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The Irish Society of Chartered Physiotherapists

Shoulder Pain – Assessment, Diagnosis & Management

The Shoulder or rotator cuff is made up of four muscles, tendons and ligaments that help provide stability and movement to the shoulder. The Shoulder is a very common site of pain after the lower back and knee. Shoulder Pain or rotator cuff pain can be very variable with patients still reporting persistent pain 6–12 months after seeking a consultation with a health professional. The term rotator cuff related shoulder pain is a broad term that includes rotator cuff tendinopathy, tendinitis, tendinosis, partial thickness rotator cuff tears, atraumatic full thickness rotator cuff tears, impingement and subacromial pain.

Anatomy

The rotator cuff encloses the shoulder joint. The four muscles of the rotator cuff are the subscapularis, supraspinatus, infraspinatus and teres minor. These may be view as muscles separate muscles with separate functions, but they are highly interconnected just like the four muscles of your Quads. The shoulder also contains bursae, the bursae are a normal part of our anatomy and are found across the body. Bursae alongside the rotator cuff (muscle and tendon) can all be a source of symptoms for rotator cuff pain.

Assessment & Diagnosis

To determine if the rotator cuff is the cause of someone’s shoulder pain a therapist goes through a history and does a thorough assessment with a therapist

  • To rule out that the pain is referred or related to another structure a number of tests are carried out so the surrounding structure  (e.g. cervical and thoracic) – this is determined by the characteristics of the individuals pain and by combined movement tests
  • To rule out that it is primarily related to a stiff shoulder (e.g. frozen shoulder, osteoarthritis, locked dislocation orosteosarcoma) – by range of movement and pain

 

  • To rule out instability (post subluxation, dislocation or hyper-mobility syndromes)

 

  • Determine factors that may contribute to poor or favourable recovery.

In the assessment of shoulder pain diagnosis of rotator cuff related shoulder pain can be made from a detailed history take and assessment
Commonly reported details include;

  • Pain with movement,
  • Pain lying on that side –
  • Atraumatic, but can come on after an increase in shoulder based activity
  • Dull ache, occasionally sharp with movement
  • No neural deficits (pins and needles, numbness, power loss in multiple other muscles)

Why did I get shoulder pain?
The development of shoulder pain is commonly multifactorial, with numerous contributors to the development of symptoms.
These can include;

  • Excessive loads/stress
  • Overuse or Underuse
  • Psychosocial factors
  • Age
  • Occupation
  • Biochemical,
  • Genetics
  • Hormonal influences
  • Lifestyle factors such as smoking, alcohol consumption, comorbidities and level of education

To understand why someone develops shoulder pain it is important to focus on the terms capacity and load (internal and external). We can consider the capacity of the shoulder, its ability to perform activities with capacity and intensity without pain or injury. This can be check with a number of assessment tests. The things we expose our shoulder to during work, training and leisure are the external loads placed on our shoulder (weight, repetitions, hours of manual work etc) whilst the concept of internal load incorporates all the psychophysiological responses occurring during the execution of these tasks. The development of pain can be due to complete overload due to more external load (lifting heavier, longer work days, more sport) and/or a relative overload due to an increase in internal load (heightened stress, illness, hormonal influences). All of the factors mentioned above contribute to the capacity of the shoulder to handle load and the capacity can vary day to day with changing internal loads. For example high internal loads such as reduced sleep, increased work stress and getting the flu can lead to a decrease in capacity and as such may lead to relative overload and pain can develop from the complex interaction of these factors despite completing normal tasks or loads.

Management
Common to all presentations is the need to engage with the individual experiencing the symptoms, allowing the person to voice their needs, concerns and questions. In addition, patients should be given the opportunity to discuss their understanding of the cause of the symptoms, how quickly they expect to recover, the treatments they may consider to be effective, their goals and their thoughts on the treatment the therapist recommends. A structured rehab program is unequivocally the main intervention for Shoulder/rotator cuff pain.

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