What shoulder pain usually turns out to be
Shoulder pain is a common complaint — in primary care the reported annual incidence is around 14.7 per 1,000 patients. It also has a habit of returning. Recurrence runs at roughly 25%, and something like 40–50% of people who have had shoulder pain still report some of it twelve months later.
That last figure is the one worth sitting with. Shoulder pain is not usually a thing that resolves and is forgotten. It is a thing that comes back — which is an argument for treating the pattern rather than the episode.
The most common pathology by a distance is rotator cuff disorder, at upwards of two thirds of cases.
The rotator cuff is four muscles that hold your arm bone in its socket and rotate it. Their bellies sit on the shoulder blade; their tendons wrap around the head of the humerus and pull it into the glenoid cavity. They are known collectively as the SITS muscles: supraspinatus, infraspinatus, teres minor, subscapularis.
Rotator cuff problems come in four broad shapes:
- Inflammation of the tendons
- Inflammation of a bursa in the area
- Impingement of a tendon
- Partial or complete tears of a tendon
Adhesive capsulitis — frozen shoulder — accounts for around 2% of cases. The connective tissue around the joint stiffens, becomes inflamed and may thicken. Nobody is entirely sure why it starts. The result is restricted movement and pain that outlasts everyone’s patience.
Beyond that: tendonitis, labrum tears, acromioclavicular joint problems. They all suck in their own particular way.
Why an image is not a diagnosis
Surgery relies heavily on imaging — MRI, X-ray — to decide on a course of action. The difficulty is that what shows up on an image does not reliably correspond to what hurts.
Plenty of people have findings on a scan and no symptoms. Plenty of people have significant pain and unremarkable scans. And surgically correcting an anomaly found on an image does not always resolve the pain that sent someone for the scan in the first place. For low back, neck and shoulder pain, several studies have found surgery performing about as well as physical therapy alone.
Which is not an argument against surgery. After a traumatic event it may well be the right call, and a full-thickness tear that completely severs the tendon will need repairing. But for less traumatic presentations the research has been pointing toward conservative treatment — and a partial tear in particular usually responds well to it.
The distinction that matters is not how bad the image looks. It is whether the structure is severed or still continuous.
Where pain medication fits, and where it doesn’t
Medication treats the symptom. It is prescribed across a broad range of presentations that may have very little to do with your particular one, and it will usually mask pain rather than change what is producing it.
That is not nothing. If you cannot sleep, or cannot get through a working day, being able to do those things matters, and short-term medication is a reasonable tool for getting there.
What it should not be is a substitute for working out what is actually going on. Your pain is telling you something about your body, and turning the volume down on the message does not answer it.
What each profession is actually good at
This is the part most people never get explained to them, and it is the whole reason the two work well together.
Physical therapy is for load, strength and motor control. A physical therapist is trained to assess movement restriction precisely, then build a programme that restores strength, activation and control. With most shoulder pathologies the joint has to be both strengthened to protect the structure and retaught how to move. That is a physical therapist’s core competence and it is not a massage therapist’s.
Massage therapy is for the tissue, and for what is pulling on it. A physical therapist’s training may include some manual therapy, but rarely at the depth a massage therapist’s does. Most PTs would rather hand detailed manual work to someone who does it all day, and in our experience most of them are glad when a client already has one.
Manual therapy in a shoulder case does a few specific things. It changes how a painful area reports to the nervous system, which can lower the guarding that keeps a joint locked down. It can address how scar tissue and adhesions behave — nobody breaks up scar tissue with their hands, but elasticity improves at the border where scar meets healthy fascia, and over a longer horizon the scar itself can be loaded so it glides more like the tissue around it. And techniques like PNF (proprioceptive neuromuscular facilitation) can work at the edge of available range to gradually extend it.
It also looks outside the shoulder. A shoulder that will not settle is frequently being pulled on by something that is not the shoulder — the ribs, the mid-back, the obliques, sometimes the neck. That is difficult to see from inside a rehab programme, and it is most of what we are assessing for.
Together, the two answer questions neither can answer alone. Which muscles aren’t firing. Where range is genuinely restricted versus guarded. What is being compensated for. When a massage therapist is working from a physical therapist’s assessment — and vice versa — both get considerably more specific.
A worked example: a partial rotator cuff tear
Say you are a painter. Ten years of interior work, much of it overhead, most of it repetitive.
A couple of months ago your right shoulder started feeling fatigued and sore. That has happened before and it has always settled in a few weeks. This time it doesn’t. It slowly gets worse, until holding your arm up for a full working day is a problem.
An orthopedist sends you for an MRI. It shows a partial tear in the supraspinatus tendon. Partial, not complete, so conservative treatment is on the table and you decide to try it.
Your physical therapist starts gentle loading of the rotator cuff — the torn muscle and the ones around it — and builds resistance slowly. The target is using the shoulder without provoking pain, then extending the range you can do that through.
Your massage therapist works on the tenderness and guarding in the cuff itself, uses stretching and neuromuscular work to complement what the PT is loading, and addresses whatever else is contributing — which for a painter very often includes the obliques and the mid-back, because ten years of overhead work does not stay in the shoulder.
Over several weeks the discomfort eases. Over a few months you are working normally again. You keep ten to fifteen minutes of exercise and stretching most days and come in for maintenance work every four to six weeks, because the recurrence figures at the top of this post are real and a small ongoing habit is what keeps you on the right side of them.
No surgery, and no ongoing need for pain medication. That is a realistic outcome for this presentation, not a promised one. Partial tears often respond well to conservative treatment, some do not, and which group you are in is not knowable at the start.
If you have already had surgery
Massage therapy still has a role. Once you are working with a physical therapist post-operatively it is generally safe to add manual work alongside, and the same division of labour applies — they load and stabilise, we work on the tissue and on whatever the rest of you has been doing to compensate while the shoulder was out of action.
Check with your surgeon on timing. After that, the sooner the compensations get addressed, the less there is to undo.
Come and get the shoulder looked at
Our therapists are trained across the common shoulder pathologies and — just as usefully — trained to read a physical therapist’s notes and speak the same language back. If you are already working with a PT, bring their assessment. It makes the first session considerably more useful.
If you are not, we will tell you honestly whether we think you need one.
You can book a shoulder pain massage in Midtown West or at our Financial District studio, or book online at either.
David Weintraub, LMT – Owner, Bodyworks DW Massage Therapy
