Shoulder Pain
Shoulder Pain
Shoulder pain can come from many different structures, and the place that hurts does not always tell us what needs treatment.
The shoulder works as a coordinated system involving the glenohumeral joint, shoulder blade, clavicle, thorax, muscles, tendons and nervous system. A problem in any one of these areas can change how the arm moves and how the shoulder manages load.
At Montefiore Clinic in Tel Aviv, we assess the movement that is painful or limited, identify the structures that may be contributing, and then test whether changing those structures actually improves the patient's movement.
Evgeny Dizik, MPT, DO
Physiotherapist & Osteopath
60-minute, one-to-one assessment and treatment.
Shoulder Pain Is Not One Condition
A patient may describe pain when reaching overhead, putting on a jacket, sleeping on one side, lifting weight, reaching behind the back or using the arm repeatedly at work or in sport.
Another patient may have weakness without much pain. Someone else may have a shoulder that has gradually become stiff. Others arrive after a fall, dislocation or sudden injury.
These presentations may look similar at first, but they are not necessarily the same problem.
The first task is therefore to establish whether the symptoms are actually coming from the shoulder complex or whether they may be related to the neck, nervous system or another source.
Only then do we begin narrowing down what within the shoulder needs attention.
The Shoulder Is More Than One Joint
The shoulder does not function through the glenohumeral joint alone.
Normal arm movement depends on coordination between the glenohumeral joint, acromioclavicular and sternoclavicular joints, the scapula moving over the thorax, the thoracic spine and rib cage, and the muscles that stabilize and move all of these structures.
This is especially important during overhead movement.
If the shoulder blade is poorly controlled, the thorax does not extend adequately, a joint is restricted, or a muscle is not producing normal force, the shoulder may compensate elsewhere.
The goal is not to find every small asymmetry.
It is to find the parts of the system that actually change the patient's painful or limited movement.
What We Assess
Whenever possible, we begin with an asterisk, a movement or task that reproduces the patient's complaint.
It might be raising the arm, reaching behind the back, putting on a shirt, lying on the shoulder, lifting weight or performing a sporting movement.
That becomes our reference point.
The assessment may include:
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active and passive shoulder movement
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glenohumeral joint mobility
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AC and SC joint mechanics
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scapular control and stabilization
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thoracic and rib-cage mobility
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resisted muscle testing
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rotator-cuff function
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cervical and neurological screening
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upper-limb neurodynamic testing where appropriate
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previous trauma, surgery and scars
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instability or generalized hypermobility
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posture and shoulder mechanics under load
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other contributing factors suggested by the history
A finding is not considered important simply because it looks abnormal.
We may temporarily support, reposition, stabilize or mobilize a suspected structure and then repeat the patient's painful movement.
If the movement becomes easier, pain decreases or range improves, that structure becomes more clinically relevant.
If nothing changes, we reconsider the hypothesis.
We treat what changes the patient's problem, not simply what we are able to find on examination.
Active and Passive Movement Tell Us Different Things
The difference between active and passive movement can provide important information.
If the patient struggles to actively raise the arm but relatively normal movement is available when the arm is moved passively, we look more carefully at muscular function, motor control, neurological output and stabilization.
If both active and passive movement are restricted, we think more about structures that are themselves limiting the available range, such as the joint, capsule or other tissues being stretched or compressed at the end of movement.
Sometimes the shoulder is not the only limiting structure.
Neural tension, scar tissue, thoracic stiffness or poor rib-cage mechanics may also reduce the movement that appears available at the shoulder.
The examination is therefore not simply a measurement of how many degrees the arm can move.
It is an attempt to understand what is stopping that movement and whether changing it changes the patient's symptoms.
Painful Arc and “Impingement”
Many patients are told that they have shoulder impingement because the arm hurts through part of its elevation.
A painful arc is useful information, but it does not automatically tell us why the shoulder hurts.
The important question is what happens to the shoulder complex during that part of the movement.
We assess joint mechanics, muscle function, scapular control, thoracic movement and possible neurological contribution.
Sometimes temporarily supporting the scapula or another part of the shoulder changes the painful arc immediately.
Taping can also occasionally be used as a temporary support to help determine whether changing stabilization or load improves the movement.
This does not prove that one structure is the single cause of the pain.
It tells us that the way the shoulder is being supported or loaded may be relevant and deserves further investigation.
“Impingement” describes when the movement hurts. It does not necessarily explain why.
Rotator Cuff Pain and Tears
Rotator-cuff problems can range from pain and loss of function to tendinopathy, partial tearing or a full-thickness tear.
