Do exercises help shoulder pain

If you see a doctor with shoulder pain you’ll likely be given some exercises to “correct” the problem, but when I reviewed the clinical trials and other scientific information I found these are unlikely to fix shoulder problems, and more likely to cause harm.

The key issue is that there are two major (often overlooked) issues that cause poor shoulder function and pain. while these persist:

• your shoulder function will continue to be abnormal and cannot be restored, and
• pain will persist.

These need to be dealt with first to allow the joint to work properly, then once the joint is able to work normally exercises can be an important part of a rehabilitation program. While this approach is advocated by the US National Academy of Sports Medicine (28), it is way too often ignored.

In this article we will outline what these problems are, why "corrective exercises" will not work, and how these are correctly dealt with.

CONTENTS

• An overview of the problem
• How abnormal balance and function cause shoulder pain
• How (myofascial) trigger points cause shoulder pain
• Why exercises will not fix the problem
• The sensible solution for shoulder problems
• Professionals
• References

An overview of the problem

The following is a point by point overview of why "corrective exercises" cannot correct shoulder function, but how they can be used as part of a rehabilitation program.

• A major cause of shoulder pain is a poorly functioning shoulder joint causing pinching and creating abnormal stresses.
• This poor function is usually caused by issues affecting balance and neuromuscular control.
• If you use exercises without fixing these issues:

1. the poor function will remain, and
2. the exercises will be done using the same poor function (causing further damage and pain).

• If you first fix the balance and neuromuscular control issues function can return to normal and rehabilitation exercises can be used.
• Another major cause of shoulder pain is (myofascial) trigger points (discussed later). Exercises will not help these either.

How abnormal balance and function causes shoulder pain

Along with (myofascial) trigger points (discussed later), abnormal function is the major cause of shoulder pain. Normal function requires correct balance and neuromuscular control. When something affects this the joint will move abnormally, causing it to pinch, wear fast and become damaged. We will look at this in more detail, why exercises will not fix the problem, then how to deal with these properly.

In this section:

• The anatomy of your shoulder joint
• How your shoulder moves
• Faulty shoulder joint movement
• Abnormal shoulder joint balance
• How these cause pain

The anatomy of your shoulder

The key issue is that shoulders are very unstable joints. This is easiest to understand when comparing it with a hip joint. As this diagram shows the hip joint has a ball sitting snug in a socket and held in place with tight bands. In contrast your shoulder has a large ball sitting in a shallow socket. To keep that ball sitting snugly where is should be we have a complex control mechanism involving balance and the muscles around your shoulder.

The role of your shoulder muscles and balance

In order for the shallow unstable ball to sit snugly in the socket and move around smoothly your shoulder relies on:

• balance, and
• the coordinated efforts of the muscles shown in this diagram.

How your shoulder moves

For your arm to move the ball need to slide within the shallow socket. For example, as this diagram shows, as your arm lifts up the ball needs to slide down in the socket. Again, this movement requires balance and the coordinated effort of many muscles.

Faulty shoulder joint movement

Let us look at what happens when the balance of your shoulder is affected or the muscles are unable to coordinate the movement. As this example shows:

• We can see it is pinching at the top.
• Instead of the load being spread out over the joint surfaces there is a lot of pressure in one spot.
• The gap at the bottom is much bigger so tissues are being stretched and it is a lot less stable.

These issues can cause pain, accelerated wear, and the joint to be vulnerable to injury.

An example: impingement syndrome

When pain and injury is caused this way doctors call it "impingement syndrome". They recognising the pinching and resultant injury, but not why this is happening. This diagram shows an example.

When abnormal function is allowed to remain

If you leave this condition for long enough some of those parts will become damaged or worn enough to show up on a scan and x-rays. Again theses changes are recognised, but their cause is not.

Abnormal shoulder balance

Postures like shown in this diagram alter the angles and balance of shoulder structures placing them under abnormal stress. Several studies have found this to be a major cause of shoulder impingement (1-7), while one found that if this posture was corrected it relieved shoulder pain (7).

Do not expect your doctor to recognise this

Despite all the evidence about this and (myofascial) trigger points discussed below the medical journals doctors read usually do not mention these (8,9). The drug companies that heavily fund these journals prefer doctors to prescribe useless therapies and pain relieving drugs.

How (myofascial) trigger points cause shoulder pain

(Myofascial) trigger points, or “trigger points” for short are those tender lumps in your muscles that massage therapists find. They cause shoulder pain three ways.

1. They inhibit muscles making them unable to maintain the shoulder joint in it’s correct position.
2. They refer pain directly like it shows in these charts.
3. They can contribute to postural issues

As is the case with postural issues (discussed above), despite the huge amount of scientific evidence this information is usually omitted from medical journals.

