The shoulder complex. A few bones and joints, 17 different muscles acting on each shoulder, some cartilage, capsules, nine identified bursa, a multitude of ligaments, and other connective tissue holding everything together. Not to mention a large bundle of nerves, lymphatic vessels, arteries, and veins traveling through it. So when someone comes into the clinic having a problem with their shoulder, there is a lot to unpack. And with some research1 reporting that up to 70% of people can experience shoulder pain at least once in their life, it is a common reason why we see people in the clinic. But as physical therapists, where do we start? How do we determine the best plan for our patients? That is the topic of this article.
The Shoulder, Across the Lifespan
First, a little background on the shoulder across the lifespan. As we age, the prevalence of various shoulder problems will increase or decrease depending on said age. Which inherently makes sense, as not only do our bodies adapt over time, but our demands and priorities we have do so as well. And the integrity and quality of our tissue also changes. For instance, younger people tend to see more shoulder issues related to the sports they play – traumatic injuries more commonly involving the stability of the shoulder such as subluxations and dislocations.
One study2 followed high school athletes from 2005-2006 through the 2011-2012 years and reported nearly 821,000 injuries occurred across the nine sports they followed. Shoulder strains/sprains and dislocations/separations were the two most common injuries sustained for these athletes. Over subsequent years the demands we require for the shoulder change, thus new issues can occur.
Enter the rotator cuff muscles!
This often heard of muscle group is a key component in how our shoulders move. It’s uncommon to see problems in these muscles in our youth. In their research, Codding and Keener3 found that only 9.7% of patients 20 years and younger had issues related to their rotator cuff musculature, versus 62% of patients who were 80 years and older experience rotator cuff problems, typically degenerative in nature. And the years in between tend to be rotator cuff related injuries due to single incident or repetitive trauma. Research has proven that the rotator cuff loses integrity as we age. Similarly, we start seeing age-related and asymptomatic joint arthritis in the shoulder complex develop in 93% of the population who are over 30 years old.4 As physical therapists, an understanding of these generational tendencies regarding what is more likely to be a problem in a patient’s shoulder allows selection of specific rehab strategies to help them. Additionally, a broader view of each person’s situation and psychosocial environment is imperative for us to determine how best to develop a treatment plan unique to each patient’s needs. And that requires a broader approach in how we evaluate the shoulder.
With all of the moving parts in the shoulder and the various problems that arise as we age, where do we start? We start with you! Researchers suggest that a robust and thorough history of your shoulder problems far outweigh any specific test we can administer.5 In addition, the patient’s expectations and specific preferences to treatment can play huge roles in a positive experience with physical therapy.5 Looking at the shoulder itself, there are generally two things it needs to do: the shoulder needs to move and it needs to move well.
First, movement. Shoulders that are stiff, or too irritable to move, generally require therapy that focuses on symptom-free range of motion at first. Developing a program can entail hands-on manual therapy, exercises in which gravity or leverage is less of a factor, or any number of fun equipment to help restore movement at the shoulder. Second, the shoulder needs to move well. As mobility is established, the shoulder needs to have enough strength and stability to manage the load it is under. The exact method of strengthening largely depends on the preference of the patient – what their goals are or what exercise equipment they have at their disposal, or not. What we do know is that the tissue in our body – muscle and tendon, ligament, capsule and bone – need load; progressive load to stimulate cellular activity for healing and building capacity to load and activity. – Weights can be used, sure, but strength and stability could also mean repeating shoulder movements for a period of time. Exercises of coordination and motor control, or exercise focusing on replicating a patient’s functional demands are also necessary. It all depends!
What is important to know about the shoulder is that it is a richly complex part of our body with many components. Each shoulder is different because each person is different! Different needs, different wants, different expectations. And with those differences comes different plans to treat the shoulder. As physical therapists, it is our job to determine how your wants and needs fit into the best plan possible to get your shoulder back to moving and moving well. If you have any questions our physical therapists who are shoulder specialists are happy to get on a call with you or have you stop in for a complimentary screening to discuss your problems and determine what successful treatment would look like.
Dr. Ryan Bourdo completed his undergraduate education at the University of Oregon and received his Doctorate of Physical Therapy at Regis University in Denver, Colorado. He believes in treating the whole person and creating an environment that best enables the body to heal through exercise and manual therapy. Click here for full bio.
Having shoulder problems and needing help? Give us a call at 503.228.1306 or request appointment so we can help get you back to being active
- Lewis, J. S., Cook, C. E., Hoffmann, T. C., & O’Sullivan, P. (2020). The Elephant in the Room : Too Much Medicine in Musculoskeletal Practice. Journal of Orthopaedic & Sports Physical Therapy, 50(1), 1–4. https://doi.org/10.2519/jospt.2020.0601
- Robinson, T. W., Corlette, J., Collins, C. L., & Comstock, R. D. (2014). Shoulder Injuries Among US High School Athletes, 2005/2006–2011/2012. Pediatrics, 133(2), 272 LP – 279. https://doi.org/10.1542/peds.2013-2279
- Codding, J. L., & Keener, J. D. (2018). Natural History of Degenerative Rotator Cuff Tears. Current Reviews in Musculoskeletal Medicine, 11(1), 77–85. https://doi.org/10.1007/s12178-018-9461-8
- Cadogan, A., Laslett, M., Hing, W. A., McNair, P. J., & Coates, M. H. (2011). A prospective study of shoulder pain in primary care: Prevalence of imaged pathology and response to guided diagnostic blocks. BMC Musculoskeletal Disorders, 12(1), 119. https://doi.org/10.1186/1471-2474-12-119
Ristori, D., Miele, S., Rossettini, G., Monaldi, E., Arceri, D., & Testa, M. (2018). Towards an integrated clinical framework for patient with shoulder pain. Archives of Physiotherapy, 8(1), 1–11. https://doi.org/10.1186/s40945-018-0050-3