When symptoms develop gradually, we do not look only at the tendon.
We also assess the environment in which that tendon has been working: shoulder mechanics, muscular control, load, scapular stabilization, neurological function and general capacity.
Resisted testing helps us identify which muscle-tendon functions deserve closer attention.
If a resisted movement reproduces the patient's pain or shows selective weakness, that structure becomes relevant to investigate further.
But clinical testing cannot tell us with certainty whether a tendon contains a partial tear, full-thickness tear or other structural change.
When that distinction matters for treatment or prognosis, imaging may be appropriate.
And even when imaging shows a tear, the scan does not automatically determine the treatment.
Many structural abnormalities can exist without preventing useful shoulder function.
The important question is whether the patient can recover movement, strength and function with appropriate rehabilitation.
If they can, the structural finding may have relatively little importance to everyday function.
If meaningful disability persists despite well-directed rehabilitation, the diagnosis and the structural lesion both need to be reconsidered.
Shoulder Instability and Scapular Control
A shoulder can feel unstable for different reasons.
Sometimes the glenohumeral joint itself is genuinely unstable. In other patients, the joint may be structurally stable but poorly controlled because the muscular system and scapula are not providing adequate support.
These are different problems.
Specific tests help us assess true glenohumeral instability. We also examine the muscles responsible for positioning and stabilizing the scapula and shoulder.
If supporting the scapula immediately improves the patient's movement, the next question is not simply:
“How do we hold the scapula there?”
It is:
“Why are the muscles that should normally provide that control not doing it effectively?”
That may lead us toward muscular weakness, pain inhibition, neurological dysfunction, altered mechanics or another contributor.
Marked generalized hypermobility may also require a broader assessment rather than treating the shoulder as an isolated problem.
Frozen Shoulder
Frozen shoulder is different from an ordinary painful shoulder.
It often begins with increasing pain and guarding, followed by progressive restriction of both active and passive movement.
As the condition develops, a characteristic capsular restriction becomes more apparent, particularly loss of external rotation together with increasing restriction of elevation and internal rotation.
The stage matters.
In a very painful and irritable early shoulder, aggressively forcing movement is usually not helpful.
The first priority is to reduce irritability, maintain whatever useful movement remains, and avoid creating repeated painful flare-ups.
As the shoulder becomes less painful and stiffness becomes the dominant limitation, progressive mobilization, self-movement and exercise become more appropriate.
The patient may then gradually work into tolerated restriction without repeatedly provoking severe pain.
Frozen shoulder can take time to recover, and rehabilitation often needs to be approached as a longer process rather than an intensive sequence of painful treatments.
Regular reassessment allows us to make sure that movement is progressing and that the exercise program remains appropriate.
General health also matters. Conditions such as diabetes and thyroid disorders are associated with frozen shoulder and may require medical management alongside rehabilitation.
In frozen shoulder, more force is not necessarily more treatment. The painful stage and the stiff stage need different strategies.
Trauma and Structural Injury
Shoulder pain after trauma is approached differently.
A fall, dislocation, sudden traction injury, heavy lifting incident or sporting trauma may increase the possibility of fracture, significant tendon injury, labral damage or another structural lesion.
In the acute stage, we do not force the shoulder through painful movement simply to complete a standard examination.
The history and pattern of weakness help determine whether the problem appears to be pain-related inhibition or whether a particular structure may have been damaged.
If significant structural injury is suspected, imaging or orthopedic assessment may be needed before more aggressive rehabilitation.
Once serious injury has been excluded or appropriately managed, physiotherapy can help restore movement, muscular control, strength and function.
What About Bursitis or Calcification?
Ultrasound reports often describe findings such as subacromial bursitis or calcific tendinopathy.
These findings may be clinically relevant, but they do not automatically explain the entire shoulder problem.
An irritated bursa tells us that inflammation is present. Calcification tells us that there is a structural process occurring in a tendon.
The next question is still:
Why does this shoulder hurt during this particular movement, and what can we change to improve it?
We therefore assess the shoulder in the same way: movement, stabilization, joint mechanics, muscular function and load.
If the imaging finding matches the clinical presentation and changes management, it becomes more important.
If the patient improves substantially despite the finding remaining visible on imaging, its functional significance becomes much smaller.
What About Corticosteroid Injection?
An injection can sometimes be useful when pain or inflammation is so significant that the patient cannot progress with rehabilitation.
In that situation, reducing symptoms may create an opportunity to restore useful movement and begin appropriate exercise.
But injection is not a substitute for understanding why the shoulder became symptomatic.
