The shoulder is one of the most common areas of chronic upper body pain, particularly among an exercising population. A low-grade shoulder ache can progress quickly to more severe pain if not treated properly. However, an understanding of the basic mechanism of chronic shoulder pain, as well as simple treatment options, can stop shoulder pain dead in its tracks and get you back to exercising quickly.
Shoulder Impingement Syndrome
First off, let’s define what we’re talking about here. When I’m referring to shoulder pain, I’m talking about discomfort in and around the shoulder joint itself. Since the shoulder joint is so complex (with several muscles, tendons, and ligaments running through the joint), it is often difficult to diagnose injury to a specific structure, either on manual examination or MRI. As a result, a simple “catchall” diagnosis used in the medical and rehabilitation communities is shoulder impingement syndrome (SIS).
The hallmark symptom of SIS is pain when raising the arm in front or out to the side of the body, with increasing levels of pain occurring as you reach shoulder height. The pain is generally a result of damage to soft tissue, such as tendons or muscles. This damage results in swelling of the injured soft tissue. As this swelling increases, it begins to reduce the space within which other soft tissue can move, which can then result in further damage and greater inflammation. Sounds like a vicious cycle, right? Well, it’s not good, but fortunately there are some simple treatment options.
Before I get into those treatments, however, I want to caution everyone reading right now that even if you think you don’t have to worry about SIS or other shoulder pain, you should reconsider. One of the biggest predispositions is our poor seated posture.
Are You At Risk?
Think about the position you’re sitting in reading this article right now — leaning into the computer screen, shoulders rounded forward, upper back rounded, head protruding forward and looking down. This is the posture we have during most of our day. When you consider the fact that body tissues are viscoelastic (which is a fancy way of saying they get “stuck” in the position they’re in most of the time), our posture predisposes all of us to SIS on some level. This seated posture results in tightened chest and shoulder muscles, while at the same time weakening upper back muscles. The end result from a postural perspective is some variation of the Hunchback of Notre Dame. Well, maybe I’m being a little dramatic, but the fact still remains that our posture predisposes even the most fit exercisers to SIS, as that rounding forward of the shoulders puts the soft tissue in the perfect position to be injured when we exercise (or even do the activities of daily life).
So, what’s the fix, you might ask? Well, it depends on your level of pain, and the amount of time that has passed since your symptoms presented themselves.
First and foremost, let’s be clear — I’m talking about chronic and progressing shoulder pain. I’m not referring to an acute injury; if you can’t move your arm off your side at all, or doing so results in severe pain, you need to go to your doctor immediately. The pain I’m referring to is lower level (1-6 on a pain scale of 10), intermittent, and something that is limiting, but not debilitating.
With that established, there are two phases to injury treatment. The first phase is the acute/symptom management phase, and the second is the long-term treatment phase. In the acute/symptom management phase, you are trying to decrease pain and inflammation. To do so, you should ice the injured shoulder 2-4 times per day for about 20 minutes each time (particularly post-exercise), and use NSAIDs (like Motrin or Aleve), as directed and tolerated. In this acute phase, you should avoid movements that elicit pain, but not necessarily all movements. Movements (ranges-of-motions or loads) that result in a pain level of greater than six on a pain scale of ten should be avoided, as they will result in greater damage. But, movements that cause some discomfort (but not pain) can be performed. In fact, doing so may be a good idea, as these movements can bring blood flow to the injured area and promote healing.
Rotator cuff exercises (raising the arms with low or no weight to mid-chest level), or even low load upper body pulling exercise (curls and rows) can be a great way to drive blood flow to damaged tissue to speed up regeneration and remodeling. However, overhead motions and movements with the elbows raised up to shoulder level (like while bench pressing or doing pushups) should generally be avoided, as these can result in pain and further damage to the joint. Also, please keep in mind that even if your shoulder is injured, you can still perform lower body exercise and improve other aspects of fitness, so don’t think all is lost!
As for long-term treatment, this has to do with getting to the underlying cause. As I mentioned earlier, SIS is really posture-related for a lot of people, but there is a technical component with respect to exercise that can be addressed as well.
For the posture component, aggressive strengthening for the musculature around the shoulder blades and back is necessary. Rowing motions performed with bands or resistance tubing will usually do the trick. Going hand-in-hand with the strengthening component is increasing flexibility to the musculature of the chest and shoulder. Gentle chest stretching daily can help loosen up those tight chest muscles, and aid in the development of upper back strength. For a simple daily routine to combat poor posture, do 4 sets of 20 reps of rows with resistance tubing, combined with 4 sets of a doorway chest stretch. Doing this daily will help to address some of the underlying muscle imbalances that caused the injury in the first place. Also, keep in mind that it’s just not enough to strengthen and loosen muscles; your posture needs to improve (since that’s likely what caused the problem in the first place). Try sitting up straight (keeping your shoulders directly above your hips), with your shoulders and head back. Doing so will help enhance the effect of the postural strengthening and stretching you’re doing.
From an exercise standpoint, try to be very aware of posture. Keeping your chest and head up, shoulder blades pulled together, and abdomen tight – while you’re exercising – puts your body in the least likely position to be injured. While in the early stages of recovery, be cautious of overhead motions as well as any upper body pressing that has your elbows rotated up to shoulder level. Instead, keep your elbows at approximately 45-60 degree angles with your sides — this keeps the shoulder joint in a much better position for soft tissue to move around freely.
So, now you know about shoulder impingement syndrome, its causes, treatments, and that we’re all really predisposed to it. Armed with this knowledge, hopefully you’ll be able to exercise injury-free for a long time to come.