Shoulder pain

By Peter Poon, PT


Have you ever experienced jabbing pain in the front of shoulder when reaching up, out or across your body?  Interestingly, between 7%-34% of adults have shoulder pain at some point in their lives and the level of discomfort can range from annoying to debilitating (Diercks et al., 2014).

Shoulder impingement and pain syndromes

The above pain pattern can be a symptom of SAPS or Subacromial Pain Syndrome. SAPS is defined as all non traumatic, usually unilateral, shoulder problems that cause pain, localized around the acromion (top part of shoulder), often worsening during or subsequent to lifting of the arm (Diercks et al., 2014). The above scenarios fall under the external impingement subtype, which include compression or abrasion of muscle under subacromial space. People with impingement type pain often have altered shoulder blade movements as well. If left untreated, it will lead to more severe rotator cuff diseases.


Anatomy of the shoulder girdle complex

The shoulder refers to the union between scapula (shoulder blade), humerus, clavicle (collar bone) and its ligaments plus overlying muscles.


Here are some important bits you need to know:

  1. The humeral head – This is the top portion of the bone in your upper arm. Normally it should stay snugly fit centered into its socket, the glenoid fossa
  2. Acromion, Coracoid and Coracoacromial ligament – These structures sit above the humeral head and provide a small space aptly named the subacromial space.
  3. Supraspinatus Tendon (part of the rotator cuff), long head of the biceps tendon and a bursa – These structures sit between the humerus and the subacromial space.  These are the structures that get impinged upon with this syndrome.
  4. Shoulder muscles important for normal shoulder movement: deltoid, biceps, rotator cuff muscles
  5. Scapular muscles important for normal shoulder movement: (upper/mid/lower) trapezius, serratus anterior and pectoralis muscle group


Efficient movement of the shoulder

While it may look like reaching up consists of the head of the humerus rolling upwards within the socket, the scapula and the clavicle actually plays an immensely important role in helping us reach. While the humerus rolls within the socket, the scapula upwardly rotates, posteriorly tilts, and the clavicle posteriorly rotates. Furthermore, shoulder girdle muscles (rotator cuff, trapezius, serratus anterior, pectoralis and biceps) have coordinated contraction and relaxation to help us with reaching. Certain muscle tendons will need to cross under the subacromial space in order to complete the motion.

Muscle imbalances and impingement pain

As mentioned above, patients with impingement pain often have different shoulder blade movements. Part of the problem can be due to the scapular muscles controlling the movement.  These include an overactive upper fibers of trapezius, tightness in the pectoralis and/or weakness in the serratus anterior.  Not only do changes within the scapular muscles cause changes to the movement of the scapula, they can also alter the orientation of the humeral head in its socket, thus decreasing the subacromial space during shoulder movement.  This can lead to compression of the rotator cuff tendons, bursa and the biceps tendon resulting in tendon pain.


Risk Factors for impingement pain

There are many common factors that influence the scapular muscles and can increase the chance of developing shoulder impingement syndrome.

Muscle timing issues

Full flexibility of the joints may be present, however there can be a problem where the muscles are not firing in the proper sequence.  This can be a result of muscle weakness or muscles that are too short and overpowering or too long and functioning as weak muscles.

Thoracic and cervical posture

Postural problems that affect the neck and thoracic spine can result in changes in the length/tension of muscles surrounding the spine.  This change in starting posture can affect the efficiency of scapular muscles.

Age and hand dominance

As we get older, our dominant hand’s shoulder girdle complex may also undergo degenerative changes which could increase the chances of developing SAPS.


Jobs that require heavy labour and/or repetitive movements can predispose individuals to repetitive strain injuries in the shoulder girdle or scapular muscles, which can also lead to SAPS. Furthermore, sedentary workers could be at risk of developing SAPS if their desk is not setup ergonomically. Simple changes can be done to help alleviate these problems.

