36 Shoulder Pain

Shoulder Pain

The rotator cuff is a group of tendons that holds the shoulder joint in place allowing people to lift their arm and reach overhead. Rotator cuff related shoulder pain is a term that encompasses a spectrum of conditions including subacromial pain syndrome, rotator cuff tendinopathy, and symptomatic partial and full thickness rotator cuff tears (Lewis, 2016).


Rotator Cuff Related Shoulder Pain
In some cases of rotator cuff disorders pathoanatomical explanations do not account for why pain persists, which is why it is important to take into account patient-specific assessment findings and psychosocial factors (Wylie et al., 2016; Wong et al., 2020). In other cases, pathological changes (e.g., fibrosis, interstitial collagen deposition, and inflammatory cells) may be associated with sensorimotor declines, and symptomatic rotator cuff disorders (Fouda et al., 2017).

Frozen Shoulder
Frozen shoulder also known as “Adhesive Capsulitis” is classified as idiopathic (primary) or following shoulder surgery or trauma (secondary). Traditionally it has been taught that regardless of therapeutic intervention the affected shoulder will eventually improve or “thaw out”. This long held idea of complete resolution without treatment for frozen shoulder is unfounded. In most cases an understanding of the pathophysiology of frozen shoulder will lead to improved treatment outcomes, reduced pain and suffering associated with the condition (Wong et al., 2017).

The progression of the frozen shoulder is a complicated process, involving a cascade of molecular and cellular events. Connective tissue fibrosis and storage of leukocytes and chronic inflammatory cells is thought to play a fundamental role. Ongoing inflammation feeds into a cycle and upregulation of pro-inflammatory cytokine production, namely transforming growth factor beta (TGF-β). This may be further perpetuated by sympathetic dominance of autonomic balance, and neuro-immune activation (Pietrzak, 2016).

Clinical Examination

A thorough health history intake can be done to gather information about patients’ limitations, course of pain, and prognostic factors for delayed recovery (e.g., low self-efficacy, fear of movement, ineffective coping strategies, fear-avoidance, pain catastrophizing) and answers to health-related questions. Screen patients to identify those with a higher likelihood of serious pathology/red flag conditions. Then undertake a physical examination: neurological screening test, assess mobility and/or muscle strength.

Outcome Measurements

Incorporate one or more of the following outcome measurements when assessing and monitoring patient progress:

  • Self-Rated Recovery Question
  • Patient-specific Functional Scale
  • DASH Outcome Measure
  • Upper Extremity Functional Index
  • Western Ontario Rotator Cuff (WORC) Index

Neurovascular Assessment
Medial axillary space – The Axillary space is bounded by teres major muscle, teres minor muscle and humerus. The long head of triceps brachii splits this area into medial and lateral groups. Scapular circumflex artery and scapular circumflex vein pass through it.

Lateral axillary space – The axillary nerve and posterior circumflex humeral artery can be irritated by soft tissue structures. Symptoms include axillary nerve related weakness of the deltoid muscle, resulting in a reduction in shoulder abduction. The pain from axillary neuropathy is usually dull and aching rather than sharp and increases with increasing range of motion. Many people notice only mild pain but considerable weakness when they try to use the affected shoulder.

Triangular interval – The radial nerve and profunda brachii artery pass through the triangular interval, on route to the posterior compartment of the arm. The triceps brachii has potential to irritate the radial nerve in the triangular interval.

Drag and Drop: Anatomy Review

Physical Examination

Incorporate one or more of the following physical examination tools and interpret examination results in the context of all clinical exam findings.

  • Apprehension Test (Crank Test)
  • Hawkins Kennedy Impingement Test
  • Acromioclavicular Shear Test
  • Speed’s Test
  • Yergason’s Test
  • Supraspinatus Test (Empty Can Test)
  • Drop Arm Test (Codman’s Test)
  • Apley’s Scratch Test
  • Sulcus Sign Test
  • Neer’s Test
  • Roo’s Test (EAST)
  • Slap Lesion Cluster
  • Load & Shift – Anterior
  • Scapular Retraction
  • AC Crossbody Adduction Test (Acromioclavicular Crossover)
  • Posterior Capsule Tightness
  • Serratus Anterior Strength Test (Punch Out)
  • Jerk Test (Posteroinferior Labral Tear)
  • Scapular Load Test
  • O’Brien Test (Active Compression Test)
  • Lift-off Sign
  • Belly Press Test
  • Painful Arc Test

Jeremy Lewis: Rotator Cuff Shoulder Pain – Exercise is as effective as surgery



Provide reassurance and patient education on condition and management options and encourage the use of active approaches (lifestyle, physical activity) to help manage symptoms.

Manual Therapy

A massage therapy treatment plan should be implemented based on patient-specific assessment findings and patient tolerance. Structures to keep in mind while assessing and treating patients suffering from shoulder pain may include neurovascular structures and investing fascia of:

  • Rotator Cuff (subscapularis, infraspinatus, teres minor, supraspinatus)
  • Pectoral Region (pectoralis major, pectoralis minor, serratus anterior and subclavius)
  • The Upper Arm (biceps brachii, brachialis, coracobrachialis, triceps brachii)
  • Deltoid Muscle Group (anterior, middle, posterior)
  • Erector Spinae (iliocostalis, longissimus, spinalis) & Multifidus
  • External Obliques, Internal Obliques, and Transverse Abdominal
  • Thoracolumbar Fascia, Latissimus Dorsi and Teres Major
  • Quadratus Lumborum

Self-Management Strategies

Massage therapists not only provide hands-on treatment they can also develop self-management programs to help patients manage symptoms. Simple home-care recommendations such as stretching and strengthening exercises may be useful for people with shoulder pain.


Prognosis is favorable when therapists use a multidisciplinary approach to treatments. Exercise is the mainstay of treatment; a strong recommendation may be made regarding the effectiveness of manual therapy when combined with exercise for subacromial shoulder pain (Pieters et al., 2020). Several systematic reviews support the use of exercise and manual therapy for the treatment of shoulder pain (Hawk et al., 2017; Steuri et al., 2017).

Massage Therapeutics: How to treat frozen shoulder: Massage video with Maria Natera

Key Takeaways

Contemporary multimodal massage therapists are uniquely suited to incorporate a number of rehabilitation strategies for acute and chronic shoulder pain based on patient-specific assessment findings including, but not limited to:

  • Manual Therapy (soft tissue massage, neural mobilization, joint mobilization)
  • Education that is Person-Centered (e.g., biopsychosocial model of health and disease, self-efficacy beliefs, active coping strategies)
  • Stretching & Loading Programs (e.g., concentric, eccentric, isometric exercises)
  • Hydrotherapy (hot & cold)
  • Self-Management Strategies (e.g., engaging in physical activity and exercise, social activities, and healthy sleep habits)

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Evidence-Based Massage Therapy by Richard Lebert is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License, except where otherwise noted.

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