Relieving Shoulder Pain with Osteopathy and Exercise: 5 Common Causes Explained

By Bronwyn La Brooy, Advanced Exercise Rehabilitative Osteopath, Burwood Osteo & Rehab

Quick answer: The top 5 causes of shoulder pain are rotator cuff injuries, bursitis, frozen shoulder, referred pain and arthritis. The majority of shoulder problems can be treated conservatively, with osteopathy and exercise rehabilitation. You don't need a referral to see us.

Shoulder pain is very common, and one of the most frequent musculoskeletal complaints we see. Up to 26% of adults experience shoulder pain, and it is the 3rd most common area for people to see a GP for musculoskeletal pain, after lower back and neck pain. Shoulder pain most commonly affects men and women over 40 years old, but it has a high link to occupational tasks, repetitive movements and postural positions.

What is the shoulder complex?

The "shoulder complex", as it's known, is quite an intricate structure. It moves in every direction, and is made up of four main attachment areas:

• Glenohumeral joint (GH joint): known mainly as the "true shoulder joint"

• Acromioclavicular joint (AC joint): at the collarbone

• Sternoclavicular joint (SC joint): connecting the breastbone to the collarbone

• Scapulothoracic joint (ST joint): not really a "joint", it's more of a functional/floating joint and tells us how the shoulder blade moves around the spine

So you can see why shoulder pain may be a bit tricky to diagnose and treat! When someone comes in for shoulder pain, they could mean behind the shoulder blade, at the front of the arm, pain referring down the arm, or across the top near the neck. It's important to have a thorough assessment with your osteopath to understand exactly what is causing your discomfort and what is triggering it, so we can work together to alleviate your pain. At Burwood Osteo & Rehab we understand how a shoulder moves, and what tasks you need to perform to help rehab your arm the best way possible. We look for why you have hurt yourself and how to stop you from injuring yourself in the future.

What are the top 5 causes of shoulder pain?

We will look at the top 5 causes of shoulder pain, and explain each one.

1. Rotator cuff injuries, including tendinopathy, tear or impingement

2. Bursitis (subacromial, subdeltoid bursitis)

3. Frozen shoulder (adhesive capsulitis)

4. Referred pain to the shoulder

5. Arthritis (GH OA, AC OA)

What are the main structures of the shoulder that I may have injured?

Rotator cuff injuries: tendinopathy, tears and impingement

The rotator cuff group is four muscles that stabilise the shoulder joint. These four muscles blend into tendons as they connect the bone of the humerus (upper arm) to the shoulder socket. Ligaments and tendons are strong structures, however the shoulder joint relies heavily on these rotator cuff muscles and tendons to stay stable. This means that the rotator cuff is prone to injuries. The rotator cuff helps with the small movements of the arm, for example writing, throwing, computer work, or getting dressed. They are small movements, but something we need daily.

The four rotator cuff muscles and their actions are:

• Supraspinatus: lifts the arm out to the side for the first 15 degrees of movement (the start of a snow angel)

• Infraspinatus: externally rotates the shoulder (baseball throwing)

• Teres minor: externally rotates the shoulder

• Subscapularis: stabilises the shoulder blade to the rib cage, and internally rotates the shoulder (reaching behind your back)

The bicep muscle isn't part of the rotator cuff group, however it acts very similarly to the rotator cuff muscles and can be involved in a shoulder injury as well. We generally include the bicep tendon in the rotator cuff muscle injury screen.

You may have a tear, a tendinopathy or an impingement of these muscles. Your practitioner will perform some musculoskeletal tests to determine which muscle is affected and/or how injured your shoulder may be.

For persistent rotator cuff tendinopathy, including calcific tendinopathy, shockwave therapy may also be an option as part of your treatment plan.

Common rotator cuff injury symptoms

Symptoms may include dull aching pain, or sharp pain with lifting and moving your arm, weakness with lifting your arm, or discomfort when sleeping. Functionally, you might find it hard to turn a door knob, open a jar, put on a jacket, wash your hair or get dressed.

Shoulder bursitis: types and symptoms

The bursa are fluid-filled sacs/cysts that absorb shock and cushion the shoulder joint. There are four main types of bursitis in the shoulder. How things have been injured (traumatic like a fall, or over time like postural) can determine your treatment methods and exercise rehabilitation.

• Subacromial bursitis is the most common type of shoulder bursitis. It usually occurs as a reaction to a rotator cuff injury. It typically presents as pain with lifting the arm over 90 degrees.

