Incidence of Shoulder Pain
Ever had a shoulder injury that concerned you – so you demanded an ultrasound, X-ray or MRI to figure out why things were pinching and bugging you so much?
Based on the shoulder survey we put out a few weeks ago, at least 10% of our newsletter responded that they have been dealing with some shoulder issues recently. Other surveys would lead us to believe that the incidence of shoulder pain is even higher than that:
“The community prevalence of shoulder pain varied widely across the countries included in our review, with a median of 16% (range 0.67 to 55.2%). Estimates were generally higher for women than men and were higher in high-income nations.” (Lucas et al, 2022).
(Lucas et al, 2022)
The problem we see is that people with pinchy shoulders always think they are one ultrasound or MRI away from solving all their issues. They will beg clinicians to give them referrals, and tell us that they can’t train until they figure out what is causing them pain or pinching when they move.
What are shoulder abnormalities?
The reality is, when you scan asymptomatic shoulders with no pain, their ultrasound findings look like this:
Girish et al (2011)
In the associated paper from the above table, 96% of ASYMPTOMATIC people ages 40-70 had “abnormal findings” and pretty serious sounding injuries, despite being pain free and having zero clue.
Let that sink in for a second, ASYMPTOMATIC shoulder abnormalities were found in 96% of subjects 40–70 years old (Girish et al 2011).
It’s been awhile since I took a math class but if I’m not mistaken, if 96% of cases have an “abnormal finding”, maybe that should be categorized as NORMAL and not ABNORMAL?
This raises the question, if you’re in pain, and you get an MRI and it shows up with one of these things, does it change the course of your rehab? I would argue no… most of the time.
If MOST people are walking around with tears, calcifications, and arthritis in their shoulders and NO pain, what distinguishes them from people who have these things and DO have pain?
The problem is complex and other researchers have tried to figure out why this might be.
What causes pain?
Pain is complex and this is not a blog post going into the mechanisms of how pain happens. What we’re interested in finding out is what could be driving this pain? And should we train through it?
Researchers have some ideas about why pain happens, and its very complex and multifactorial. Take this web-plot below outlining all of the complex reasons why someone might have (low back, in this case) pain:
Cholewicki et al (2019)
The webbed-plot for shoulder pain probably doesn’t look much different that this. Your shoulder pain is likely driven by a combination of these types of things such as:
- Individual factors (a genetic predisposition for a deep glenoid fossa that predisposes you to more pinching of the rotator cuff in certain internally rotated positions, for example)
- Psychological factors (a practitioner who told you your ultrasound results look TERRIBLE which drove up your fear and set off a cascade of more pain and negative feelings, for example)
- Contextual factors (timely and appropriate referrals to the correct professionals, for example)
- Biomechanical factors (poor motor control of the muscles of the rotator cuff which stabilize the shoulder joint and prevent pinching, for example)
From this research study, they deduced that the more ways in which someone tackles their pain, the higher their likelihood of reduction in pain:
Cholewicki et al (2019)
So if presence of degradation isn’t predictive of pain, and pain is complex and multifactorial that you can address in more ways than 10, as an exercise physiology and strength and conditioning professional – how would I tackle shoulder pain you might be wondering? That’s coming up.
“Abnormal findings” are normal
We tend to think people with no pinch/pain versus pinch & pain looks like this:
When in reality, it looks more like this:
…because you might feel healthy… but have degeneration that’s normal and common!
This is why it’s so important to not get caught up in the fact that there is a pinch & pain, and to increase capacity in the tissues no matter the issue….because we know that increased capacity of the muscles, the bones, the ligaments and the tendons still results in better function long term than passive solutions, injections, or even surgery.
“When compared to more invasive treatment approaches, such as injection and surgery, exercise fares well…. There is no clinically important difference between exercise therapy and subacromial decompression surgery and rotator cuff repair surgery (Karjalainen et al 2019 & Lahdeoja et al 2020).”
Toolbox & Case Study
As most kinesiologists, strength and conditioning coaches, and exercise physiologists, the tools I have in my toolbox are: biomechanical factors (is the WAY you’re moving causing the problem?), strength factors (are there obvious asymmetries or deficits that could explain WHY one area is getting overloaded or underloaded?), and individual factors (are there things YOU are choosing to do with your body that could explain the problem?).
With a recent client, we did an assessment to find out just this, and found that there weren’t too many strength imbalances that could explain her shoulder pain, there weren’t obvious biomechanical problems with the WAY she was moving, but individual factors came to the forefront. In a front raise exercise, a lat pulldown, a dumbbell bench press, and other exercises, she would get a pinch in the shoulder with specific hand rotations. We found the positions that caused the least amount of pain, then trained through some pain, and increased the capacity of the muscles, tendons, and ligaments to help create a more robust system.
HERE’s an exercise we used with this client and how we might modify it for someone experiencing pain with the movement, just like we did with that client. Watch it til the end to get some of those specialized cues.
After a few months of training with us, this client was pain free in most or all shoulder movements and submitted this review:
So the answer to the header of this post, as we like to say: “Train with some pain”.
PLUS, THOSE WHO TRAIN WITH SOME PAIN HAVE BETTER OUTCOMES THAN THOSE WHO DON’T:
“A systematic review and meta‐analysis found that painful therapeutic exercise was not a barrier to experiencing a successful outcome with exercise therapy for a variety of musculoskeletal conditions (Smith et al., 2017). In fact, at short‐term follow‐up, exercising into pain was significantly better (Smith et al., 2017).”
Train with some pain…. But how much? Research says up to 5/10 on the scale below!
With our 12-week Shoulder Foundations program, you can start self-assessing these things too, for less than the cost of one appointment with us. We will help guide you through any modifications you might need from the regular program, and can offer advice on your rehab.! We encourage you to check it out.
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