Shoulder Pain

The most mobile joint in your body

The shoulder trades stability for mobility. It's a ball-and-socket joint with a socket so shallow it's often compared to a golf ball on a tee, which lets you reach overhead, behind your back, and across your body — but it means the surrounding muscles, tendons, and ligaments have to work constantly to keep the ball centered while it moves.

When something goes wrong, it's rarely just one structure. The shoulder is a system: the glenohumeral joint, the scapula and the seventeen muscles that attach to it, the acromioclavicular joint, the cervical and thoracic spine, and the rib cage all have to coordinate. Every degree of overhead reach is a negotiated settlement between the arm, the shoulder blade, and the spine. Shoulder pain is usually a breakdown somewhere in that negotiation.

Common causes

Rotator cuff dysfunction. The four rotator cuff muscles hold the humeral head centered in the socket during movement. When they're weak, irritated, or torn, you feel pain with reaching, lifting, and especially overhead activity — classically on the outside of the upper arm rather than at the joint itself, and classically worse at night, lying on that side. Tendinopathy and partial tears are far more common than complete tears.

Here is the fact that should calibrate every conversation about cuff tears: rotator cuff tears are extremely common in people with no shoulder pain at all. By the sixties and seventies, a large fraction of pain-free adults have partial or even full-thickness tears on imaging. A tear on your MRI is a finding, not automatically a diagnosis — the exam decides whether it matters.

Subacromial pain (impingement). Pain from the tendons and bursa in the space under the acromion, provoked when the arm elevates. It's usually a mechanics problem more than a space problem — poor scapular control, a stiff thoracic spine, or a restricted first rib all change how that space behaves during motion. This is also why decompression surgery for it has fared poorly in trials against sham surgery: the shape of the bone was rarely the issue.

Calcific tendinitis. Calcium deposits form within a cuff tendon and can smolder for months or flare into some of the most severe shoulder pain there is. Ultrasound shows it immediately, and it's one of the shoulder problems with genuinely good targeted options — shockwave therapy has strong evidence here, and ultrasound-guided barbotage (needling and aspirating the deposit) can clear it.

Adhesive capsulitis (frozen shoulder). The capsule surrounding the joint becomes inflamed, then contracts, causing progressive loss of motion in all directions — including when someone else moves the arm for you, which is the key exam finding. It's common enough, and different enough in its treatment, that it has its own article.

AC joint problems. The small joint where the collarbone meets the shoulder blade causes pain localized to the very top of the shoulder, worse reaching across the body or under load. Common in lifters and after falls.

Referred pain from the neck. Cervical nerve root irritation refers pain into the deltoid and upper arm in a pattern that convincingly mimics cuff disease. Numbness, tingling, pain past the elbow, or a shoulder exam that's surprisingly clean all point up to the neck — and treating the shoulder for a neck problem is a common way to waste three months.

Biceps tendon, labrum, instability — each with its own story, more common in throwers, climbers, and the young and hypermobile.

How we approach it

The exam covers the whole system: cervical spine, thoracic spine, ribs, scapular mechanics, and then the shoulder itself. A shoulder that hurts at 90 degrees of elevation frequently improves on the table when we restore motion to the upper thoracic spine or release a restricted first rib — that's not magic, it's geometry: the shoulder blade rides on the rib cage, and the rib cage was stuck.

In-office ultrasound is the shoulder's home turf. In the same visit as the exam, we can see the cuff tendons, the bursa, calcium deposits, the biceps tendon, and the AC joint, and — unlike an MRI — watch structures move and sort out which finding actually reproduces your pain. For most shoulder problems, this plus a good exam answers the question without any other imaging.

OMM addresses the joint restrictions and fascial patterns limiting normal mechanics — thoracic spine, ribs, clavicle, scapula. Cuff rehab performed on top of restored mechanics holds; performed on top of a rigid thoracic spine, it fights itself.

Progressive loading is the core treatment for rotator cuff–related pain, with evidence comparable to surgery for most degenerative cuff problems: months of structured, progressively heavier work for the cuff and scapular muscles. We make the program specific and we progress it — vague sheets of band exercises are where shoulder rehab goes to die.

Ultrasound-guided injections when a precisely placed corticosteroid dose can break a pain cycle that's blocking rehab or sleep — into the bursa, the AC joint, or the glenohumeral joint. Guidance matters: blind shoulder injections miss their target often enough to change outcomes.

Shockwave therapy for chronic cuff tendinopathy and especially calcific tendinitis, layered onto the loading program.

Surgical referral for the shoulders that need it: acute full-thickness tears in younger patients, traumatic tears with real weakness, instability that keeps dislocating, and the failed conservative course. Getting those to the right surgeon early is part of doing this well.

When to seek care

Come in if shoulder pain is limiting what you can do with your arm, if you can't sleep on that side, if your range of motion is shrinking (that's the frozen shoulder pattern — early is the time to catch it), or if an injury hasn't settled within a couple of weeks. Come in promptly if the arm is genuinely weak after an injury — not just sore but unable — or if shoulder pain comes with numbness or tingling into the hand.

What you can do right now

Modify, don't abandon. Keep the arm moving through comfortable range daily; a guarded shoulder stiffens fast. Pause the specific aggravators — usually overhead pressing and bench work — rather than everything.

Work on thoracic mobility: cat-cow, thoracic rotations, extension over a foam roller. If the upper back doesn't move, the shoulder blade can't, and the cuff pays for it.

Start scapular work: wall slides, serratus punches, rows within comfort. For most shoulder problems, the muscles that steer the shoulder blade matter more than another set of tiny external rotations with a band.

And if the pain has been there for months while you've waited for it to leave on its own — that's the most common story in the clinic, and it usually responds to an actual diagnosis and a structured plan within weeks.