Previous traumas or injuries

Certain shoulder girdle injuries (ie. frozen shoulder, fractures and dislocations) can cause stiffness in the shoulder joint and its surrounding ligaments/capsules, which will have detrimental consequences to the efficiency of the scapular muscles.

Anatomical differences in the shape of the acromion

There are 3 common varieties of acromions found in the population. Certain types of acromions will decrease the subacromial space and may increase the chances developing SAPS.

What can be done?

Luckily, research has shown conservative treatments have favourable results in combating impingement type pain. Rehab professionals can help to identify underlying sources of why your shoulder isn’t moving the way it should. Part of the assessment should include a detailed history pertaining to previous injuries, medical conditions, occupation and social factors; followed by a careful analysis on how you move your shoulders.  A physiotherapist would then be able to offer a series of exercises to help restore the movement pattern. Often, this will be enough to reduce the initial pain. As your symptoms reduce, it will be important to address the next areas of mobility restrictions, postural changes or muscle imbalances that may have caused the initial symptoms in the first place.  Making positive changes in predisposing factors to injury will help prevent future re-injury.  Some of the possible interventions could include body weight exercises, flexibility programs and/or lifestyle modifications.


Not Sure Where to start?

You’re not alone. There are a number of risk factors that can prevent “traditional” shoulder and posture programs from succeeding.  Our physiotherapists and massage therapists have the experience and training to evaluate and diagnose your current status and the tools to get you started and progressing towards better health.  Contact us to get started on your goals!


Family Physiotherapy, assessing and treating sports injuries for the residents of Thornhill, Markham and Vaughan

The physiotherapists at Family Physiotherapy have been providing high quality assessment and treatment techniques using safe and evidence based techniques to the residents of Thornhill, Markham, Richmond Hill, Woodbridge, Vaughan and Toronto. Our therapists are continually upgrading their skills and take the time to provide you with the one on one care necessary to quickly get you back to the activities you love doing.  Comprehensive assessment and treatment techniques are always one on one without the use of assistants or double booking patients to make sure that you achieve your functional and sports goals as soon as possible.  Our therapists would be happy to help you to achieve your goals, call the clinic to schedule a consultation to get you back on track.  Don’t let pain ruin your day!



Ludewig, P.M. & Braman J.P. (2011). Shoulder impingement: Biomechanical considerations in rehabilitation. Manual Therapy, 16, 33 – 39

Diercks, R., Bron, C., Dorrestijn, O., Meskers, C., Naber, R., de Ruiter, T.,  Willems, J., Winters, J., & Van der Woude, H.J. (2014). Guideline for diagnosis and treatment of subacromial pain syndrome, Acta Orthopaedica, 85:3, 314-322



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Breaking the Cycle of Injury: Treatment for Tendinopathies

By Brianne Burton, PT


What is a tendon?

A tendon is a tissue that connects muscle to bone. Unlike muscle, it does not contract, but it is connected to a muscle pic-1-235x300  that contracts so it sustains loading forces every time that muscle tightens. Tendons are made up of many bundles of fibers of collagen, which form a strong but flexible tissue.

The rotator cuff muscles of the shoulder connect to the

humerus or arm bone via tendons, shown above in white.

Image from Nucleus Medical Media / Getty Images


What is a tendinopathy?

The word tendinopathy refers to a non-rupture injury affecting a tendon. You may also hear people use the word tendonitis. There has been a shift in recent years favoring the word tendinopathy because it is a more general term, whereas tendonitis focuses the presence of inflammation, which may or may not be there. The two terms, however, are often used to talk about the same thing. Tendinopathies can occur at any tendon in the body. Some common sites include: rotator cuff tendons in the shoulder, tendons in the elbow (also known as lateral and medial epicondylitis), the hamstring tendons in the posterior thigh, patellar tendon in the knee, and the Achilles tendon in the ankle.


What causes a tendinopathy?

