an exercise that causes pain or feels off. When in doubt, ask for help from a physical therapist.

Doorway Stretch

This is a great way to start opening up the shoulders and chest. Tight chest muscles can make it feel impossible to sit upright, plus it places additional strain on the front of the shoulder where many sensitive tissues are located.

  • Stand in a doorway with your elbows at 90 degrees and upper arms at about shoulder height.
  • Step forward with one foot into a lunge position until you feel a stretch in the front of your chest and shoulders.
  • Hold for 30 seconds and repeat 2 to 3 times daily.

Chin Tucks

Chin tucks help to retrain your postural muscles and take the strain off of your neck and shoulders- where muscles are often compressed and overworked.

  • Start by sitting up tall or standing with good posture, keeping your shoulders back and spine erect.
  • Gently tuck your chin towards your chest, without slouching at the midback, until you feel a stretch in the back of your neck near the base of your skull.
  • Hold for 30 seconds and repeat.
  • Do this exercise slowly and with control to avoid strain on your neck. Make sure you keep your body relaxed throughout this move.

This exercise is a great starting point for posture training. Chin tucks may feel awkward at first but they help give you great awareness of how you're moving your upper body and how your head is aligned on top of your neck and shoulders. Once you get the hang of it, pay closer attention to how you're holding your chin, shoulders, and spine throughout the day and make improvements as needed.

Trapezius Stretch

The trapezius is a large triangular muscle that attaches to the cervical spine (neck), shoulder blades, and thoracic spine (midback). The top section of this muscle, known as the upper trapezius, is often very tight in people who work at desks, drive frequently, or have chronically poor posture. Stretching can help alleviate pain and tension in this common problem area.

  • Start by sitting up tall or standing with good posture (as if you're a puppet with a string pulling your head up toward the ceiling)
  • Reach one arm up overhead and place your hand on the opposite side of your head.
  • Gently pull your head sideways towards that same shoulder until you feel a stretch in the opposite side of the neck.
  • Hold for 30 seconds and repeat on the other side. Repeat 2 to 3 times each day as needed. Do not force this stretch.

Child's Pose

This is a great all-around stretch for the entire upper body, including the shoulders, chest, and back. It can also help to calm the mind and relieve stress.

  • Start on all fours with your knees about hip-width apart and your hands under your shoulders.
  • As you exhale, slowly lower your buttocks back towards your heels and stretch your arms out in front of you.
  • Allow your forehead to rest on the floor (or as close as comfortable) and take deep, relaxing breaths.
  • Focus on keeping your arms outstretched to promote increased overhead shoulder range of motion (as tolerated).
  • Hold for 30+ seconds or longer for up to 3 sets.

To specifically isolate the shoulders for stretching, try grabbing a yoga ball and placing it in front of you to put your hands on. This will deepen the stretch and range in your shoulders.

Thoracic Rotation

This exercise helps to improve mobility in the upper back, which is often tight in people who spend a lot of time sitting. A stiff spine can alter the normal kinetics of the shoulder blades — part of the shoulder complex — making it a great way to help improve overall shoulder mechanics.7

  • Start by lying on your back with both knees bent and feet flat on the ground.
  • Cross one arm over your body and place that hand on the opposite knee.
  • Gently twist your torso by bringing both knees toward the ground with the guidance of your hand.
  • Hold for 30+ seconds for 2 to 3 sets per day. Don't forget to repeat it on the opposite side.

Shoulder Blade Squeezes

This is a great exercise to help improve your posture awareness and relieve tension in the shoulders and upper back.

  • Once again, start with an upright posture that puts your neck in a neutral position.
  • Gently squeeze your shoulder blades together and hold for 5 to 10 seconds.
  • Imagine that a quarter is between your shoulder blades that you are trying to hold in place.
  • Do not let your neck tense up.
  • Repeat 10 to 15 times for 2 to 3 sets.

Once you're ready, you can progress to resisted squeezes with a band and rows.

External Rotation with a Resistance Band

This is a great exercise to help improve the strength of the rotator cuff muscles, essential for shoulder stability and function.

