Shoulder pain: we break down the real causes!
The shoulder is the 2nd most common area we treat here at Fighting Fit.
This blog will discuss one of the most common shoulder presentations; Rotator Cuff Related Shoulder Pain or RCRSP.
When seeing someone with shoulder pain for the first time I usually hear complaints of:
“I’ve just moved house and cleaned out the garage and now have an irritating ache in my shoulder”
“I fell onto my shoulder after riding my dirt bike on trails and now it still aches”
“I can’t wash my hair and put my bra on because I get a sharp pain when I move my arm”
“I’m sore after heavy bench press at the gym last week, now my shoulder aches at night”
“My shoulder has been sore for a long time, it gets better while I’m gardening then is really sore after, I can’t remember hurting it, it just started one day”
Does that sound like something you have said?
If so these types of reposts and complaints of shoulder pain very common and it’s something we see every day at Fighting Fit and you should keep reading!
What is Rotator Cuff Related Shoulder Pain (RCRSP)
Rotator cuff related shoulder pain is a new, broad term to describe a cluster of common shoulder complaints & pathologies.
Most people will attribute pain to pathology, so thinks like:
- Rotator cuff tendinopathy or tendinitis
- Partial / Full thickness tears of the rotator cuff muscles
- Subacromial bursitis
- Subacromial or rotator cuff impingement syndrome
Many patients will have under gone scans suchas A) MRI or B) Ultrasound of the shoulder to determine the cause their shoulder pain.
Let’s Break down a few different pathologies under the umbrella of RCRSP
Partial / Full thickness tears of the rotator cuff muscles
One thing we see often is a scan reporting rotator cuff tear. Whether it on MRI or Ultrasound.
We know that many people go through life with a rotator cuff tear and have absolutely no pain (Just like disk bulges in the lower back).
A recent study (Barreto et. al 2019) of 123 people 18-77 years of age, showed that when you hurt one shoulder and scan the unaffected shoulder, there is only a 6% difference in findings of partial tears and 5% in full thickness on MRI.
26% of sore shoulders had a partial cuff tear, compared with a 20% prevelance of partial cuff tears in non-painful shoulders.
6% of sore shoulders had a full cuff tear, compared with a 1% of full cuff tears in non-painful shoulders.
It’s the size, location, age of the person, how the tear occurred, clinical presentation and function, is far more important and we will help you make an informed decision on how to proceed if it becomes an ongoing issue
Rotator Cuff Tendinopathy or Rotator Cuff tendinitis
Tendinopathy is another very common complaint of shoulder pain.
You know the scan that say your supraspinatus has tendinitis or a calcific tendinopathy, or thickening of the rotator cuff tendons.
In the same study mentioned above 92% of sore shoulders shoulder displayed tendinopathic changes, but 88% also displayed tendinopathic changes in the non-painful side.
In many cases, tendinopathic change ie thickening, fraying, calcification is just normal age related change and probably just your bodies way of adaptation to load over time!
4% just get pissed off at any one time!
“I have a bursae in my shoulder!”
The amount of times I have heard this doozy is incredible.
Everyone has a bursae in their shoulder, its normal. Sometimes that just get annoyed and sore.
But here is an interesting finding from the same study. 54% had sub acromial bursitis in the painful side. 56% had sub acromial bursitis in the pain-free shoulder!
Subacromial bursitis is very common, all you need is thickening and build trace on MRI or on an ultrasound with impingement on abduction (elevation of the shoulder out to the side) to be termed bursitis.
Many sore shoulders with subacromial bursitis are weak shoulders that couldn’t handle the load thrown at it and the tissues got pissed off!
Assessing shoulder strength is very important, monitoring improvements over time is vital to success!
Subacromial or rotator cuff impingement syndrome
Another super common one.
“I don’t have enough space in my shoulder for the tendons and bursae to move without pain!”
This also leads to many unwarranted and failed shoulder surgeries such as a subacromial debridement, where they shave the bone to create more space.
Recent research and thinking now suggests that the lack of sub acromial space is actually a result of physical deconditioning, reduced strength and resilience of the rotator cuff causing the humeral head to migrate north and reduce the space for everything to move.
By creating more space with surgery, but not addressing the underlying strength impairment and reduced function of the cuff, surgery is unlikely to be useful and result in failed outcomes.
The take home message is that reported pathology doesn’t always indicate the causation of pain!
Here are some more important factors for RCRSP that don’t come up on a scan!
Lifestyle; it is very important to identify and address other factors that may be contributing to your shoulder pain.
Smoking status; those that smoke, have impaired tissue healing capacity!
Sleep heath; poor sleep = poor recovery, poor recovery results in poor adaptation. If your life is busy and stressful, your tissues don’t have time to repair.
General exercise; in-activity is the best predictor of injury when someone decides or needs to become physically active. If you regularly do nothing, then all of a sudden life requires a lot of physical work. Expect to be sore and increase your risk of tissue damage and/or over load due to your lack of strength and endurance.
Diet; Poor nutrition results in poor tissue health and a delayed tissue healing response. If you eat well, you will optimise your bodies ability to heal but also adapt to tissue stress.
General Health; as we age, and if we age poorly due to long standing poor lifestyle choices, then we are at risk of other co-morbid health concerns.
- Diabetes = poor tissue recovery,
- Heart disease = poor oxygenation and circulation to peripheral tissues, impairing tissue recovery and adaptation.
That just to name two… imagine if we went into the three or more co-morbid conditions that most people have over the age of 65 these days!
Stay tuned for my next blog:
“What you need to do to over-come shoulder pain?”
I will dive into the treatment of shoulder pain at Fighting Fit Physio.
Plus give you some tips and tricks on making that shoulder better for the long term!
Kyle Wells is a Physiotherapist at Fighting Fit Physio.
He has a special interest in arthritis, neck pain and tendinopathy. Just to name a few.
Kyle loves cross fit and has an exceptional eye for technique and performing exercise correctly.
He use exercise to improve patient results and get them moving better for the long term.