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The Infamous Rotator Cuff, non-traumatic Shoulder Pain

Did you know that 1 in every 50 adults seeks medical care for a new shoulder pain every year? (1) Shoulder pain is quite a common complaint, with 50% of the population having an episode annually. (2)


Shoulder pain can be very debilitating (more than a knee or back pain) because it forms such a major foundation of all the meaningful movements and positions that we adopt in our day. Think about it. You use your shoulder when going to the loo, getting dressed, eating, driving, sleeping, sports, having a drink with friends. It has a huge impact on both your physical and mental quality of life when you can’t participate in activities most people take for granted.


Sadly, 40-50% of the people that experience shoulder pain will continue to have symptoms for another 6-12 months after their first episode. (3) How and why does this still happen in our modern society with all its advances? We have painkillers, anti-inflammatories and well, we also have Google, right? If that doesn’t work, we eventually visit the GP. Their likely treatment regime will consist of prescribing stronger anti-inflammatory drugs (NSAID), sending you for imaging (x-ray and ultrasound) and recommending rest.


Shoulder pain GP


Will any of these solutions fix the problem?


Not really. NSAIDs only address one part of the cause. X-rays are often inconclusive and ultrasound images make you think your arm is about to fall off. You have also probably Googled all the worst-case scenarios, believe you need surgery but are terrified at the prospect, have stopped using your arm out of fear and it is getting slowly weaker from all that recommended rest. By the time you eventually reach the physio, your expectations of getting better are slim to none.


Conservative treatment (exercise and education) has evidence stacked high in support of it being the gold standard for shoulder pain treatment, yet only 8-11% of these patients will be referred for this. (4)


Something must change.


We don’t want people to become a statistic and accept the norm. We don’t want them to reach physio when they have long lost their hope. This loss of hope and low expectation is in fact one of the biggest mountains to climb in the road to recovery. How someone responds to the pain at the outset is where we can influence the stats.


Here is a fact that most people haven’t heard of. Patient expectation and self-efficacy are the biggest predictors of positive or negative outcome of conservative shoulder management. (7)


Don’t misunderstand if you are reading this and have had pain for a long time. It doesn’t mean all doom and gloom. For both the new and long-term shoulder pain, expectations can be changed from negative to positive with understanding. Understanding comes from education and sharing helpful facts. That is partly the aim of this article.


To start, we need to understand that shoulder pain is complex and multifactorial and cannot be blamed on just one factor. It is generally a combination of factors and is unique to each individual. Let’s look at some of the factors that could contribute.


Factors Contributing to Shoulder pain


1. Biological state

  • Age (prevalence increases over 50)
  • Metabolic conditions e.g., diabetes, menopause
  • Overhead activities >90 degrees (occupation or sport therefore high repetition over time)
  • Overload – too much load too fast (>20% increase when poor shoulder blade control or external rotation weakness is present; >60% increase when no biomechanical abnormalities are present) (5).
  • Underload – too little load, so tissues weaken.
  • Reduced external rotation strength
  • Reduced abduction strength
  • Genetics (family history)


2. Lifestyle

  • Smoking
  • Obesity
  • Poor sleep
  • Poor diet
  • More than 2 drinks per week
  • Stress
  • Inactivity


3. Psychological state

  • Poor self-efficacy
  • Negative feelings
  • Stress
  • Poor expectations/predictions
  • Catastrophizing thoughts
  • Negative beliefs


4. Social state

  • Family support
  • Meaningful community participation
  • Friends
  • Culture
  • Access to care


Starting to understand the complexity?


Why do we experience pain?


Pain is a protection mechanism of the brain. Damage and pain are not mutually exclusive. You can have no pain in the presence of damage, and you can have pain in the presence of no damage. In the case of a shoulder pain, it is likely that threat detectors (nerve receptors) in the shoulder registered a higher-than-normal external load and because the brain also gets its information from internal threat detectors that pick up internal loads (stress levels, amount of sleep, cellular health, muscle strength) it may decide that the combined load (internal plus external) currently exceeds the capacity (ability) of the shoulder. The brain sees this as a threat and protection kicks in. The brain produces pain as protection. You respond in a protective manner to that pain. The take-away here is that the pain is there to protect you. If the pain production succeeded in protecting you from injury, the brain will continue to employ this tactic until we change the input via these internal or external threat receptors.