When a tendon is continually exposed to loading forces (such as compression, friction, or tension) that are beyond its capacity, a cycle of injury begins. The cycle of injury, inflammation, and repair happens repeatedly with each movement involving the tendon. This results in pain, swelling, and an accumulation of poor-quality tissue that never has the chance to fully heal. Overuse tendon injuries are common in athletes, but also common in less active people and people with jobs that require repetitive movements.


Why do overuse injuries happen?

It may be more correct to think about these injuries as ‘continued misuse’ injuries. Most often, overuse of the tendon in the wrong way is what actually leads to the injury. For example, if you have poor posture (slouched shoulders) and you continually reach overhead during volleyball, a tendon will be out of alignment; causing it to rub against the bone that sits above it. The repeated friction force starts the cycle of injury. This is what commonly occurs in a rotator cuff tendinopathy of the shoulder. The activity brings on the injury, but the root of the problem is improper positioning from poor posture.

Tendinopathies are also common with a sudden increase or change in load on a tendon, for example starting a new sport/activity or abruptly changing running surfaces. Use of improper equipment, for example worn out footwear or incorrect chair height in a workspace, also puts someone at risk for developing a tendon injury. Other risk factors for tendinopathies include smoking, obesity, hypertension, dyslipidemia and certain drugs like statins, flouroquinolones, and corticosteroids.


What happens to a chronically injured tendon?

When a tendon is chronically injured, some structural changes to the tissue take place. These changes lead to a disorganized, pic-2-263x300thicker, and weaker tissue that cannot withstand loading forces and continues to cause pain and swelling. Structural changes to a chronically injured tendon include:

  • Disorganized fibers
  • A higher number of a smaller, immature type of fiber (type III collagen)
  • Fewer mature fibers (type I collagen)
  • Increased number of vessels and nerves
  • More swelling in the tissue lining
  • Areas of dead cells



What are the symptoms of a tendinopathy?

Each person will experience symptoms differently, depending on the specifics of their injury. Most commonly people with tendinopathies experience pain and weakness with specific movements (whenever you use the injured tendon), localized pain and stiffness, and pain with increased activity.


What are the treatment options for tendinopathy?

Each tendinopathy is different and it is important to develop an individualized treatment plan; however some common elements include:

• Rest from aggravating activities. An early return to the aggravating activity will increase the risk of re-injury and could have negative effects on the structure of the tendon. Studies have shown that continued exposure to inflammatory chemicals contributes to the break-down of the collagen fibers and encourages scar tissue formation, which will set back recovery time.

• Electrotherapeutic modalities, like ultrasound therapy or Extracorpeal Shockwave Therapy. Shockwave therapy can be effective for stubborn injuries that are slow to heal.

• Manual Therapy to stimulate healing and encourage proper alignment of collagen fibers

• Eccentric strengthening. An eccentric contraction is a type of muscle contraction where the muscle is lengthening instead of shortening. For example, slowly lowering a weight with your arm is an eccentric use of your biceps muscle. Studies have shown that eccentric strengthening programs have produced better results than other programs because this type of loading stimulates tendon remodeling and leads to improved collagen structure and organization.


Image from

• Your physiotherapist will assess your movements and address any contributing factors that are specific to each person (such as improper posture or poor joint mobility). These factors may have either contributed to the injury in the first place, or developed since the injury occurred.


At Family Physiotherapy, we pride ourselves on providing a comprehensive assessment and individualized treatment for your tendinopathy. Don’t hesitate to contact us if you are experiencing these symptoms, have had a recurring tendon injury, or feel you are at risk for developing a chronic tendinopathy.





[1] Scott, A., Backman, L. J., & Speed, C. (2015). Tendinopathy: Update on pathophysiology. Journal of Orthopaedic & Sports Physical Therapy, 45(11), 833-841.
[2] Murtaugh, B., & Ihm, J. M. (2013). Eccentric training for the treatment of tendinopathies. Current Sports Medicine Reports, 12(3), 175-182.
[3] Coombes, B.K., Bisset, L., Vicenzino, B. (2015). Management of lateral elbow tendinopathy: One size does not fit all. Journal