What Causes Persistent Shoulder Pain?

What Causes Persistent Shoulder Pain?

If you are suffering from persistent shoulder pain, it is important to know that you are not alone. In fact, in those with persistent shoulder pain, research has shown that over half of sufferers (54%) have ongoing symptoms after 3 years (Vecchio et al 1995).

In those with a new episode of shoulder pain, 70% have not recovered by 6 months. Half of individuals show persistent shoulder pain for more than 6 months & 40% fail to recover at one year (Ottenheijm et al. 2011)

If your shoulder pain is characterised by stiffness or lack of movement then you would consider the following causes:

  • Frozen Shoulder
  • Arthritis
  • A-C (acromioclavicular) joint injury

If the shoulder has been sore for several weeks to a few months then you would consider:

  • A tendon injury
  • A rotator cuff tear

Weakness of the shoulder or arm can be caused by the following:

  • A muscle tear
  • A rotator cuff tendon rupture
  • A disc herniation in the neck
  • Calcific tendonitis. This is where a pocket of calcium is laid down randomly in a shoulder tendon

persistent shoulder pain blog Naas Physio Clinic

Why is my shoulder pain not going away? Could it be a Frozen Shoulder?

Frozen shoulder can give rise to persistent shoulder pain and is one of the more challenging presentations for a physiotherapist or chiropractor to manage. This condition is more common in women and in those who are suffering from diabetes or going through the menopause.

Frozen shoulder is characterised by thickening and the development of adhesions around the capsule that surrounds the shoulder joint.

The adhesions that develop within the capsule can cause a severe restriction of shoulder movement.


If you are suffering with a frozen shoulder you might notice some of the following:

  • Difficulty putting on jumpers or coats
  • Difficulty brushing your hair
  • Reaching into cupboards becomes challenging.

Recent research has shown that in the early stages of a frozen shoulder, new blood vessel growth is evident on the involved side. This may occur as an attempt to initiate healing, or, can occur in response to lack of adequate blood supply to the tissue. Those suffering with diabetes, for example, have significant alterations in circulation. This may explain part of the link between conditions like diabetes, metabolic syndrome, and hypothyroidism and the presence of frozen shoulder.

Recent research has pointed to a link between chronic low grade inflammation and the presence of a frozen shoulder. Inflammatory cells have been demonstrated to be present in the early stages. One paper suggested that frozen shoulder may be an age related symptoms of metabolic syndrome and chronic low-grade inflammation (Pietrzak 2016). Indeed, the research is delving further into the link between systemic (body-wide) health state and the presence of such conditions.

If you are suffering with a frozen shoulder you are likely to report the following history:

  • A slow onset over several weeks
  • Difficulty lifting your arm up overhead to the front or lifting up towards your ear from the side
  • Trouble sleeping on the painful side

A Frozen Shoulder has 3 Stages:

1) Stage 1 is the “freezing” stage. This stage is characterised by progressive shoulder pain
2) Stage 2 is the “Frozen” stage. This is characterised by a progressive stiffness of the shoulder. You may notice a significant limitation in lifting your arm overhead or behind your back
3) Stage 3 is the” thawing” phase. This is where the contraction of the shoulder capsule begins to ease and movement gradually increases.

Now here’s the bad news: the average duration of each of these 3 stages is 30 months. The range of time for each stage varies from between 12 to 24 months. Don’t panic just yet though: with appropriate treatment you can make significant inroads into this timescale.


What is the Best Treatment for a Frozen Shoulder?

A recent review of the literature analysed the impact of various techniques and determined which ones have been shown to be effective in treating shoulder pain.

They reported that joint mobilisation, when combined with intermittent stretching, proved more effective than either intervention when applied individually (Celik ad Kaya Mutlu).

Another option, supported by the literature, is the application of passive progressive stretching to increase shoulder range of motion. This led to improvement in movement and pain at 12 month follow-up.

Certain techniques demonstrated significant improvements in terms of pain. These included Mulligan joint mobilisation techniques, continuous passive motion, lidocaine injections and rotator cuff strengthening.


Why is my shoulder pain not going away? Could it be the Rotator Cuff Impingement?

A recent consensus paper published in the Journal of Physiotherapy Practice and Research provided guidelines on the diagnosis and rehabilitation of Shoulder Cuff Injuries.

