Shoulder Pain: Causes, Diagnosis and Treatment

Sommario

Introduzione: Anatomia e Funzione della Spalla
Lussazione di SpallaTendinite del Sovraspinato
Lesioni della Cuffia dei Rotatori
Capsulite Adesiva (Spalla Congelata)
Capsulite Traumatica

Frattura del Trochite Omerale: Un Caso Clinico
Quando Rivolgersi al Fisioterapista
Domande Frequenti (FAQ)

Summary

Introduction: Shoulder Anatomy and Function
Supraspinatus Tendinitis
Shoulder DislocationRotator Cuff Injuries
Adhesive Capsulitis (Frozen Shoulder)
When to Consult a physical therapistTraumatic Capsulitis

Humeral Tuberosity Fracture: A Clinical Case

Frequently Asked Questions (FAQ)

Introduction: Shoulder Anatomy and Function

Shoulder pain: The shoulder is the most mobile joint in the human body, and precisely this extraordinary freedom of movement makes it particularly vulnerable to injuries and degenerative pathologies. A correct understanding of anatomy is the first step towards recovery.
The shoulder joint complex is composed of four joints — glenohumeral, acromioclavicular, sternoclavicular, and scapulothoracic — which work in synergy to allow movements of flexion, extension, abduction, adduction, internal and external rotation. Dynamic stability is ensured by the rotator cuff, a group of four muscles (supraspinatus, infraspinatus, teres minor, and subscapularis) whose tendons envelop the head of the humerus like a cuff.
Shoulder pain affects approximately 18-26% of the adult population at any given time, with an incidence that increases after age 50. Causes range from simple tendon inflammation to complex structural lesions, from capsular stiffness to joint instability. In this guide, we will analyze the most frequent pathologies, offering for each an overview of symptoms, diagnosis, and rehabilitation pathway, with links to specific in-depth information available on our website.

Supraspinatus Tendinitis

Supraspinatus tendinitis is the most common cause of shoulder pain in the adult population. The supraspinatus muscle, located in the upper part of the scapula, has the fundamental task of initiating arm abduction and stabilizing the humeral head in the glenoid cavity during all overhead movements.
Inflammation of this tendon typically develops due to repeated microtraumas, repetitive overhead movements (common in sports like swimming, volleyball, and tennis), or age-related degenerative processes. The patient complains of pain in the anterolateral region of the shoulder, often exacerbated by lifting the arm between 60° and 120° of abduction — the so-called “painful arc”.
Diagnosis relies on specific clinical tests (Jobe’s test, Neer’s test, Hawkins’ test) and is confirmed by musculoskeletal ultrasound or magnetic resonance imaging. Physiotherapy treatment involves an initial phase of pain and inflammation control, followed by a progressive program of eccentric exercises, rotator cuff strengthening, and scapulohumeral rhythm re-education. Clinical experience shows that a well-structured conservative approach resolves the majority of cases in 8-12 weeks.
Read the complete guide →

Rotator Cuff Injuries

The rotator cuff is the true functional core of the shoulder. When one or more of its four tendons suffer an injury — partial or full-thickness — the patient experiences significant pain, weakness, and limitation in daily movements such as combing hair, fastening a bra, or reaching for overhead objects.
Injuries can be degenerative, typical of advanced age and often associated with chronic subacromial impingement, or traumatic, resulting from falls on an outstretched arm or sudden movements under load. The distinction is fundamental because it influences the therapeutic strategy. In partial degenerative lesions, conservative physiotherapy treatment achieves excellent results in most cases. In full-thickness traumatic lesions, especially in young and active patients, arthroscopic surgical repair followed by targeted rehabilitation is often the preferred path.
The rehabilitation pathway after a rotator cuff injury requires patience and expertise. It generally consists of four phases: protection and pain control, recovery of passive mobility, progressive strengthening, and return to functional and sports activities. Each phase has precise timings that must be respected to avoid compromising tissue healing.
Read the complete guide →

Adhesive Capsulitis (Frozen Shoulder)

Adhesive capsulitis, commonly known as “frozen shoulder,” is one of the most frustrating pathologies for both the patient and the therapist. It is characterized by a progressive and severe limitation of shoulder movement, accompanied by intense pain, especially in the initial phases. The key to managing it effectively is proper patient education about the self-limiting, but potentially long, nature of the condition.
The disease classically evolves in three phases: the “freezing” phase, with increasing pain and progressive loss of mobility; the “frozen” phase, with pain subsiding but marked stiffness; and the “thawing” phase, with gradual recovery of movement. The entire cycle can last from 12 to 24 months, but timely and appropriate physiotherapy intervention can significantly shorten the duration.
Treatment is based on gentle and progressive joint mobilization, manual therapy techniques, capsular stretching exercises, and, when indicated, ultrasound-guided corticosteroid injections for inflammatory component control. Diabetes mellitus and thyroid pathologies are recognized risk factors that the physical therapist must always investigate in the anamnesis.
Read the complete guide →

