Shoulder Pain

Understanding Shoulder Pain: Rotator Cuff, Impingement, Labral Tears, and Bursitis

Your shoulder is a remarkable structure—the most mobile joint in your entire body, capable of an extraordinary range of motion that allows you to reach, lift, throw, and perform countless daily activities. This incredible mobility, however, comes at a cost: your shoulder is also the most unstable joint in your body, making it vulnerable to a variety of painful conditions.

The Complexity of the Shoulder Joint

Unlike the hip joint, which is deeply seated in a stable socket, your shoulder sacrifices stability for mobility. Understanding this anatomy helps explain why shoulder problems are so common and why proper diagnosis and treatment are essential.

Shoulder Anatomy: A Brief Lesson

Your shoulder is actually a complex of several joints working together:

The Glenohumeral Joint: The main “ball and socket” joint where the head of your upper arm bone (humerus) sits in a shallow socket (glenoid) of your shoulder blade (scapula). This shallow socket allows tremendous range of motion but provides minimal bony stability.

The Labrum: A ring of fibrocartilage attached to the rim of the glenoid socket that:

• Deepens the socket by about 50%
• Provides crucial stability to the shallow joint
• Serves as an attachment point for ligaments and the biceps tendon
• Acts as a seal to help maintain negative pressure in the joint
• When torn, can cause significant pain, clicking, catching, and instability

The Rotator Cuff: Four primary muscles and their tendons that surround the shoulder joint like a cuff:

• Supraspinatus: Initiates arm elevation and is the most commonly injured
• Infraspinatus: External rotation of the arm
• Teres minor: External rotation and stabilization
• Subscapularis: Internal rotation

These muscles work together to stabilize the ball in the socket during movement and control shoulder motion.

The Bursa: Your shoulder contains several fluid-filled sacs called bursae (plural of bursa), with the subacromial bursa being the most commonly problematic:

• Sits between the rotator cuff tendons and the bone above (acromion)
• Cushions and reduces friction during movement
• When inflamed (bursitis), it swells and causes pain
• Often involved in impingement syndrome

Supporting Structures:

• Ligaments: Connect bones and provide passive stability
• Scapula (shoulder blade): Provides the foundation for shoulder movement
• Clavicle (collarbone): Connects the shoulder to the trunk

This intricate system must work in perfect coordination. When any component becomes dysfunctional, pain and limitation can result.

Why Shoulder Mobility Matters

Your shoulder’s extensive range of motion is what makes you human in many ways. It allows you to:

• Reach overhead to retrieve objects
• Throw with precision and power
• Perform personal care activities
• Work at various heights and angles
• Embrace loved ones
• Participate in sports and recreational activities

This mobility is possible because of the shoulder’s unique design—but this same design makes it prone to injury and degenerative changes.

The Reality About Rotator Cuff Tears

Here’s an important fact that surprises many patients: most people over 50 have some degree of rotator cuff tearing, and the majority of these tears cause no symptoms whatsoever.

Research using MRI has shown that:

• Rotator cuff tears are present in approximately 25% of people in their 60s
• This percentage increases to 50% or more in people over 70
• Many of these tears are completely asymptomatic—people live normal, active lives without knowing the tears exist
• The presence of a tear on imaging doesn’t predict pain or disability

So when does a rotator cuff tear become a problem?

A tear becomes symptomatic when:

• Inflammation develops around the tear
• Compensation patterns fail
• The tear progresses or involves critical portions of the tendon
• Biomechanical changes create abnormal stress
• Other shoulder structures (like the bursa) become involved

This is why we don’t treat MRI findings—we treat patients. Just because imaging shows a tear doesn’t mean surgery is necessary or that you can’t improve with conservative care.

