There are a number of specific pathologies which go on at the shoulder, such as rotator cuff tendinopathies, labral tears, AC joint degeneration or bursa issues, the problem here is that these pathologies occur in asymptomatic populations (Schwartzberg et al, 2016, Grish et al, 2011) so the question that arises is, is it one of these pathologies which are causing your symptoms or is it just sensitized tissues with an incidental pathology? Another thing to consider which is a bit more controversial, is posture and scapulo-thoracic kinematics i.e. how the shoulder blade/girdle moves on the rib cage, as discussed in another blog (scapula dyskinesis) some people see this as relevant (Malmstrom et al, 2015) and others not (Barrett et al 2016), and that is pretty much my opinion, sometimes it is relevant to the presentation and in other cases it is not.
What are we trying to achieve if we have asymptomatic pathologies but sensitized tissues? well to steal a saying from Greg Lehman we need to ‘calm stuff down and build stuff back up’. Part of the calming stuff down might be some passive therapies such as soft tissue work or mobilization but it might also be adding load to the shoulder and the shoulder girdle, stimulating the tissue to calm down while also getting you to recognize that it won’t get any worse with load. This will hopefully give you the confidence to start using the shoulder again which in itself will help with the rehabilitation of the shoulder.
Once we’ve ‘calmed stuff down’ we need to ‘build stuff back up’ i.e. add more load to the shoulder, progressing from static isometric exercises, to eccentric (getting longer) and general strength work. Beyond this will be determined by the patient and their individual goals, someone aiming to get back playing tennis or swimming will need a different level of rehabilitation to those wishing just to get back to meeting the demands of every-day life.
Schwartzberg et al, High Prevalence of Superior Labral Tears diagnosed by MRI in Middle-Aged Patients with Asymptomatic Shoulders, The orthopaedic journal of sports medicine, 2016
Grish et al, Ultrasound of the Shoulder: Asymptomatic Findings in Men, AJR, 2011, 197, pp713-719
Malmstrom et al. A slouched body posture decreases arm mobility and changes muscle recruitment in the neck and shoulder region. Eur J Appl Physiol. 2015 Dec;115(12):2491-503. doi: 10.1007/s00421-015-3257-y. Epub 2015 Oct 1.
Barrett et al, Is thoracic spine posture associated with shoulder pain, range of motion and function? A systematic review. Man Ther. 2016 Dec;26:38-46. doi: 10.1016/j.math.2016.07.008. Epub 2016 Jul 21.