Traumatic Capsulitis

Unlike idiopathic adhesive capsulitis, traumatic capsulitis develops as a consequence of a specific traumatic event — a fall, a car accident, shoulder surgery — or a period of prolonged immobilization. The joint capsule, irritated by the trauma, responds with an inflammatory process that evolves into fibrosis and capsular retraction, progressively limiting the range of motion.
The clinical presentation is similar to that of classic adhesive capsulitis, but with some important differences: the onset is more rapid, the correlation with the triggering event is clear, and the response to rehabilitation treatment is generally more predictable. The patient reports marked stiffness in all directions of movement, with particular limitation of external rotation and abduction.
Physiotherapy treatment for traumatic capsulitis requires a gradual but constant approach. In clinical practice, a combination of Maitland and Mulligan joint mobilizations, prolonged capsular stretching, and a structured home exercise program that the patient must perform daily is used. Instrumental physical therapy (high-power laser, tecartherapy) can assist manual treatment in pain management and promotion of tissue remodeling.
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Shoulder Dislocation

Shoulder dislocation is one of the most common orthopedic emergencies and consists of the complete displacement of the humeral head from the glenoid cavity. In the vast majority of cases (over 95%), the dislocation is anterior, meaning the humeral head moves forward and downward. It is particularly frequent in young athletes, especially in contact sports, and in the elderly after accidental falls.
The first episode of dislocation represents a crucial moment: initial management and subsequent rehabilitation profoundly influence the risk of recurrence. In patients under 25, the recurrence rate after the first episode can exceed 70% if rehabilitation is inadequate. For this reason, the rehabilitation pathway must be rigorous and complete, even when the patient already feels “healed” after a few weeks.
Rehabilitation after shoulder dislocation follows a well-defined protocol: initial immobilization (whose duration and position are subject to scientific debate), progressive recovery of mobility, intensive strengthening of stabilizing muscles (particularly external rotators and scapular stabilizers), and proprioceptive re-education. Return to sport generally requires 4-6 months and must be guided by objective functional criteria.
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Humeral Tuberosity Fracture: A Clinical Case

A fracture of the humeral tuberosity (or greater tuberosity) is an injury that deserves particular attention because it is often underestimated. The tuberosity is the bony prominence on the lateral part of the humeral head where the tendons of the supraspinatus, infraspinatus, and teres minor — three of the four rotator cuff muscles — insert. A fracture of it therefore directly compromises the functionality of the cuff.
This fracture can occur in isolation or, more frequently, associated with an anterior shoulder dislocation. The typical traumatic mechanism is a fall on an outstretched arm or a direct impact on the shoulder. Diagnosis requires an accurate radiographic examination and sometimes a CT scan to assess the extent of displacement.
On our website, we have documented a detailed clinical case that illustrates the complete pathway from diagnosis to full rehabilitation of a humeral tuberosity fracture. The case study shows how a personalized rehabilitation approach, respecting the biological times of bone healing and attentive to the functional recovery of the rotator cuff, can lead to excellent results even in clinically complex situations.
Read the complete guide →

Shoulder Exercises: Strengthening and Mobility Program

The following exercises represent a basic program for improving shoulder mobility and strength. Before starting, it is advisable to consult your doctor or physical therapist to ensure that the exercises are appropriate for your condition. In case of acute pain during execution, stop immediately and consult your doctor or physical therapist.

Phase 1 — Mobility and Pain Control

Exercise 1: Codman’s Pendulum
Difficulty: Easy | Equipment: Stable table or chair | Duration: 3 minutes

Starting position:
Stand next to a stable table or chair. Lean forward, resting the hand of your healthy side on the table. The painful arm hangs freely towards the floor, completely relaxed. Your feet are shoulder-width apart to ensure stability.
Step-by-step execution:

• Step 1: Gently shift your body weight back and forth, allowing your arm to swing passively like a pendulum, without contracting your shoulder muscles.
• Step 2: After 30 seconds, change direction and swing your arm from right to left, always passively and relaxed.
• Step 3: Finally, make small circles clockwise for 30 seconds and then counter-clockwise for 30 seconds, keeping your arm completely relaxed.

Sets and repetitions: 3 sets of 2 minutes each — 30-second rest between sets
Common mistakes to avoid:

• Contracting shoulder muscles during movement: the arm should swing by inertia
• Making circles that are too wide, which can cause pain
• Not leaning forward enough, reducing the decompressive effect on the shoulder

How to know you’re doing it correctly:
You feel a slight sense of relief in your shoulder, as if the joint is “opening up.” Your arm swings freely without any voluntary muscular resistance, and you don’t feel pain during the movement.