Get curious. Is it the external load that needs to be adjusted (overload), is it that the muscles/tendons that aren’t strong enough (weakened due to underload) or is it perhaps the poor sleep or poor diet over the last few days that needs to be addressed (biological/psychological/lifestyle/social influencers)?


It is not as simple as just a massage, meds, and some tape. If the other contributing factors aren’t identified and addressed, the biological treatment is doomed to fail.


Two titles, same problem

Subacromial Shoulder Pain = Rotator Cuff Related Shoulder Pain


Shoulder pain area


70-80% of all shoulder pain falls in this diagnosis bracket.

The pain is usually a dull ache over the outer part or outer front of the shoulder/upper arm. This can radiate to the elbow too.

Numbness or pins and needles are not common.

Occasional sharp pain with specific movements.

It is often painful to sleep on that shoulder.

Structures found in this area (subacromial) and possibly contributing to the pain include the rotator cuff tendons, subacromial bursa, biceps tendon, acromioclavicular joint, glenohumeral joint capsule and a number of shoulder ligaments just to mention a few.

The rotator cuff consists of 4 muscles – the supraspinatus, the infraspinatus, teres minor and subscapularis. The tendons of these muscles plus the coracohumeral ligament and joint capsule are all woven together tightly before attaching to the bones. The number of sensitive structures in the subacromial space and their interwoven nature makes it very hard (some may even argue that it is impossible) to distinguish between the structures causing pain.

Therefore, a generalized term, Subacromial Shoulder Pain (SSP) or Rotator Cuff Related Shoulder Pain (RCRSP), indicating location rather than patho-anatomical structure is used to describe and diagnose this shoulder pain. The pain indicates which movements rather than structures are sensitized and this directs treatment.


Surgery versus exercise


In the past, the go-to treatment for SSP/RCRSP was acromioplasty surgery. This was based on the thinking that the bones were making the space too small. However, according to research, conservative treatment (exercise therapy) is just as effective as acromioplasty surgery in the long term (>8 weeks) for treating SSP/RCRSP. (8) In our humble opinion, based on the long-term effects, exercise is your best option because it is cost effective and less invasive than surgery. And keep in mind, that rehabilitation (exercises) forms an integral part of the long-term treatment after surgery anyway.


Corticosteroid injection versus exercise


The other very common treatment is a corticosteroid injection. The research shows that it is helpful in the short term (6-8 weeks) to improve function but not necessarily pain or mobility. However, in the long run (>8 weeks) it was no better than exercise therapy. (9) There is some evidence that corticosteroid injections are harmful to shoulder tissue integrity in the long term, but more robust research is needed to confirm this. It has been shown to be harmful to the patellar tendon and the tennis elbow tendon. This is enough evidence for me to avoid it.


What about a rotator cuff tear?


Atraumatic tears are very common with aging, especially pain-free tears (2x more likely to be pain-free than painful). Therefore, a tear seen on an ultrasound MIGHT NOT be the cause of your pain. Many people live with tears completely unaware of their ‘abnormality’. Atraumatic tears where pain is present respond well (75%) to conservative (exercise) treatment, even full thickness tears. (6) Partial tears also have a good outcome with exercise therapy. Partial tears are more common in those <40 years. Tears can get bigger over time (it is a natural progression even seen after surgical repair) and if the tear gets bigger over a relatively short time, surgical repair may be helpful.


If the tear was caused by trauma (fall, accident etc.), is full thickness i.e. >1cm and the person is <65, a surgical opinion is highly recommended. It does not mean that conservative treatment isn’t an option or that it won’t be successful. Full thickness tears are more common amongst those >40 years.


Exercise therapy – the physiotherapist’s approach to shoulder pain


Shoulder pain exercise


All SSP/RTRSP and tear treatments follow the same principles.


  1. Identify pain contributing factors and change or adjust those that are modifiable (through education and behaviour/habit modification).


  1. Load management
  • Calm things down – movement modification to reduce load on sensitised structures and build trust in movement (pain reduction).
  • Build things up – slow progressive loading of tissues to increase capacity and challenge the brain’s pattern of pain prediction.