• Subdeltoid bursitis is pain more on the side of the arm. This type of pain can be difficult to sleep with, as lying on your side at night can be an aggravating action.

• Subscapularis bursitis is less common, and can be injured with postural positions or repetitive internal rotation movements.

• Subcoracoid bursitis is less common, with pain when moving the arm across the body. We would also rule out an AC joint injury here.

Generally, bursitis pain comes along with a rotator cuff injury. It's like a friction rubbing injury, either from an acute injury (eg. gym weights, a fall, reaching to lift something and hurting your arm straight away), or over time from long-term postural behaviours (eg. lifting kids on the one side, or desk ergonomics).

Rotator cuff injuries and bursitis can present very similarly to each other. Sometimes imaging can help us differentiate the diagnosis, as well as your history of how you injured yourself. Your practitioner will perform some assessments to understand what is aggravating you, understand your lifestyle to see if that plays a role in your injury, and if needed will discuss extra pain relief management with your GP to go alongside your rehabilitation exercises.

Frozen shoulder (adhesive capsulitis): symptoms and phases

True frozen shoulder (adhesive capsulitis) is characterised by pain, stiffness and progressive loss of movement. Frozen shoulder is a tricky injury. It's also probably one of the most painful injuries. It can take 18 months to 24 months to resolve and can be quite painful during this time.

Frozen shoulder tends to affect more women over 40. Diabetes is a big risk factor, as are hormonal changes. Pain can be a constant, dull ache with restricted range of movement, or can follow a previous shoulder injury that hasn't healed effectively. Most of the time, there is no clinical reason as to why this has happened.

Frozen shoulder usually has three phases:

Phase	Duration
Freezing phase	Up to 6 months
Frozen phase	Up to 6 to 12 months
Thawing out phase	Up to 6 to 12 months

It is a self-limiting condition, meaning after around 2 years the shoulder can heal itself and slowly return to function. Early treatment and diagnosis can help the timeline of this injury.

What else might be causing my shoulder pain?

Referred pain

Referred shoulder pain is pain felt around the shoulder that may be originating in another area. Your osteopath will be assessing your shoulder, but also your neck and middle back, trying to determine where your pain is coming from: is it coming from the shoulder joints as above, or is it coming from other areas?

A good example is the neck. Sometimes pain can be around the shoulders referring into the head, or you may have neural sensations from your neck into your upper arm. (Read more about neck pain and pain between the shoulder blades.)

Other examples may include a visceral (organ) referral. The gall bladder refers to the right shoulder, and the diaphragm can refer to the left shoulder. The heart always needs to be cleared for this area, as do the lungs.

Shoulder arthritis

Shoulder osteoarthritis (OA) is where the cartilage of the shoulder joints can start to wear down. Typically this may present as stiffness, pain and reduced movement at the shoulder complex. There are two main areas that tend to get arthritis in the shoulder:

• Glenohumeral joint OA

• Acromioclavicular joint OA

Having a shoulder injury may lead to the shoulder joint changing its loading and stabilising over time, leading to arthritic changes and joint wear. OA can also be occupational or lifestyle related. For example, a builder or a football player may have more shoulder OA due to the microtrauma performed on the shoulder over their younger years. (Read more about osteoarthritis vs rheumatoid arthritis.)

How do exercise rehabilitation and osteopathy help shoulder pain?

The majority of shoulder problems can be treated conservatively, with osteopathy and exercise rehabilitation to help strengthen the shoulder complex as a whole, including upper arm and chest strength, as well as specifically around the injured areas.

Osteopathy treatment aims to correct the imbalances in how your arm is functioning, in relation to your back and neck. We will be treating to decrease any inflammation, improve blood flow, and increase mobility and range at the shoulder joint. We will also discuss postural imbalances, or anything aggravating in your lifestyle that you may be doing without realising, for example walking the dog when it's pulling on one side of the body.

Exercise rehabilitation is one of the first things we do. We want to strengthen within pain-free ranges first. These are called isometric exercises. This allows blood to come to the muscles to help stimulate healing, without you moving your arm in a painful range.

The next phase may involve light weights or body weight exercises to increase the strength in your arm, or improve the endurance of your arm with similar loads.

The final phase can be more challenging exercises. This is when you may be almost 100% improved, with some modifications as required.