The term ‘shoulder impingement’ is one that I commonly hear in practice. The old theory was that rotator cuff tendons could become impinged by the overlying bone (the acromion) of the shoulder, thus causing pain. You can feel this bone yourself by tapping down on the the most lateral point of the shoulder.

Should I have a Scan for my Shoulder Pain?

Scans would often demonstrate degeneration and give the impression of compressing the underlying tendon. The supposed logical conclusion was that the bone was pressing on the tendon below and, therefore, removing some of this bony pressure would alleviate symptoms. Well, as I always say to my patients:

“be careful of reading too much into MRI scan or x-ray results”


Repeated studies have refuted the theory that performing a decompression surgery has a positive impact on cuff tendon pain. A decompression surgery is where part of the bone over the tendons is shaved or removed to ease pressure on the tendon.

Indeed, the consensus guidelines of the expert group suggested that the term “impingement” should no longer be used as impingement of the structures of the shoulder has not been proven to correlate with pain.

I often see people from 50 to 70 years of age who have been diagnosed with a rotator cuff tear based on an MRI scan. The question is: how significant is this finding and is it definitely the source of their shoulder pain?


I hate to repeat myself but be very wary of the relevance of MRI findings.

The problem with having certainty that the tear found on your MRI scan is the source of your pain is that a significant proportion of people without any shoulder pain whatsoever will demonstrate cuff tears if they have an MRI of the shoulder. In fact, research demonstrates that:

  • Up to 50% of people over 50 demonstrate tears in the rotator cuff
  • 70% of 70 year old’s have tears of the rotator cuff muscle or tendon but not necessarily in the presence of pain

Rotator cuff tears are, however, rare in those under 35 years of age and tears in this group are usually trauma related.


How can I tell if my shoulder pain is from a rotator cuff tear?

  • The pain is normally located at the outside of the shoulder at the top of the arm
  • Movement of other body parts, such as the neck, should not reproduce your pain
  • When the therapist assists you in moving the arm it should go to full range of motion without any blockage


What can I do for constant shoulder pain induced by a cuff injury?

  • Generally, MRI or x-ray should be avoided due to poor correlation between imaging findings and a patient’s pain. Only if you are suffering with considerable shoulder stiffness or chronic pain of several month’s duration should you consider a scan.
  • The expert group do not recommend steroid injections unless the pain fails to improve after an acceptable period of physiotherapy led rehabilitation (e.g. 6 to 12 weeks)
  • Likewise, seeking an orthopaedic consultation should only be considered after a similar period of physiotherapy rehabilitation
  • Lifestyle factors such as sleep quality, nutrition, alcohol and smoking should be assessed as such factors can impact on cellular function and can act as a driver of shoulder pain.


Oag et al. 2012. Chingford Cohort Study

The value of MRI scans are being brought into questions with greater frequency in recent years. Such scans have been shown to demonstrate structural changes which may be reflective of the natural ageing process as opposed to being the cause of pain or restricted movement

persistent shoulder pain blog Naas Physio Clinic

As shown in the table above, findings of cuff tears are present in high numbers in individuals who do not suffer from shoulder pain.


RELATIONSHIP OF ROTATOR CUFF TEARS, SHOULDER PAIN AND FUNCTIONAL LOSS IN A NORMAL POPULATION. Oag Hannah, Daines Michael, Nichols Alexander, Kiran Amit, Arden Nigel, and Carr AndrewOrthopaedic Proceedings 2012 94-B:SUPP_XXXVII, 420-420. https://online.boneandjoint.org.uk/action/showCitFormats?doi=10.1302%2F1358-992X.94BSUPP_XXXVII.EFORT2011-420
Ottenheijm, R.P., Joore, M.A., Walenkamp, G.H. et al. The Maastricht Ultrasound Shoulder pain trial (MUST): Ultrasound imaging as a diagnostic triage tool to improve management of patients with non-chronic shoulder pain in primary care. BMC Musculoskelet Disord 12, 154 (2011). https://doi.org/10.1186/1471-2474-12-154. https://link.springer.com/article/10.1186/1471-2474-12-154#citeas

To read more about shoulder pain visit our webpage on shoulder pain at: https://www.physioclinic.ie/conditions/shoulder-pain/


What is the best treatment for achilles tendon pain?

What Causes Achilles Tendon Pain?

