The Hidden Causes of Chronic Shoulder Pain: Beyond Rotator Cuff Injuries

When people experience chronic shoulder pain, they often think of one thing: rotator cuff injuries. The rotator cuff, a group of muscles and tendons that stabilise the shoulder, is the most commonly discussed source of shoulder pain. However, long-term shoulder pain can stem from several other less obvious causes, including scapular dysfunction and nerve impingement.

In this post, we’ll take a closer look at these hidden causes of chronic shoulder pain and why it's important to consider them when seeking treatment.

1. Scapular Dysfunction: The Silent Culprit

The scapula, or shoulder blade, plays a key role in shoulder movement and stability. It acts as the base from which many of the shoulder's muscles operate. When the scapula is not moving properly, it can cause a cascade of issues that lead to shoulder pain. This condition, known as scapular dyskinesis, can lead to muscle imbalances and poor posture, which places undue stress on the shoulder joint.

How It Contributes to Shoulder Pain
When the scapula doesn’t function optimally, it alters the mechanics of the shoulder joint, leading to strain on the muscles, tendons, and ligaments surrounding the shoulder. Over time, this dysfunctional movement can cause pain, inflammation, and a range of shoulder conditions, including rotator cuff tendinitis, shoulder impingement, and even labral tears.

What to Do About It
Physiotherapy can help by addressing the root cause of scapular dysfunction. Specific exercises can strengthen the muscles responsible for stabilising the scapula, correct postural imbalances, and improve overall shoulder movement patterns. Proper scapular mechanics are essential for long-term shoulder health and function.

2. Nerve Impingement: A Subtle Source of Pain

Nerve impingement or compression is another often-overlooked cause of chronic shoulder pain. Nerves that originate from the neck, such as the brachial plexus, travel through the shoulder and can become compressed or irritated, leading to pain, numbness, and weakness in the shoulder, arm, or hand.

How It Contributes to Shoulder Pain
When nerves become compressed in the cervical spine (neck) or in the shoulder area, it can cause pain that radiates into the shoulder and even down the arm. This type of pain is often misdiagnosed as a shoulder problem when it’s actually nerve-related. Conditions like thoracic outlet syndrome, where the nerves are compressed between the collarbone and the first rib, are common causes of nerve impingement.

What to Do About It
A thorough assessment by a physiotherapist is essential to determine if nerve impingement is causing your shoulder pain. Physiotherapists can work on relieving the pressure on the affected nerves through manual therapy, posture correction, and specific exercises designed to improve neck mobility and reduce nerve compression.

3. Shoulder Instability: A Growing Problem

Shoulder instability occurs when the shoulder joint doesn’t stay securely in its socket. This can be caused by trauma, repetitive movements, or even poor posture, leading to a feeling of looseness in the joint. While shoulder instability is often associated with dislocations, it can also result in chronic pain and discomfort even without a complete dislocation.

How It Contributes to Shoulder Pain
When the ligaments and muscles that stabilse the shoulder joint become overstretched or weakened, the joint becomes unstable. This can lead to chronic pain, weakness, and difficulty with overhead movements. Over time, instability can cause further damage to the cartilage and soft tissue surrounding the shoulder, worsening the pain.

What to Do About It
Physiotherapy can help stabilise the shoulder joint by strengthening the muscles around the joint and improving proprioception (the body’s ability to sense its position in space). A well-rounded rehabilitation program focusing on strengthening the rotator cuff and scapular stabilisers can help restore proper shoulder function and reduce pain.

4. Labral Tears: The Silent Source of Shoulder Pain

The labrum is a ring of cartilage that surrounds the shoulder socket and provides stability to the joint. Labral tears, which can be caused by trauma or repetitive motion, often go undiagnosed and can lead to long-term shoulder pain.

How It Contributes to Shoulder Pain
A torn labrum can cause pain, clicking, or a sensation of instability in the shoulder. Unlike rotator cuff injuries, which are typically associated with specific muscle tears, labral tears may not always present with obvious symptoms. The pain is often vague and can mimic other shoulder conditions, making it difficult to pinpoint the exact cause.

What to Do About It
If a labral tear is suspected, a thorough clinical assessment and imaging (such as an MRI) may be required to confirm the diagnosis. Treatment typically includes physiotherapy to strengthen the muscles around the shoulder and improve joint stability. In severe cases, surgery may be necessary to repair the torn labrum.

5. Bursitis: Inflammation That Causes Persistent Pain

Bursitis occurs when the small fluid-filled sacs (bursae) that cushion the shoulder joint become inflamed. This condition is often caused by repetitive motion, such as overhead activities, and can result in significant discomfort.

How It Contributes to Shoulder Pain
Bursitis causes pain, swelling, and tenderness in the shoulder, particularly during movements that involve the shoulder joint. The inflammation in the bursa can irritate the surrounding tissues, leading to more severe pain and stiffness.

What to Do About It
Treatment for bursitis often includes anti-inflammatory medications and physiotherapy to reduce inflammation, strengthen the shoulder, and restore movement. Proper posture and modifications to activity levels can also help prevent further irritation.

Final Thoughts: Looking Beyond the Obvious

While rotator cuff injuries are the most well-known cause of shoulder pain, they are far from the only cause. Conditions like scapular dysfunction, nerve impingement, shoulder instability, labral tears, and bursitis can all contribute to chronic shoulder pain. Identifying and treating these hidden causes requires a thorough assessment by a skilled physiotherapist, who can develop a tailored treatment plan that addresses the root of the issue.

At Muscle People Physiotherapy, we are committed to helping you understand the full scope of your shoulder pain and providing effective treatments to alleviate it. If you’re struggling with chronic shoulder pain, don’t hesitate to reach out to us for an assessment and personalised treatment plan.