When to Seek Evaluation: Symptomatic Shoulder Pain

While asymptomatic rotator cuff changes are common and normal with aging, you should seek evaluation when shoulder pain becomes symptomatic:

Signs your shoulder problem needs professional assessment:

• Pain interfering with daily activities (dressing, reaching, lifting)
• Difficulty sleeping due to shoulder discomfort
• Weakness when lifting or reaching
• Progressive loss of range of motion
• Pain that doesn’t improve with rest or basic self-care within a few days
• Inability to perform work duties
• Pain that radiates down the arm
• Catching, clicking, popping, or locking sensations
• Instability or feeling that the shoulder may “give out” or “slip”
• Deep, aching pain inside the joint

Early evaluation when symptoms develop is crucial for preventing progression and maintaining function.

Common Shoulder Conditions

Rotator Cuff Tendinopathy and Tears

Tendinopathy refers to degeneration and irritation of the rotator cuff tendons without a full tear. This causes:

• Pain with overhead activities
• Weakness, especially with lifting away from the body
• Night pain, particularly when lying on the affected shoulder
• Difficulty reaching behind your back
• Gradual onset (usually, though acute tears can occur with injury)

Partial or full-thickness tears involve actual disruption of tendon fibers. Symptoms are similar but may include:

• More significant weakness
• Inability to lift the arm in certain directions
• Sometimes a popping sound at the time of acute injury
• Progressive difficulty with previously manageable tasks

Shoulder Impingement Syndrome

Impingement occurs when the rotator cuff tendons and bursa get pinched between the bones of your shoulder during movement. This commonly happens because:

• The space between bones narrows (due to bone spurs, inflammation, or poor mechanics)
• The bursa becomes swollen and inflamed
• The rotator cuff tendons thicken from chronic irritation
• Poor shoulder blade mechanics alter the available space
• Postural abnormalities reduce clearance during movement

Symptoms of impingement include:

• Pain with overhead reaching or lifting
• A “painful arc” of motion (pain at specific points when raising your arm, typically between 60-120 degrees)
• Swelling and tenderness in the front or side of the shoulder
• Weakness from pain inhibition
• Pain that worsens with repetitive overhead activities
• Sometimes pain radiating down the upper arm
• Difficulty sleeping on the affected side

Impingement and rotator cuff problems often coexist—chronic impingement can lead to tendon damage, and rotator cuff weakness can cause impingement. Bursitis is frequently part of the impingement syndrome picture.

Bursitis

Subacromial bursitis is inflammation of the bursa that sits between your rotator cuff and the bone above. This condition:

Causes:

• Often develops from repetitive overhead activities
• Can result from direct trauma or fall onto the shoulder
• Frequently occurs alongside impingement syndrome
• May develop from altered shoulder mechanics
• Sometimes caused by calcium deposits irritating the bursa

Symptoms:

• Sharp pain with overhead movements
• Tenderness on the outside of the upper shoulder
• Pain that may feel like it’s “on top” of the shoulder
• Difficulty lying on the affected shoulder at night
• Swelling (sometimes visible, sometimes not)
• Pain with reaching across the body
• Warmth in the area (in acute cases)

What makes bursitis unique: The bursa can swell significantly, taking up valuable space in an already crowded area. This swelling perpetuates impingement and creates a cycle of inflammation and pain.

Labral Tears

The labrum is critical for shoulder stability, and when torn, it can cause distinctive symptoms. Labral tears come in different types:

SLAP Tears (Superior Labrum Anterior to Posterior):

• Occur at the top of the labrum where the biceps tendon attaches
• Common in overhead athletes or from repetitive overhead activities
• Can also result from falling on an outstretched arm or lifting heavy objects

Bankart Lesions:

• Tears of the front (anterior) or back (posterior) labrum
• Often associated with shoulder dislocations or instability
• More common in younger, active individuals

Symptoms of labral tears:

• Deep, aching pain inside the shoulder joint
• Catching, clicking, popping, or grinding sensations with movement
• Feeling of instability or that the shoulder may “give out”
• Pain with specific movements (particularly overhead activities or lifting)
• Decreased range of motion
• Weakness or difficulty with certain positions
• Pain that’s difficult to pinpoint—often described as “deep inside”
• Sometimes pain radiating down the arm
• Night pain, especially when rolling onto the shoulder

What makes labral tears challenging:

• Symptoms can be similar to rotator cuff problems
• May not always show clearly on standard MRI (sometimes requires MRI arthrogram)
• Can coexist with other shoulder problems
• Some small labral tears may be asymptomatic
• Require specific clinical tests to identify

How These Conditions Relate

Often, shoulder problems don’t exist in isolation:

• Impingement and bursitis frequently occur together—the inflamed bursa takes up space, worsening impingement
• Chronic impingement can lead to rotator cuff tears over time
• Rotator cuff weakness (whether from tear or pain inhibition) can cause poor mechanics leading to impingement and bursitis
• Labral tears can create instability that overworks the rotator cuff
• Multiple conditions often coexist, requiring comprehensive treatment

This complexity is why accurate diagnosis through thorough examination is essential.

The Shoulder-Spine Connection

Here’s something many people don’t realize: your shoulder and spine work together as an integrated system.

Research has demonstrated that postural abnormalities and spinal dysfunction significantly influence shoulder pain. Specifically:

• Forward head and rounded shoulder posture alters shoulder blade position
• This altered position changes the mechanics of the rotator cuff and reduces the space available for tendons and bursa
• Thoracic spine (mid-back) stiffness restricts normal shoulder blade motion
• Neck problems can refer pain to the shoulder
• Poor spinal posture increases the risk of shoulder impingement and bursitis

This is why comprehensive shoulder evaluation must include assessment of your neck, upper back, and posture—not just the painful shoulder itself.

Our Comprehensive Diagnostic Approach

When you visit our office with shoulder pain, we conduct a thorough evaluation to understand exactly what’s causing your symptoms and why:

Detailed History

1. Symptom onset and pattern: Understanding how and when pain began—sudden injury or gradual onset
2. Pain characteristics: Deep vs. superficial, sharp vs. aching, constant vs. intermittent
3. Mechanical symptoms: Any clicking, catching, popping, or feelings of instability
4. Functional limitations: What specific activities are affected
5. Previous injuries: Past shoulder dislocations, falls, or neck problems
6. Work and recreational demands: Activities that stress the shoulder (especially overhead work or throwing)
7. Sleep positions and night pain: Often reveals important clues about the condition

Physical Examination

1. Postural Assessment: Evaluating head, neck, shoulder blade position, and thoracic spine alignment
2. Cervical and Thoracic Spine Evaluation: Checking for referred pain or mechanical restrictions affecting shoulder function
3. Shoulder Range of Motion: Active and passive movement in all directions, noting painful arcs
4. Strength Testing: Assessing each rotator cuff muscle individually to identify specific weakness patterns
5. Special Orthopedic Tests:
   • Impingement tests (Neer’s, Hawkins-Kennedy)
   • Rotator cuff specific tests (empty can, drop arm, external rotation tests)
   • Labral tests (O’Brien’s, Crank test, anterior and posterior apprehension tests)
   • Instability testing
   • Biceps tendon tests
6. Shoulder Blade (Scapular) Assessment: Observing scapular movement patterns and control
7. Palpation: Examining for tenderness over the bursa, rotator cuff insertions, biceps tendon, and AC joint; identifying muscle imbalances and trigger points
8. Neurological Screening: Ensuring nerve function is intact and ruling out cervical radiculopathy

Advanced Evaluation When Indicated

Based on examination findings, we may recommend:

• Imaging studies:
  • X-rays to evaluate bone structure, arthritis, and calcium deposits
  • Referral for MRI to visualize rotator cuff, labrum, and bursa
  • MRI arthrogram if labral tear is suspected (dye injected into joint provides better labral visualization)
  • Ultrasound for dynamic assessment of rotator cuff and bursa
• Specialist consultation: Referral to orthopedic surgery if surgical intervention may be necessary, particularly for:
  • Significant labral tears in younger, active patients
  • Complete rotator cuff tears with substantial weakness
  • Recurrent shoulder dislocations
  • Mechanical symptoms suggesting loose bodies or significant structural damage

Important reminder: Even if imaging shows rotator cuff tears, labral changes, or bursitis, this doesn’t automatically mean surgery is needed. Many people with these findings visible on MRI respond excellently to conservative care.