Trigger points are a major cause of poor neuromuscular control

As discussed in our Guide To (Myofascial) Trigger Points , trigger points will inhibit the function of muscles. Because of this one researcher found that when the shoulder muscles contained trigger points they were unable to control the joint properly, but when the trigger points were treated the control went back to normal (10).

Trigger points and shoulder pain

Other researchers found that compared with non-sufferers the muscles of shoulder pain sufferers contain large numbers of trigger points, and treating these trigger points relieves shoulder pain (11-17)

Why exercises will not fix the problem

Exercises will not correct shoulder function

The key issue is that abnormal shoulder function will have underlying causes such as a postural imbalance or muscles not doing what they need to. If you exercise the shoulder with those issues remaining the joint will still move around abnormally. If anything it will accelerate the damage.

The scientific findings

Clinical trials confirm this, showing that:

• exercises cannot fix these functional problems (18-21),
• exercises do not fix shoulder pain (22), and
• in many cases make the pain worse (22).

Exercises will not fix trigger points

Exercises will not eliminate trigger points, and in many cases can cause them to flare up. For more information please see our Trigger point therapy guide .

Exercises will not fix postural problems

The postural problems discussed have complex causes, and usually cannot be fixed by just doing exercises. For more information please see this article.

The sensible solution for shoulder problems

This research raises three important issues for dealing with shoulder pain and functional problems

• First do no harm
• Correct shoulder function then do rehabilitation exercises
• Take care of the (myofascial) trigger points

First do no harm

As mentioned above, doing “corrective exercises” without first enabling the shoulder to function normally will just accelerate damage. Further, a study in the Journal of elbow and shoulder surgery found that the evidence does not support the use of analgesics, anti-inflammatory drugs, corticosteroids, physiotherapy or exercises, and after six months 79% of shoulder pain is un-resolved (23). You need to stop doing things that have no proven benefit and likely cause harm.

Correct shoulder function- then do rehabilitation exercises

The logical thing to do is to:

• first correct anything that inhibits normal shoulder function, allowing the joint to work normally, then
• do exercises for rehabilitation.

Examples using this approach

Example one: in clinical trials

There have been several studies of shoulder pain where exercises alone have been compared with exercises plus physical therapies such joint manipulation (freeing up restricted joints) and soft tissue therapy (massage and trigger point therapy) (24-27). In each case the results were way better when using the therapies.?Those therapies help take care of the issues inhibiting normal joint function, allowing more normal function for rehabilitation.

Example two: (USA) National Academy of Sports Medicine guidelines

The (USA) National Academy of Sports Medicine (NASM) produces a 400+ page guide called “NASM Essentials of Corrective Exercise Training" (28). It advises that several issues including those muscular problems we’ve mention need to be addressed before doing “corrective” exercises.

Take care of the (myofascial) trigger points

In this section:

• Trigger points are a universal source of shoulder pain
• Treatment of trigger points is highly effective for shoulder pain
• Treatment advice
• Treatment resources

Trigger points are a universal source of shoulder pain

Researchers have found that trigger points are almost universally present in shoulder pain sufferers (12–14) . They can:

1. cause pain directly by referred pain,
2. by preventing the muscles that control movement from working normally, and
3. can be a major factor in altered posture.

Treatment of trigger points is highly effective for shoulder pain

Treatment of trigger points can therefore stop the referred pain, plus help restore normal posture and shoulder joint function. Because of this treating trigger points alone has proven to be very effective for shoulder pain (11,14,15,17,29).

Treatment advice

With the right equipment trigger point therapy to your shoulder muscles is very easy to do. Below we will link to an excellent guides and a video. However, due to some very common misinformation and advice we will briefly discuss some basics you need to know.

Courses of treatment typically just relieve pain, not rid trigger points

Whether it is needles, laser or manual therapies courses of trigger point therapies are only designed (and scientifically proven) to relieve symptoms, not eliminate the trigger points. This means they are still there, so they continue to inhibit shoulder muscles and will eventually start causing pain again. To rid trigger points you need to continue therapy for long after the pain goes, which is why we recommend self therapy. For more information please see our article The best treatment for trigger points.

A lot of heavily marketed self therapies are not suitable

Despite being common advised and heavily promoted:

• Self pressure techniques are just marginally effective, plus because they are painful and hard to do people rarely continue with them for long enough to eliminate the trigger points.
• massage guns and foam rollers are not very effective and many people hurt themselves using them.

Treatment resources

For effective self trigger point therapy for your shoulder muscles please check out the resources below.

• The simple effective way to treat trigger points yourself
• Massage and trigger point therapy for shoulder pain
• Video: How to treat trigger points in your shoulder muscles

Try this therapy with a sample massager (professionals only)

Most of our massagers sell through colleagues using our machines and recommending the therapy to patients/clients, so we are very happy to send appropriately qualified professionals a complimentary sample machine to trial. For more info please see our Professional sample page or see the video below.

References

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