  1. Adjunct treatment to support (shockwave, massage, dry needling).


A few take-away points to consider


  • Whatever form of treatment you choose, give it time, and trust the process. Conservative treatment for any less than 12 weeks is a waste of your time and effort. Surgery is not a miracle cure and will still require a minimum of 12 weeks of rehabilitation. Rehabilitation has a very high success rate but requires commitment to exercise and changing mindset and behaviour.


  • Improving lifestyle habits and mindset are just as helpful as physical treatment and in some cases the difference between positive and negative outcomes of conservative treatment.


  • Surgery or injections are not always the answer – it often only focusses on one contributing factor to the pain experience and on short term outcomes.


  • Shoulder pain does not have to be a life sentence.


  • When it comes to the shoulder, rest is not best. Movement modification and the right exercises is a better option.


  • Slow progressive loading (exercise) that does not exceed 20% load increase per week is a safe way to avoid shoulder pain.


  • Pain is a protection mechanism of the brain.


If you are struggling with shoulder pain, please don’t delay, call our rooms to book today or click here to make your own online booking with one of our physios.


Medical Disclaimer

This content is for education and information purposes only. It is not intended to replace professional medical advice, diagnosis or treatment. If you have any health concerns or pain, please contact your local healthcare provider directly.



  1. Lahdeoja, T. A. K., T. V., Jain, N. B., Page, C. M., Johnston, R. V., Salamh, P., Kavaja, L., . . . Buchbinder, R. (2019). Subacromial decompression surgery for rotator cuff disease. Cochrane Database Syst Rev, 1, CD005619. doi:10.1002/14651858.CD005619.pub3
  2. Luime, J. J., Koes, B. W., Hendriksen, I. J., Burdorf, A., Verhagen, A. P., Miedema, H. S., & Verhaar, J. A. (2004). Prevalence and incidence of shoulder pain in the general population; a systematic review. Scand J Rheumatol, 33(2), 73-81. doi:10.1080/03009740310004667
  3. (2011). The Maastricht Ultrasound Shoulder pain trial (MUST): Ultrasound imaging as a diagnostic triage tool to improve management of patients with non-chronic shoulder pain in primary care.
  4. Chester, R., Khondoker, M., Shepstone, L., Lewis, J. S., & Jerosch-Herold, C. (2019). Self-efficacy and risk of persistent shoulder pain: results of a Classification and Regression Tree (CART) analysis. Br J Sports Med, 53(13), 825-834. doi:10.1136/bjsports-2018-099450
  5. Moller, M., Nielsen, R. O., Attermann, J., Wedderkopp, N., Lind, M., Sorensen, H., & Myklebust, G. (2017). Handball load and shoulder injury rate: a 31-week cohort study of 679 elite youth handball players. Br J Sports Med, 51(4), 231-237. doi:10.1136/bjsports-2016-096927
  6. Kuhn, J. E., Dunn, W. R., Sanders, R., An, Q., Baumgarten, K. M., Bishop, J. Y., . . . Group, M. S. (2013). Effectiveness of physical therapy in treating atraumatic full-thickness rotator cuff tears: a multicenter prospective cohort study. J Shoulder Elbow Surg, 22(10), 1371-1379. doi:10.1016/j.jse.2013.01.026
  7. Martinez-Calderon, J., Struyf, F., Meeus, M., & Luque-Suarez, A. (2018). The association between pain beliefs and pain intensity and/or disability in people with shoulder pain: A systematic review. Musculoskelet Sci Pract, 37, 29-57. doi:10.1016/j.msksp.2018.06.010
  8. (2013). No evidence of long-term benefits of arthroscopic acromioplasty in the treatment of shoulder impingement syndrome.
  9. Burger, M., Africa, C., Droomer, K., Norman, A., Pheiffe, C., Gericke, A., Miszewski, N. (2016). Effect of corticosteroid injections versus physiotherapy on pain, shoulder range of motion and shoulder function in patients with subacromial impingement syndrome: A systematic review and meta-analysis. S Afr J Physiother, 72(1), 318. doi:10.4102/sajp.v72i1.318



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