Shoulder Pain

Have you ever considered which of the joints in your body is the most important? 

It’s a difficult question… but if I had to answer, the humble shoulder would be right up there. Why’s that? Well consider what life would be like if you couldn’t move your arms at all and they were simply stuck by your sides. Being able to move our hands to manipulate objects, bring food to our mouth, or to communicate are very important abilities for humans.

Where does most of that movement come from? The shoulder!

The shoulder is one of the most mobile joints in our body. We can reach right up over our head, behind our back and out in front. When we don’t have any shoulder problems, it can be easy to take for granted just how much we use them. Unfortunately, many people over 50 experience shoulder problems that limit their ability to do daily tasks, the things they love and exercise.

Now there are many different causes of shoulder pain like rotator cuff problems, osteoarthritis, frozen shoulder and biceps tendinopathy, to name a few. It is beyond the scope of this article to take a deep dive into each condition, but rather, it will give insights and address misconceptions for those suffering from the symptoms of these various issues. Most of the tips provided in this article are applicable to anyone with shoulder pain, regardless of the specific diagnosis.


The causes of shoulder pain

Two of the most common structural contributors to shoulder pain are rotator cuff changes and shoulder osteoarthritis, so it is worth briefly discussing these.


Rotator Cuff Related Pain

The rotator cuff is a group of 4 muscles that attach the humeral head (the top of your upper arm) to the scapula (your shoulder blade). Their role is to rotate the arm, and to help keep the humeral head in the middle of the shoulder socket during movements like reaching in front or overhead. One of the key issues affecting older adults is rotator cuff tears. These can be the result of a specific acute injury like a fall, or they can be the result of long term changes in the tissue, without any one specific cause. Rotator cuff tears can result in pain in the shoulder and down the arm, weakness in the shoulder muscles and restricted movement, especially over head and behind the back.

HOWEVER, it’s not as simple as tear = pain. In fact, many people with rotator cuff tears don’t even know they have one! One study looking at 664 patients with an average age of 69, found that 22% of the population had a full thickness rotator cuff tear. One third of these were symptomatic, but the other two thirds had zero symptoms! The study also showed that the older you got, the more likely you were to have a rotator cuff tear, but the LESS likely you were to have symptoms associated with it! (Minagawa et al. 2013)

This is great news for people who have had their shoulder pain attributed to a tear - it means that even if the muscles stays torn, you can improve or eliminate your symptoms!

Interesting… but let’s now talk about the other common cause of shoulder pain.


Glenohumeral Osteoarthritis

The glenohumeral joint is the ball (humeral head) and socket (glenoid) joint of your shoulder. Like other joints of the body, it can be affected by osteoarthritis. Commonly thought of as a ‘wear and tear’ or ‘degenerative’ condition, osteoarthritis can be more accurately thought of as an ‘overdoing’ of the healing and repair process in the joint as a whole, rather than simply wearing down of the cartilage. Like rotator cuff issues, shoulder osteoarthritis can result in pain and reduced movement. Once again, it makes sense to assume that the features of osteoarthritis like cartilage thinning, osteophyte formation and subchondral sclerosis would cause pain… and once again, that is an incorrect assumption!

A study by Gill and colleagues (2014) compared the x-rays of a group of people with shoulder pain to those without shoulder pain. They found no difference between the groups in terms of the arthritic shoulder changes. So, whilst osteoarthritis can be a contributor to shoulder pain, it’s not clear cut.


If tissue changes aren’t always the problem...

What factors determine why some people get pain with these conditions, and others do not?

It’s a difficult question to answer. What we do know is that pain is an incredibly complex phenomenon with lots of different inputs. It’s not as simple as pain = damage (as we have seen). For a full explanation of pain and how it works, have a read of this article.

Whilst there are lots of different factors affecting whether your shoulder becomes painful, it can be useful to conceptualise the problem as an imbalance between what the shoulder can tolerate and what is asked to do. The solution therefore, is to increase the shoulder’s load tolerance.


The Case for Exercise

Exercise is the closest we’ve come to a magic pill for health. The list of benefits is nearly endless, and thankfully, that list includes shoulder health. Exercise has multiple benefits for the shoulder:

1. Increased load tolerance - exercise (especially resistance training) gradually exposes the structures of the shoulder to more and more loading. This causes adaptations in the tissues that make the shoulder more robust and resilient. Additionally, loading the shoulder has the effect of reducing the threat of loading for our brain and nervous system, which can mean less symptoms as a result.
2. Increased strength and function - exercise (once again, especially resistance training) causes adaptations that allow the shoulder muscles to produce more force, which means easier performance of daily tasks and meaningful activities.
3. Increased mobility - exercise can decrease the stiffness and restricted movement that can result from shoulder issues.
4. Improved confidence - exercising and challenging the shoulder can boost your confidence that your shoulder is resilient and safe to use.
5. Weight management - people who are a healthy weight are less likely to suffer from conditions such as osteoarthritis.

Beyond these specific changes, being active has many more general health benefits that can reduce risk and impact of shoulder pain.

Hopefully, I’ve convinced you of the benefits, but if you need more persuasion check out the video we made about the benefits of exercise.

What sort of exercise?

We always recommend aiming for the minimum physical activity guidelines such as those set in Australia.