Exercise 2: Assisted Stick Capsular Stretch (Assisted Flexion)
Difficulty: Easy | Equipment: Stick or broom handle | Duration: 5 minutes

Starting position:
Lie on your back (supine position) on a mat or bed. Hold a stick with both hands, slightly wider than shoulder-width apart. Your arms are extended in front of your chest with elbows slightly bent.
Step-by-step execution:

• Step 1: Using your healthy arm as a guide, slowly lift the stick upwards and overhead, keeping both arms extended.
• Step 2: Reach the point of maximum tolerable stretch (without acute pain) and hold the position for 5 seconds.
• Step 3: Slowly return the stick to the starting position with a controlled movement, without letting your arms drop.

Sets and repetitions: 3 sets x 10 repetitions — 30-second rest between sets
Common mistakes to avoid:

• Forcing the movement beyond the pain threshold: the stretch should be felt as tension, never as acute pain
• Arching your back while lifting the stick: your lower back should remain flat against the mat
• Performing the movement too quickly, losing control

How to know you’re doing it correctly:
You feel a sensation of tension in the front or top of your shoulder, without sharp pain. As repetitions progress, the range of motion slightly increases. Your lower back remains in contact with the supporting surface.

Phase 2 — Rotator Cuff Strengthening

Exercise 3: External Rotation with Resistance Band
Difficulty: Intermediate | Equipment: Light-medium resistance band | Duration: 5 minutes

Starting position:
Stand with the side to be trained facing outwards from the resistance band’s anchor point (door handle, column). Your elbow is bent at 90 degrees and tucked against your side. Your hand grips the band, which has a slight tension already in the starting position. You can place a small rolled towel between your elbow and your side to maintain the correct position.
Step-by-step execution:

• Step 1: Slowly rotate your forearm outwards, keeping your elbow firmly tucked against your side. Imagine opening a door.
• Step 2: Reach the maximum controlled external rotation (approximately 45-60 degrees) and hold the position for 2 seconds.
• Step 3: Return to the starting position with a slow and controlled movement (3 seconds for the return phase), resisting the pull of the band.

Sets and repetitions: 3 sets x 15 repetitions per side — 45-second rest between sets
Common mistakes to avoid:

• Moving the elbow away from the side during rotation, compensating with the deltoid
• Using a band that is too resistant, forcing compensation with the trunk
• Performing the movement in jerks instead of smoothly and controlled

How to know you’re doing it correctly:
You feel muscle work in the back of your shoulder, in the rotator cuff region. Your elbow remains still and tucked against your side throughout the exercise. You don’t feel pain, but a progressive sensation of muscle fatigue.

Exercise 4: Internal Rotation with Resistance Band
Difficulty: Intermediate | Equipment: Light-medium resistance band | Duration: 5 minutes

Starting position:
Stand with the side to be trained facing the resistance band’s anchor point. Your elbow is bent at 90 degrees and tucked against your side. Your hand grips the band with slight tension. Your forearm is pointing outwards.
Step-by-step execution:

• Step 1: Slowly rotate your forearm inwards, towards your abdomen, keeping your elbow still at your side.
• Step 2: Reach the position where your hand is in front of your abdomen and hold for 2 seconds.
• Step 3: Slowly return to the starting position in 3 seconds, controlling the band’s return without letting your arm snap back.

Sets and repetitions: 3 sets x 15 repetitions per side — 45-second rest between sets
Common mistakes to avoid:

• Rotating your torso to assist the movement instead of isolating shoulder rotation
• Shrugging your shoulder towards your ear during execution
• Holding your breath: maintain regular breathing throughout the exercise

How to know you’re doing it correctly:
You feel muscle work in the front of your shoulder and in the subscapular region. The movement is fluid and controlled, and your torso remains still without lateral swaying.

Phase 3 — Scapular Stabilization

Exercise 5: Scapular Retraction (Squeeze)
Difficulty: Easy | Equipment: None | Duration: 3 minutes

Starting position:
Sit on a chair with your back straight, feet flat on the floor, and arms relaxed at your sides. Shoulders are in a neutral position, away from your ears.
Step-by-step execution:

• Step 1: Bring your shoulders slightly back and down, squeezing your shoulder blades together as if holding a pencil between them.
• Step 2: Hold the contraction for 5 seconds, breathing normally and without arching your lower back.
• Step 3: Slowly release the contraction in 3 seconds, returning to the starting position without letting your shoulders drop forward.