Our Evidence-Based Treatment Approach

Research, including a 2019 study in the Journal of Chiropractic Medicine, demonstrates that spinal manipulation provides immediate benefits for shoulder range of motion and pain relief. This supports our integrated approach addressing both the shoulder and spine.

Your personalized treatment plan may include:

Manual Therapies

• Spinal manipulation: Addressing thoracic and cervical spine restrictions that affect shoulder mechanics
• Joint mobilization of the shoulder: Restoring proper movement in the glenohumeral joint, shoulder blade, and AC joint
• Instrument-assisted soft tissue mobilization: Breaking down scar tissue and adhesions in rotator cuff muscles and reducing bursal inflammation
• Myofascial therapy: Releasing tension in shoulder, neck, and upper back muscles
• Trigger point release: Addressing painful muscle knots that refer pain to the shoulder

Advanced Technologies

• Shockwave therapy:
  • Stimulating healing in degenerative rotator cuff tendons
  • Breaking down calcium deposits that irritate the bursa
  • Reducing chronic bursal inflammation
  • Promoting tissue regeneration in labral and tendon injuries
• Laser therapy:
  • Reducing acute and chronic inflammation in tendons and bursa
  • Accelerating healing in damaged tissues
  • Decreasing pain and swelling
• Cupping therapy: Improving blood flow, reducing muscle tension, and decreasing bursal swelling

Movement-Based Rehabilitation

This is crucial for shoulder recovery:

For Rotator Cuff and Impingement/Bursitis:

• Rotator cuff strengthening: Progressive exercises to rebuild tendon strength and endurance
• Scapular stabilization: Training the muscles that control shoulder blade position and movement
• Postural correction exercises: Addressing rounded shoulders and forward head posture to create more space
• Range of motion exercises: Restoring full, pain-free movement
• Proprioceptive training: Improving shoulder stability and control

For Labral Tears:

• Dynamic stabilization exercises: Training muscles to compensate for labral compromise
• Closed-chain exercises: Building stability through weight-bearing positions
• Neuromuscular control training: Improving coordination and joint position sense
• Progressive loading: Carefully advancing exercises based on symptoms

For All Conditions:

• Functional training: Practicing movements required for your work or sport
• Activity-specific rehabilitation: Tailoring exercises to your goals (throwing, lifting, reaching)

Education and Lifestyle Modification

• Ergonomic adjustments: Optimizing workspace to reduce shoulder strain and impingement positions
• Activity modification: Temporarily adjusting overhead activities while healing
• Sleep position guidance: Reducing night pain from bursitis or rotator cuff compression
• Movement pattern retraining: Teaching proper lifting, reaching, and throwing techniques
• Load management: Balancing activity and rest to allow tissue healing

Treatment Approach by Condition

For Impingement and Bursitis

Focus on:

• Creating space through postural correction and scapular training
• Reducing bursal inflammation with laser therapy and activity modification
• Strengthening rotator cuff to improve mechanics
• Addressing thoracic spine stiffness

For Rotator Cuff Problems

Focus on:

• Progressive tendon loading to stimulate healing
• Addressing mechanical factors causing repetitive stress
• Improving scapular control to optimize rotator cuff function
• Shockwave therapy for chronic tendinopathy

For Labral Tears

Approach depends on severity:

• Conservative management for small tears or degenerative changes:
  • Dynamic stabilization to compensate for labral compromise
  • Strengthening surrounding structures
  • Activity modification
  • Monitoring for progression
• Surgical referral may be needed for:
  • Large tears causing mechanical symptoms (catching, locking)
  • Significant instability in younger, active patients
  • Tears not responding to appropriate conservative care
  • SLAP tears in overhead athletes (case-dependent)

Why Movement Matters for Shoulder Recovery

As with other musculoskeletal conditions, controlled movement is essential for shoulder healing. The rotator cuff tendons, bursa, and even the labrum respond positively to appropriate loading and negatively to complete rest.