When it comes to shoulder health however, many of the aforementioned benefits such as increasing strength, load tolerance and confidence in the shoulder can be brought about by a good resistance training program.


Resistance Training

Strength based exercise or resistance training is any form of exercise where you are moving against a resistance. This could be lifting weights, lifting your bodyweight or using resistance bands. Similar to aerobic exercise, we want to start low and build up slowly over time. A good resistance training program will involve exercises that challenge all the major muscle groups and gradually progresses in the loads used for each exercise. 

There are many exercises that can challenge the shoulders. However, we prefer to focus on big, multi joint movements that have carry over to daily tasks. Two challenging shoulder exercises we virtually always employ in our workouts are overhead pressing and push up variations. Overhead pressing replicates tasks like lifting things into overhead cupboards, whilst pushing up is a great way of replicating the action of getting up from the floor. In nearly all cases, these movements can be modified to make them more tolerable for people with shoulder pain. Here are the steps we often take to make a movement more tolerable:

1. Weight - Reduce the weight or try no weight at all for movements such as the overhead press, or making the push up easier by performing a kitchen bench or wall push up. 

1. Range of motion - if reducing the weight doesn’t alleviate the symptoms, sometimes changing the range of motion can be an effective strategy. For example, reaching halfway up for an overhead press, or only going halfway down for a push up.
2. Substitute a similar exercise - If you are still finding the exercise intolerable, you can try an alternative. For example, a lot of people with shoulder pain during the overhead press can find relief by leaning back in a chair.

To see some of these tips in action - check out this video all about troubleshooting the overhead press!

If you’re not familiar with resistance training you can get started with our strength workout when you sign up for a free account on our website!

Frequently Asked Questions

• I can’t lift my arms overhead so I shouldn’t do any exercises where I have to lift my arms above shoulder height?
  
  There are several conditions that can cause shoulder pain when lifting your hands over head – which can make tasks like hanging out the washing or putting away crockery very frustrating and challenging. Regardless of the condition, avoiding the overhead movements will not help you improve your capacity to lift overhead. Just like a student who fails a maths test, the best way to prepare for the next test is to study. The same principle applies here – we need to better prepare the shoulder for overhead tasks by building its capacity.
  
  
• That makes sense, but I get pain whenever I use my arms, doesn’t that mean I’m causing damage?
  
  Pain is not an accurate measure of the health of our tissues. In the case of shoulder pain with overhead movements, it’s likely that the load we are placing on the shoulders is beyond the capacity of the tissues to manage. So to reduce pain, we need to increase the capacity of these tissues so they can handle more load. Pain during exercise does not mean we are doing more damage – just that we are putting load through structures that may be sensitive. If you experience pain during exercise, you should continue as long as it's tolerable for you. This means we can gradually build up the tissue tolerance and reduce symptoms.
  
  
• I have a complete tear in my rotator cuff, exercise won’t fix that?
  
  A couple of things regarding the rotator cuff– a small group of muscles that act on the shoulder. Rotator cuff tears are common and their prevalence increases with age. You can think of rotator cuff tears as an age related change, just like skin wrinkles or grey hair. The other thing to consider is that a lot of rotator cuff tears are asymptomatic. In fact, research has shown that for people in their 50s, asymptomatic tears accounted for half of all rotator cuff tears, and this number rises to two-thirds of tears in people over the age of 60. Now the rotator cuff tendon is quite broad, and most tears that occur can be thought of as more like a hole in a blanket as opposed to a torn rope. This means that the tendon is still useful, just like a blanket with a hole! We can still make the surrounding tendon tissue stronger and more resilient by challenging it with exercise.
  
  
• I’ve had a shoulder replacement/rotator cuff repair and my Surgeon told me I shouldn’t lift anything over 10kg ever again. How can I do resistance exercise?
  
  Surgeons commonly give lifting restrictions following operations to allow the affected structures time to heal. Unfortunately, a lot of surgeons unnecessarily extend these guidelines beyond the healing time of the tissues. The reality is that at some point, deliberately or not, you are going to exceed the lifting restrictions set by the surgeon. The best way to prepare for this eventuality is to build the capacity of the tissues so that they can tolerate these events. We understand that this can be daunting – which is why we strongly encourage our clients to follow the principle of progressive loading. This means that we start resistance training well below what the shoulder can tolerate and very slowly and gradually build up over time. With this process, the shoulder structures have time to adapt and build capacity, and this minimises the risk of injury. 
  
  
  

References

• Kobayashi, T., Takagishi, K., Shitara, H., Ichinose, T., Shimoyama, D., & Yamamoto, A. et al. (2014). Prevalence of and risk factors for shoulder osteoarthritis in Japanese middle-aged and elderly populations. Journal Of Shoulder And Elbow Surgery, 23(5), 613-619. doi: 10.1016/j.jse.2013.11.031
• Minagawa, H., Yamamoto, N., Abe, H., Fukuda, M., Seki, N., & Kikuchi, K. et al. (2013). Prevalence of symptomatic and asymptomatic rotator cuff tears in the general population: From mass-screening in one village. Journal Of Orthopaedics, 10(1), 8-12. doi: 10.1016/j.jor.2013.01.008