Achilles tendon pain is common in runners and those who have recently increased their exercise duration or frequency. The pain of an achilles tendon injury often appears at the start of a run and then eases out as the running  (or walking) progresses. For this reason, people often assume that continuing to run is harmless, or even helpful in alleviating the pain. Unfortunately, continuing to train through the pain frequently gives rise to more severe and intractable pain. The longer the pain is present then the longer it takes to heal.

What is the best treatment for achilles tendon pain?

Does Running Technique Impact on Achilles Tendon Pain?

A biomechanical and running assessment is a vital component of assessing an achilles injury. There are two types of foot strike that are generally discussed in the literature: these are a forefoot and a rearfoot strike. A forefoot strike is where the runner lands on the ball of the foot with the heel off the ground. A rearfoot striker hits with the heel and then pushes off through the forefoot

How does Foot Strike Impact Achilles Loading?

A toe or forefoot strike, for example, is associated with higher loading of the achilles tendon. Excessive loading of the achilles tendon is the main stimulus for injury and therefore modifying the loading through modification of the overall training load is vital to recovery. A cycle of tendon overload, followed by inadequate repair and degenerative changes forms the basis for the condition. Recovery from injury will prove challenging unless the running technique element is addressed fully.

A heel strike tend to transmit greater loads through the knee and has been linked to runner’s knee. Most recreational runners have been shown to be heel strikers. A forefoot stike creates greater forces on the achilles and calf and can predispose to achilles overload and pain.

The evidence for foot pronation as a cause of achilles tednon pain is weak, although patients consistently mention this as their perceived potential cause of their pain.

Other running technique factors such as overstriding has been linked to heel and knee pain. This is where the runner, in an attempt to take a long stride, stikes the ground with their heel and transfers significant ground reaction forces up through the leg.

Some simple tips for improving running technique include:

  • Increasing your step rate (research on Olympic athletes suggest that a step rate of 180 per minute was optimal for reducing impact forces)
  • Decreasing stride length
  • Striking the ground with the foot directly under your hip

What is the best treatment for achilles tendon pain blog

Walking Re-Education in Achilles Tendonitis Management

Any negative thoughts regarding pain can give rise to limping. This may be rationalised as “taking pressure off my heel”. Continuing with this movement pattern can give rise to wasting of the muscles and tendon and can prevent recovery if the person does not relearn how to walk properly again.

In terms of running technique, if you have been largely injury free then you are best to maintain your current foot strike pattern. Messing with your running technique can give rise to unnecessary injury. If you really feel the need to change your technique then it should be done on a very gradual basis.

Research on Exercise Rehabilitation for Achilles Tendinitis

There has been a lot of talk about eccentric resistance training for managing achilles tendon injury. Eccentrics involve slowly lowering the heel from a raised position to create tension on the achilles tendon.

A recent randomised controlled trial compared the effectiveness of 12 weeks of eccentric training (ECC) and heavy slow resistance training (HSR) among 58 patients with Achilles tendinopathy of greater than 3 months.

The authors concluded that both eccentric and regular resistance training were equally effective in the management of achilles tendinopathy

How effective is Acupuncture for Achilles Tendinopathy?

Recent research published in the journal Physiotherapy Practice and Research examined the effect of acupuncture in treating achilles pain in  twenty-two patients. The participants were randomised to receive either acupuncture or the control sham acupuncture treatment

The authors concluded that an acupuncture protocol could be used as a second line treatment alongside a physiotherapy guided exercise rehabilitation programme.

This corroborates the findings of Zhang et al. (2012) who reported significant functional improvement and decreases in pain in individuals undergoing acupuncture


Zhang BM, Zhong LW, Xu SW, Jiang HR, Shen J. Acupuncture for chronic Achilles tendnopathy: a randomized controlled study. Chin J Integr Med. 2013;19(12):900-904. doi:10.1007/s11655-012-1218-4. https://pubmed.ncbi.nlm.nih.gov/23263998/

Kishmishian, Berj, Richards, Jim, and Selfe, James. ‘A Randomised Feasibility Study Using an Acupuncture Protocol to the Achilles Tendon in Achilles Tendinopathy’. 1 Jan. 2019 : 59 – 67.

For further information on achilles tendon pain visit our achilles page at: https://www.physioclinic.ie/conditions/achilles-tendon-injury/

Should I worry about “abnormalities” found on my MRI scan?

Should I have an MRI scan to help diagnose my lower back pain?

