How many of you have ever had shoulder pain…can I have you raise your hands?
Well, maybe not if you have shoulder pain right now, because it can hurt to raise your hand.
How many of you with shoulder pain have used Google to find out what to do about your shoulder pain? Yep, that’s officially 100% of you, at least by my count.
Fellow “shoulder pain victims” can identify one another in the gym. They see each other doing the same exercises that they themselves have tried because that’s what the Google result told them to do.
But a lot of those people will still be dealing with their shoulder pain after 6-weeks of doing “the right” exercises for shoulder pain.
Why is that? Because all shoulder pain is not caused by the same problem.
A Tale of 2 Swimmers’ Shoulders
About 3-months ago I had back-to-back patients present who were swimmers.
Both had complaints of shoulder pain.
Both swam for the same collegiate team, did the same workouts, swam the number of practices, and went to the weight room at the same frequency.
The coach and the team trainer showed up with the patients to learn about what was going on with these two swimmers.
So this should have been as easy as talking to both of the swimmers, the coach, and the trainer at the same time about what swimmer’s shoulder is, how it comes on, and what to do about it.
But that actually requires a lot of assumptions to be made…and often times assumptions are inaccurate.
So please allow me to explain why all swimmer’s shoulder pain is not the same.
Swimmer’s Shoulder #1
History
The first swimmer was 18-years-old and presented with left shoulder pain with long distance freestyle swimming. Pain was present on the recovery of her stroke (when the arm is out of the water). She also noticed pain with pulling water in her backstroke, and after lifting weights overhead. She had difficulty sleeping on her sides because of shoulder pain. The swimmer also reported some off-and-on right shoulder pain. She had done previous physical therapy, which she reported as helpful. Currently, pain rating while swimming was 6/10.
Now, let’s decipher what her history tells us.
1- She has a history of shoulder pain before this episode, as evidenced by having previous PT.
2-The pain occurs when the arm is in a specific position or with a specific movement pattern. That pattern is common to all of her movements. Can you see what all the symptomatic motions have in common? It’s the position of the arm being taken to the side or slightly behind the body and being in an elevated position. We in the profession call this a position of abduction and external rotation.
This pattern of symptoms alludes to the shoulder being unstable, which means the shoulder can be moved into positions that the swimmer cannot control correctly.
3-The pain, while currently on the left, could be on either shoulder, as evidenced by the history of right shoulder symptoms as well.
Physical
Moving on to the physical exam, the swimmer showed full, pain free range of motion. She showed decent strength in all muscles, with the exception of two muscle movements on the left shoulder, which were minimally weaker than the right. Special tests that are used to discover the cause of a pain complaint were all unremarkable…meaning, this patient had a healthy shoulder!
Perhaps the most important finding was the fact that this swimmer showed signs of hypermobility. Hypermobility, often called being “double-jointed,” is defined as a greater than average range of mobility of the joints.
The swimmer showed increased joint motions in her elbows, wrists, fingers, and shoulder on both sides. She was able to bend forward when standing with her knees straight and place her palms flat on the floor. All of the testing motions gave her a Beighton score of seven out of nine possible (7/9). Any score over 4/9 is considered to indicate generalized hypermobility.
This particular swimmer’s shoulder could be moved into the position mentioned earlier, abduction and external rotation, without any feeling of worry by the patient. This was interesting because her shoulder was actually very loose in this position and caused pain. Yet, she had no worry of it being in the vulnerable position.
Assessment
This patient’s swimmer’s shoulder complaints were actually caused by a form of hypermobility that allows her shoulders to move more in every direction than normal. Because of this, she had a great deal of trouble controlling how her shoulders moved, which lead to her moving her shoulders into positions in which her muscles could not sustain stability of the joint.
This is clinically called multi-directional instability of the shoulder. The excess movement and lack of control were the underlying root of her shoulder pain.
Plan
The plan of care for this patient included coordination and muscle patterning exercises to help her gain a better understanding into what range her shoulder was moving and which muscles could be used to control the movement before it became a pain producing range of motion. Treatment was aimed at restoring the ability to sense the joint position, then to strengthen the shoulder blade and rotator cuff stabilizing muscles, and to integrate those muscles back into the entire movement pattern necessary for the patient to return to swimming without risk of re-injury/re-aggravation.