Benefits of appropriate movement:

• Stimulates tendon healing and remodeling
• Reduces bursal swelling through fluid exchange
• Maintains range of motion
• Prevents frozen shoulder development
• Preserves muscle strength
• Improves blood flow to healing tissues
• Builds confidence in shoulder function
• Promotes neuromuscular control around labral injuries

Risks of avoiding movement:

• Rapid loss of range of motion (can develop into frozen shoulder within weeks)
• Muscle atrophy and weakness
• Increased stiffness
• Fear of movement
• Prolonged disability
• Poorer long-term outcomes
• Chronic bursal thickening

The key is doing the right movements at the right intensity—something we guide you through based on your specific condition.

When Surgery May Be Necessary

While most rotator cuff problems, impingement syndrome, and bursitis respond well to conservative care, some situations may require surgical consultation:

For Rotator Cuff:

• Complete tears with significant weakness that doesn’t improve
• Tears involving multiple tendons
• Acute traumatic tears in younger, active individuals
• Progressive weakness despite appropriate rehabilitation

For Bursitis/Impingement:

• Persistent symptoms after 6 months of appropriate conservative care
• Structural bone spurs causing mechanical impingement
• Chronic bursitis not responding to conservative treatment

For Labral Tears:

• Large tears causing mechanical symptoms (catching, locking)
• Recurrent shoulder dislocations
• Significant SLAP tears in overhead athletes
• Tears with instability in younger, active patients
• Symptoms not improving with 3-6 months of appropriate rehabilitation

Even when surgery is necessary, pre-surgical rehabilitation improves outcomes, and post-surgical physical therapy is essential for recovery.

The Importance of Early Intervention

When shoulder pain becomes symptomatic, early evaluation and treatment offer significant advantages:

• Prevents progression of rotator cuff and labral damage
• Reduces acute bursal inflammation before it becomes chronic
• Maintains range of motion
• Addresses compensatory patterns before they become ingrained
• Prevents development of frozen shoulder
• Identifies and corrects contributing postural and spinal factors
• Often avoids the need for surgery
• Faster return to normal activities

Waiting and hoping shoulder pain resolves on its own frequently leads to:

• Worsening of rotator cuff damage
• Chronic, thickened bursa that’s harder to treat
• Development of stiffness and adhesive capsulitis (frozen shoulder)
• Chronic pain patterns
• Secondary problems in the neck and upper back
• Prolonged disability
• Increased likelihood of surgical intervention
• Labral tears becoming more complex

Your Path to Shoulder Recovery

If you’re experiencing shoulder pain that’s interfering with your daily activities, sleep, or quality of life, don’t delay evaluation. Schedule a comprehensive assessment so we can:

1. Identify the specific structures causing your pain: Rotator cuff, bursa, labrum, or referred from the spine
2. Determine the underlying cause: Impingement mechanics, degenerative changes, acute injury, labral tear, bursitis, or postural factors
3. Differentiate between conditions: Distinguishing rotator cuff tears from labral tears from bursitis—each requiring tailored treatment
4. Assess the shoulder-spine connection: Evaluate how your posture and spinal function affect shoulder mechanics
5. Create a targeted treatment plan: Addressing both the shoulder and contributing factors
6. Guide you through appropriate movement: Distinguishing helpful from harmful activities for your specific condition
7. Monitor your progress: Adjusting treatment based on your response
8. Coordinate with specialists if needed: Referring for advanced imaging or surgical consultation when appropriate

Remember:

• The presence of rotator cuff changes on imaging doesn’t define your outcome
• Bursitis, while painful, typically responds very well to conservative care
• Many labral tears, especially degenerative ones, can be managed without surgery
• Early intervention prevents simple problems from becoming complex

Your shoulder’s remarkable mobility is what allows you to live an active, independent life. Don’t let shoulder pain take that away. With proper diagnosis distinguishing between rotator cuff problems, impingement, bursitis, and labral tears, plus targeted treatment addressing the entire shoulder complex and spine, and appropriate movement-based rehabilitation, most people can overcome shoulder pain and return to the activities they love.

Take action when shoulder pain becomes symptomatic—early intervention gives you the best chance for complete recovery without surgery.