If symptoms repeatedly return and repeated injections are required, the situation needs to be reassessed.
That may mean reconsidering the diagnosis, the loading strategy, the rehabilitation program or whether another medical or structural factor is present.
Other interventions, including shockwave treatment for selected calcific tendon problems, may also be considered when appropriate.
They are tools, not universal solutions.
Our Approach to Shoulder Pain
Treatment follows the examination.
Depending on the findings, this may involve joint or soft-tissue manual therapy, osteopathic treatment, work on the scapular and thoracic system, neurodynamic treatment, dry needling, taping, scar treatment, movement modification and progressive exercise.
The exact combination differs from patient to patient.
A shoulder with true instability should not be treated in exactly the same way as frozen shoulder.
A traumatically torn tendon should not be approached like an atraumatic painful arc.
A neurological problem should not receive the same treatment as a restricted joint.
And weakness should not automatically be answered with more strengthening before we understand why the muscle is weak.
The technique follows the finding.
Exercise: Restore Control Before Adding Load
Exercise is central to shoulder rehabilitation, but it has to be directed toward the actual problem.
That may mean restoring muscular activation, improving scapular control, increasing endurance, strengthening the rotator cuff, rebuilding stability or gradually restoring tolerance to overhead load.
The exercise is progressed according to response.
Some discomfort may be acceptable when it remains controlled, settles afterwards and the patient's function continues to improve.
Progressively increasing pain, worsening weakness, increasing neurological symptoms or persistent aggravation after exercise means the load or movement needs to be reconsidered.
Sometimes the correct answer is less load.
Sometimes it is a different angle.
Sometimes the movement needs better mechanical support.
And sometimes another problem must be addressed before meaningful strengthening can begin.
The aim is not simply to make the shoulder stronger.
It is to make it capable of performing the patient's real activities again.
What About Imaging?
Imaging is valuable when it can change treatment.
After trauma, when a major tendon tear, fracture or another important structural injury is suspected, imaging may be necessary early.
In gradually developing shoulder pain, imaging is not always required immediately.
Tendon abnormalities, partial tears, labral changes, AC-joint degeneration and other findings can also appear in people who have little or no shoulder pain.
For that reason, an ultrasound or MRI should be interpreted alongside the patient's history, examination and actual function.
The important question is:
“Does this finding explain what the patient cannot do, and does it change what we should do about it?”
We take the scan seriously. We just do not treat the scan instead of the patient.
When Further Medical Assessment May Be Needed
Some shoulder presentations need further investigation.
Significant trauma, suspected fracture or dislocation, sudden major loss of strength, signs of a substantial tendon rupture, progressive neurological symptoms, unexplained severe pain, systemic symptoms or a presentation that does not behave like a musculoskeletal condition may require imaging or medical referral.
Generalized instability may also require further investigation when the history suggests a possible systemic connective-tissue disorder.
And the response to treatment itself provides information.
If the patient is progressing as expected, the working hypothesis gains credibility.
If the patient repeatedly fails to improve, deteriorates or behaves differently from what the diagnosis predicts, we stop and reassess.
Sometimes that means changing the physiotherapy approach.
Sometimes it means referring the patient for further medical or orthopedic investigation.
Failure to progress is not a reason to repeat the same treatment indefinitely. It is a reason to reconsider the diagnosis.
When Is Treatment Finished?
The goal is not simply for the shoulder to feel less painful during a treatment session.
We want the patient to regain the activities that matter to them.
That may mean sleeping comfortably, dressing normally, reaching overhead, carrying a child, returning to work, swimming, weight training, playing tennis or performing another demanding activity.
Relevant movement, muscular function, stability and load tolerance should recover sufficiently for those activities.
The patient should also understand what exercises or habits will help maintain that function independently.
The treatment is tested against the patient's life, not only against the treatment table.
Treatment is finished when the patient has regained enough function, strength and resilience that they no longer need us to manage the shoulder for them.
About Your Practitioner
Evgeny Dizik, MPT, DO
Physiotherapist & Osteopath
At Montefiore Clinic, shoulder conditions are assessed through orthopedic and neurological examination together with physiotherapy, osteopathic manual treatment and individualized rehabilitation.
Sessions are 60 minutes, one-to-one, allowing enough time to identify the patient's meaningful movement problem, investigate possible contributors, treat what appears relevant and immediately reassess the response.
Not Sure Whether Your Shoulder Pain Fits?
If you're unsure if physical therapy or osteopathy is right for your shoulder condition, we're happy to discuss your specific symptoms and goals before you book.