In the majority of cases of low back pain, MRI scans, and especially x-rays, are not helpful in treating low back pain. Most people are under the false impression that an MRI scan will identify the cause of their pain. The general comment that I hear from patients is: “if I can just get a scan done then I can figure out what is wrong and get it fixed.” However, in reality, a scan shows a lot of structures with varying degrees of abnormalities that are present both in those with and without back pain. This is the reason that medical guidelines are very consistent in stating that imaging for low back pain does not improve one’s pain, function, or quality of life.

About 55 percent of individuals with no back pain will have a disc bulge when an MRI of their back is performed.

Do I need an MRI to diagnose a disc bulge in my low back?

Many people believe that once they have been diagnosed with a disc bulge they need an MRI to confirm it and to assess the extent of the damage. The issue with this is that once a diagnosis of a disc bulge has been made clinically then an MRI scan will not change the diagnosis or physiotherapy management of that condition. I will often get calls from patients saying that they are holding off physiotherapy treatment until they have the results of their MRI; however, the scan generally has no influence on the treatment provided for their lower back pain. Patients are often not very receptive when it comes to being persuaded of the lack of utility of MRI scans in the management of their back pain. This is where a GP, physiotherapist, or chiropractor can agree to refer for a scan even though they know it is unlikely to be of any real benefit.


Science becoming more aware of risks of MRI scans

Healthcare practitioners such as physiotherapists and chiropractors are becoming more aware of the limitations of scans in aiding back pain recovery. However, convincing a client that they do not need a scan can prove challenging. I know from having injuries myself that you are naturally curious and there is a part of you that wants to see the area and identify ‘what is wrong’, even if the research suggests it is not beneficial. Despite medical advice to limit such imaging, research published in the British Journal of Sports Medicine in 2019 shows that MRI’s and other scans for lower back pain have increase by 53.5 percent between 1995 and 2015.

Worryingly, more recent findings in the literature have identified negative effects of having back scans. Research shows that those who undergo MRI scans can actually end up with more back pain. This is because after the MRI is performed a report of the findings will be written up by a radiographer. The report will often contain findings of areas where there is bony growth or discs bulging to varying degrees. The problem is that because such findings are present for most people and can therefore be deemed normal. However, the fact that they have been written onto a medical report suggests to the patient and physician that they are abnormal and therefore are a serious issue that should be a cause for concern. This is why MRIs can frequently lead to unnecessary surgeries and can fail to alleviate symptoms as they may not target the source of the symptoms.

If considering a spinal x-ray, it is important to be mindful of the radiation exposure from such imaging. X-rays are recognised as causing cancer in humans. The average radiation from a spinal x-ray is 75 times greater than that of a chest x-ray.

Are my MRI findings really abnormal?

Unlike other medical reports which primarily focus on abnormal findings, MRI scans can report deviations from the ideal spine that can be deemed normal. The MRI report refers to deviations relative to the ideal spine of a young person with perfect spinal curves. The problem here is obvious: most people going for MRI scans are not in this age bracket and therefore the supposedly “abnormal” findings are in fact normal for that age group. This fact is key in understanding the confusion that arises when interpreting the results from MRI scans. After the introduction of MRI and CT scans in the 1970s, medics began using the scans to make a diagnosis as opposed to using them to confirm or refute an uncertain diagnosis.

Questions to ask when you have a back scan:

The main questions you should ask your physiotherapist or chiropractor is this:

  • Can the finding on my MRI report explain all of my symptoms?
  • If the findings from the MRI report are the sole cause of my symptoms then why do my symptoms fluctuate?
  • Those with a previous diagnosis of a disc bulge should ask their physiotherapist why their symptoms disappeared or improved before returning again. Given that a disc bulge as viewed on an MRI does not tend to change position when someone is suffering from a flare in before and after the onset or eradication of symptoms

The linking of symptoms to findings on MRI scans are often illogical

These elements are difficult to explain based on MRI findings alone. These “abnormalities” reported on scans can create serious concern for patients. Things such as bulging discs have seriously negative connotations for patients and can create a degree of panic, even though these things may not be the cause of their symptoms at all.  This diagnosis can lead to fear avoidance of activity  and exercise which can create more back pain in the medium to long-term.

In most cases, the identification of a serious disc injury or other spinal conditions of concern is more accurately performed by a clinical assessment carried out by a Physiotherapist or Chiropractor who specialises in back pain. They can identify quite readily those relatively rare cases where patients  actually do require onward referral for an MRI scan.

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