Swimmer’s Shoulder #2
History
The second swimmer was 19-years-old and presented with right shoulder pain associated with swimming long distance freestyle. She also reported having pain after lifting weights, especially later that same day and the following day. She had the pain previously, had taken off time from swimming, and had an injection in the shoulder. On returning to swimming and exercises, her pain returned. Pain rating while swimming= 6/10.
Do you notice that the history sounds nearly identical to Swimmer #1?
This swimmer noticed pain with breathing to the right side, which happens when the right arm is recovering (out of the water). Again, this sounds exactly the same as Swimmer #1.
So can we glean anything different for this patient from her history?
Only this, the injection and rest did not change her ability to swim. So we know that doing that again is a recipe for the same result. That would mean failure to return to swimming without pain.
Physical
So now you might start seeing the difference when we discuss the physical findings.
Swimmer #2 had full range of motion of her shoulders actively. But while sitting at rest, her right shoulder was held higher than the left. Her right collar bone did not move downwardly on her breastbone when she shrugged her shoulders, and the right side first rib was held high. The right shoulder was limited with passive internal rotation. None of these were present in Swimmer #1.
Internal rotation is an integral part of every one of your swimming strokes and needs to be present in order to swim well. Here is what it looks like:
Swimmer #2 also did not have any signs of hypermobility, scoring a zero out of nine (0/9) on the Beighton score.
Swimmer #2 showed decent strength in all muscles, with the exception of two muscle movements on the right shoulder, which were minimally weaker than the left. Special tests that are used to elucidate the cause of a pain complaint were indicative of right shoulder tendon irritability, but not torn or physically damaged. This patient also had a healthy shoulder!
With a closer look at why the right first rib and collarbone were limited, Swimmer #2 showed limited cervical spine mobility with tightness of the right side neck muscles, which were causing the right rib and collarbone, as well as the shoulder blade, to be held higher than the left. We have seen this combination cause of the loss of shoulder internal rotation, which in turn causes increased stress on the shoulder tendons. Swimmer #2 also had very poor right rotation of her trunk, which meant she had to move her shoulder further behind her to compensate the loss of trunk rotation in order to recover and breath on that side.
Assessment
Swimmer #2 had shoulder pain because of a loss of internal rotation range motion. The internal rotation of the right shoulder was limited because of neck/cervical spine limitations. The trunk rotation limitation forced the right shoulder to have to move more, even trying to work through the internal rotation limitation, which increased the right shoulder stress.
Treatment
Treatment in this case was aimed at restoring neck mobility and decreasing right sided neck muscle tensions. That in turn allowed restoration of the right first rib, collarbone, and shoulder blade positions. With that, the right shoulder internal rotation was fully restored…without stretching.
Right trunk rotation was also improved with a combination of manual intervention and home/gym-based exercises. These were implemented so that the patient could be independent in her self-care. She was able to successfully return to swimming full practices without her shoulder pain.
Comparison and Conclusion
You can see that both swimmers presented with similar complaints of shoulder pain. Pain occurred in similar patterns. They were both training the same amount.
But they had very different reasons for the shoulder pain!
This is why so often people get frustrated by trying the “generic” exercises found on the internet when looking for the quick-fix. While they might be good exercises, they might not be the right exercises for you.
Swimmer #1 had done all the right exercises, but still had no idea how to move correctly or in a coordinated pattern.
Swimmer #2 had also done the right exercises, rested, and tried an injection, but had only focused on her shoulder, when her real problems lay in her neck and upper back mobility.
Your shoulder pain might not be the same as your friend’s shoulder pain. Shoulder pain can be caused by trauma to the shoulder, repetitive strains/overuse, referred symptoms from the neck, or from disuse/weakness.
While strengthening is a key to improving just about all shoulder problems, it is helpful to know which exercises are going to be most effective for you in the shortest amount of time.
After all, time is valuable. So get to the root cause of why you have the shoulder pain as quickly as you can, then do the exercises that address that root problem, rather than chasing the pain.