Sets and repetitions: 3 sets x 12 repetitions — 30-second rest between sets
Common mistakes to avoid:

• Shrugging shoulders towards ears instead of bringing them back and down
• Excessively arching the lower back to compensate for the movement
• Contracting only neck muscles (upper trapezius) without activating muscles between the shoulder blades

How to know you’re doing it correctly:
You feel muscle work in the area between your shoulder blades (rhomboids and middle-lower trapezius). Shoulders slightly lower during retraction. Your neck remains relaxed, and you don’t feel tension in the cervical area.

Exercise 6: Wall Slide
Difficulty: Intermediate | Equipment: Smooth wall | Duration: 5 minutes

Starting position:
Stand with your back, hips, and head against the wall. Your arms are against the wall with elbows bent at 90 degrees and at shoulder height, in a “candlestick” position. The entire back surface of your arms and hands is in contact with the wall.
Step-by-step execution:

• Step 1: Slowly slide your arms upwards along the wall, maintaining contact of the back of your hands, forearms, and elbows with the wall.
• Step 2: Slide up to the highest point reachable without losing contact with the wall and without arching your back. Hold for 3 seconds.
• Step 3: Slowly lower to the starting position in 3 seconds, always maintaining contact with the wall and controlling the movement of your shoulder blades.

Sets and repetitions: 3 sets x 10 repetitions — 45-second rest between sets
Common mistakes to avoid:

• Lifting your arms or hands off the wall during the ascent: if this happens, reduce the range of motion
• Arching your lower back to compensate for lack of shoulder mobility
• Shrugging your shoulders towards your ears during the upward movement

How to know you’re doing it correctly:
You feel muscle work between your shoulder blades and in the lateral part of your shoulder. Your arms maintain contact with the wall throughout the entire range of motion. The movement is fluid and does not cause sharp pain.

Important note: This program is for informational purposes only and does not replace individual assessment. For a personalized program, consult your doctor or physical therapist, who can adapt the exercises to your specific clinical condition.

Lateral Epicondylitis (Tennis Elbow)

Epicondylitis frequently affects those who also suffer from shoulder problems, as the muscular chains of the upper limb are closely interconnected.
Read the complete guide →

When to Consult a physical therapist

It is essential to recognize the signs that require timely professional evaluation. Clinical experience shows that many patients tend to underestimate initial symptoms, delaying the start of treatment and complicating the recovery process.
Consult your doctor or physical therapist if:

• Shoulder pain persists for more than 2 weeks despite rest
• You cannot lift your arm overhead or bring it behind your back
• You experience sudden weakness in your arm after a trauma
• Night pain prevents you from sleeping on the affected side
• You notice progressive shoulder stiffness limiting daily activities
• You have suffered a dislocation and want to prevent recurrence

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Sources and Scientific References

1. Gallardo Vidal MI et al. (2022). [Physiotherapy and health education protocol in chronic musculoskeletal shoulder pain. Experience in Primary Care]. Aten Primaria. 54:102284. DOI | PubMed
2. Klintberg IH et al. (2015). Consensus for physiotherapy for shoulder pain. Int Orthop. 39:715-20. DOI | PubMed
3. Crookes T et al. (2023). Chronic shoulder pain. Aust J Gen Pract. 52:753-758. DOI | PubMed
4. Green S et al. (2003). Physiotherapy interventions for shoulder pain. Cochrane Database Syst Rev. 2003:CD004258. DOI | PubMed
5. Pak SS et al. (2023). Comparing Digital to Conventional Physical Therapy for Chronic Shoulder Pain: Randomized Controlled Trial. J Med Internet Res. 25:e49236. DOI | PubMed

Frequently Asked Questions

How common is shoulder pain and why is it so prevalent?

Shoulder pain affects a significant portion of the adult population, approximately 18-26%, with incidence increasing after age 50. The shoulder’s extraordinary mobility, while beneficial for function, also makes it particularly vulnerable to injuries and degenerative conditions.

What is supraspinatus tendinitis and what causes it?

Supraspinatus tendinitis is the most common cause of shoulder pain, involving inflammation of the supraspinatus tendon. It typically results from repeated microtraumas, repetitive overhead movements common in sports, or age-related degenerative processes.

What are the typical symptoms of supraspinatus tendinitis?

Patients often experience pain in the front and side of the shoulder, which is frequently worsened when lifting the arm between 60° and 120° of abduction, known as the ‘painful arc.’ This pain can interfere with daily activities and sleep.

How is supraspinatus tendinitis treated?

Treatment primarily involves physiotherapy, starting with pain and inflammation control. This progresses to a structured program of eccentric exercises, rotator cuff strengthening, and re-education of scapulohumeral rhythm, with most cases resolving in 8-12 weeks.

Why is an accurate diagnosis important for shoulder pain?

Accurate diagnosis is crucial because shoulder pain can stem from various causes, ranging from simple inflammation to complex structural damage. A precise diagnosis guides the most effective treatment plan, ensuring appropriate rehabilitation and recovery.