What to expect during your visit

Treatment for shoulder injuries involves a thorough case history, to understand if there was any injury to the arm, or how the pain came about. We rarely "wake up with pain". Even if that may seem to be the case, there is usually something that has occurred a few days or weeks earlier. So your osteopath will be trying to understand what's been going on with your arm, and your general daily tasks.

We will assess your shoulder, back and neck movements. How each part of the body works with the others is a key principle in osteopathy, but it's especially relevant with a joint like the shoulder. How the back and neck move (or don't move!) can indicate muscular imbalances and loading into the shoulder that may be involved in your injury. Your osteopath will also do some "special tests". These special tests are designed to stress certain structures, to figure out which one is sore, what is provocative, and what needs treatment.

Treatment may involve working around the neck, shoulders, back and chest. We look at all the muscular attachment points to the shoulder, so sometimes the lower back or diaphragm may be involved! That's our job: to figure out what needs treatment for your particular injury, and address everything at an individualised level.

We will give you some exercises appropriate to your pain and inflammation levels. Some exercises may be for your back and neck and some may be specific to your shoulder. We can work with both gym-based and home-based exercises, depending on what access you have to rehabilitation. A trusty can of chickpeas or a theraband can go a long way for exercise rehabilitation!

You don't need anything fancy. You just need to be consistent. That's what helps the shoulder the most. (Read more about what happens during a treatment.)

When should I seek help for shoulder pain?

You can book in with your osteopath at any time. We will assess, diagnose and treat as we see fit. Sometimes shoulder injuries can be more complicated, especially if they're affecting your sleep, mental health or occupational tasks, or feel like they're worsening. Here we may need to involve your GP for some extra management or imaging. But you don't need a referral to see us.

It's always better to get treatment sooner rather than later, especially when it comes to shoulders. We always adjust our treatment based on how you feel, and want to get you moving and keep you moving as soon as we can!

Frequently asked questions

Do I need a referral to see an osteopath for shoulder pain?

No, you don't need a referral to see us. We can perform manual therapy and exercise rehabilitation after performing a thorough case history and assessment.

How many sessions will I need?

This is a tricky question, as every shoulder injury is different. Some injuries may take around 6 weeks to 3 months to heal, and in the case of frozen shoulder that may be up to 2 years. Your osteopath will work with you and your medical team to help get you back on your feet as quickly as we can, however these injuries can take time. Patience is needed with a sore shoulder!

Can osteopathy help long-term?

Absolutely, osteopathy can help long term! We look at why this is happening and correct the postural imbalances. Sometimes you can't change your workplace situation: maybe you are a teacher using a whiteboard constantly, a mum who has to pick up your children, or a builder who is always on the tools. So we teach you how to strengthen your shoulder area, alleviate the muscle tightness that is making your pain worse, and teach your body to put less strain on areas that may be injured.

Where is Burwood Osteo & Rehab located?

Burwood Osteo & Rehab is located at Highbury Consulting Suites, 429 Highbury Road, Burwood East, on the corner of Highbury and Middleborough Roads.

Should I see a doctor first?

You don't need to see a doctor first, however if you need a different type of pain relief or imaging, you are welcome to see your GP. We can treat you without a GP referral.

Shoulder pain treatment in Burwood East

Shoulder pain can be quite debilitating, especially for daily tasks like cooking, cleaning or dressing. Our shoulder is a joint that moves in every direction, it sacrifices its stability to be mobile. BUT, with the correct management, osteopathy and exercise rehabilitation, we can definitely help you with your pain.

Exercise rehabilitation doesn't need to be fancy, at a gym or cost a lot of money. You can rehab a sore shoulder with a can of chickpeas as a weight, a theraband or body weight at home. Your osteopath will guide you to the best ways to treat and manage your shoulder injury.

If you are in pain, please reach out and see us at Burwood Osteo & Rehab in Burwood East. We see patients from across Melbourne's east, including Box Hill, Camberwell, Mount Waverley, Glen Waverley and Vermont. Book online or call us on 0492 927 343, and find out more about how we treat shoulder pain.

About the author: Bronwyn La Brooy is an Advanced Exercise Rehabilitative Osteopath and Pilates instructor at Burwood Osteo & Rehab. She holds a B.Sc. in Sport Science (Exercise Physiology) and a B.Sc. Applied Science/B.Sc. Health Science (Osteopathy).

Sources

• Mitchell C et al. Shoulder pain: diagnosis and management in primary care. BMJ, 2005.

• Shanahan EM. Painful shoulder. Medicine Today, September 2010.