  • Start by holding a resistance band in both of your hands with the palms facing up, your elbows bent to 90 degrees, placed at your sides, and forearms parallel to each other.
  • Keeping your elbows at your side, slowly rotate your arms outward as you pull your palms away from each other.
  • Keep the motion slow and controlled in both directions, focusing on good posture and keeping the neck relaxed.
  • Return to the starting position and repeat.
  • Complete 10 to 15 repetitions for 2 to 3 sets as needed.

This is just one example of a rotator cuff exercise. It is a great one to start with since it is a common weak spot. Additionally, you can add resisted internal rotation, shoulder abduction/scaption (isometric or resisted with weights), and beyond.

Professional Guidance Will Significantly Improve Your Results

While DIY exercises are a place to start, they probably won't resolve your issues completely. Which exercises above will fit your needs, plus numerous other options, will depend on what is specifically going on with your body. Additionally, some of these exercises could even exacerbate your shoulder pain, depending on your particular injury and if they're done incorrectly or with poor form.

For example, a common exercise recommended for shoulder pain is a cross-body stretch. For many people, this pinches inflamed tissues in the front of the shoulder and can leave them feeling frustrated and wanting better results.

It's best to get the guidance you need the first time and you can avoid all the ambiguity. A physical therapist can also guide you in the use of tools for home that may help, such as weights, resistance bands, and a foam roller. Additionally, they can appropriately modify or progress your exercises as you start to notice changes in your shoulder function.

How to Prevent Shoulder Pain in the First Place

Of course, it is always better to prevent shoulder pain and injury before it begins.

While there are many possible causes of shoulder pain, here are some general tips to keep mind:

  • Be mindful of your posture throughout the day, especially when you're tired and want to "slump" into your couch or recliner and bury your nose into your favorite social media app.
  • Minimize tension in the neck and shoulders with adequate stress management, posture awareness, and allowing rest from straining activities as needed.
  • Avoid sleeping in awkward positions that strain the neck and shoulders.
  • Ease your way into new activities that require an extensive amount of shoulder range of motion or effort (for example, painting your house with your arms overhead all week or lifting something too heavy — ouch!).
  • Keep the upper body balanced, strong, and agile with weekly exercises (stretching, strengthening, and full-body coordination).

Not sure about your posture, range of motion, or strength? Ask! Talk to a physical therapist almost instantly with a virtual appointment.

Does Your Shoulder Need Physical Therapy?

If you found yourself browsing this article, chances are good that physical therapy can help you. Whether you have a nagging off-and-on pain or chronic debilitating pain, a physical therapist can help you feel your best. We need our shoulders for pretty much every daily activity, which becomes clear when they aren't functioning optimally.

Ready to maximize your shoulder function? We can show you exactly how to get started and feel your best with just one click. Book an appointment with a CityPT shoulder specialist today.

This guide is intended for informational purposes only. We are not providing legal or medical advice and this guide does not create a provider-patient relationship. Do not rely upon this guide (or any guide) for medical information. Always seek the help of a qualified medical professional who has assessed you and understands your condition.

References


  1. Linaker CH, Walker-Bone K. Shoulder disorders and occupation. Best Pract Res Clin Rheumatol. 2015;29(3):405-423. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4836557/
  2. Hoffman, Matthew. Picture of the Shoulder. Web MD. Updated June 23, 2021. Accessed May 4, 2022. https://www.webmd.com/pain-management/picture-of-the-shoulder
  3. Edwards P, Ebert J, Joss B, Bhabra G, Ackland T, Wang A. Exercise Rehabilitation in the Non-Operative Management of Rotator Cuff Tears: A review of the Literature. Int J Sports Phys Ther. 2016;11(2):279-301. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4827371/
  4. OrthoInfo. Shoulder Pain and Common Problems. Orthoinfo.aaos.org. Accessed May 4, 2022. https://orthoinfo.aaos.org/en/diseases--conditions/shoulder-pain-and-common-shoulder-problems/
  5. APTA. Levels of Patient Access to Physical Therapists Services in the U.S. Apta.org. Updated September 21, 2021. https://www.apta.org/advocacy/issues/direct-access-advocacy/direct-access-by-state
  6. Physiopedia. Thoracic manipulation with shoulder dysfunction. Physio-pedia.com. Accessed May 4, 2022. https://www.physio-pedia.com/Thoracic_manipulation_with_shoulder_dysfunction