Physical therapy and exercise for shoulder pain. When it works, when it does not work
Ross Hauser, MD
There is a controversy in the medical community over physical therapy for shoulder injuries as a means to prevent the need for surgery.
For many patients, physical therapy represents a treatment that they want to do and have high expectation that the treatment will help them avoid a shoulder arthroscopic surgery, rotator cuff surgery or shoulder replacement surgery. Therefore, when physical therapy fails them, these people are often very confused as to why they have progressively more pain and less function in their shoulder, elbow and arm. Clinicians, doctors, and therapists can be equally confused.
This is very typical of the patients we see. They have been to physical therapy for months and nothing seems to have improved their arm and shoulder function and pain. Many have explored online resources to which there many “Do these great shoulder exercises” articles and videos to strengthen their shoulder. These people have been told that exercise will lead to greater pain relief and an increase in mobility. So why is it not working for them, when physical therapy and exercise are so beneficial to so many others?
Physical therapy and exercise should be explored in many patients as a means to help improve function and alleviate pain. The challenges are selecting those patients that therapy will work best for and understanding which patients physical therapy will not work for and why the treatment will fail.
While there are many videos and articles on the best exercises for shoulder pain, very few deal with the reasons why physical therapy and exercise will fail and ultimately that patient will have to have a shoulder surgery.
- Physical therapy and shoulder exercise, initially beneficial and helpful, has plateaued. Progressive shoulder degenerative problems have resumed.
- Must the failure of physical therapy be a signal to your doctor that you must have a surgery?
- Favorable exercise outcomes from a good exercise program. Just as good as rotator cuff surgery?
- Exercise and physical therapy for subacromial pain syndrome.
- The ligaments of the shoulder – Once these structures are stretched or loosened, no amount of exercise will strengthen the shoulder joint enough to permanently hold it in place.
- Cortisone injections and physical therapy in the case of a frozen shoulder.
- Prolotherapy Injections
Physical therapy and shoulder exercise, initially beneficial and helpful, has plateaued. Progressive shoulder degenerative problems have resumed.
A July 2022 (1) study from E.W. Sparrow Hospital and Michigan State University puts it this way: “The shoulder is important for the completion of activities of daily living, and osteoarthritis of the shoulder can significantly reduce shoulder motion and arm function. Although shoulder rehabilitation is an integral treatment modality to improve pain and function in shoulder osteoarthritis, few high-quality studies have investigated the effects and benefits of shoulder physical and occupational therapies.”
For some people, excited by initial success, they have now reached a point where their shoulder physical therapy itself has become painful and difficult to do. Their pain is also spreading and getting “deeper.” As their shoulders become more unstable, pain spreads into the neck, upper back, and down their arms.
In June 2022, doctors writing in the journal Clinical rehabilitation (3) sought to identify barriers and facilitators related to self-management from the perspectives of people with shoulder pain and clinicians involved in their care. In reviewing previously published research, study authors noted that from the perspective of patients, three central themes emerged in why patients did not follow through with their physical therapy:
- First, support for self-management, patient knowledge of the program and how to perform it, the time required, access to equipment necessary to perform certain exercises, and patient digital literacy (the ability to get self-help information.
- Second, Personal factors, including patient beliefs, patient expectations, patient motivation, pain, and therapeutic response; and
- Third, external factors, including influence of the clinician and therapeutic approach.
- One of the reasons your physical therapy may fail is the same reason your shoulder replacement may fail. Unusual muscle activity and imbalance.
- For physical therapy to be effective, the tendons, which hold the muscle to the bone must be strong so that the muscle can get the resistance it needs to “work out.”
Generally people do not need a research study to tell them that their physical therapy and exercise program will not work for them if they do not know how to exercise on their own, they do not have the equipment necessary to successful perform training routines, they get discouraged, their clinician does not believe exercise will help them, and their pain is not improving.
A December 2022 paper in the journal Musculoskeletal science & practice (9) describes the problems we see in our new patients. Pain dictates how much exercise they can do followed by fatigue and their fear or desire of performing the exercise. “Pain was the most frequent benchmark when modulating and progressing the exercises, although other criteria were found such as fatigue or self-perceived ability. Progressive exercise seems effective to manage upper limb tendinopathies, but the superiority of a progression criterion against others remains unclear. Low-quality evidence supported progressive exercise with eccentric components in adding a significant and moderate effect on pain/function at short-term.”
In the image below the types of exercise is shown. Concentric, you are lifting the barbell towards your shoulder, Eccentric you are lowering the barbell slowly, isometric, you hold the barbell in place, neither lifting or lowering.
Why does exercise fail?
A December 2022 paper in the journal Musculoskeletal science & practice (7) explained why exercise does not help everyone with shoulder pain. “Exercise is considered to be both essential and at the forefront of the management of rotator cuff-related shoulder pain. Despite this, many fail to substantially improve with exercise-based treatment.” The reason the researchers suggest is that “The causal explanation for the beneficial effect of exercise for rotator cuff-related shoulder pain in clinical research is dominated by biomedical mechanisms, despite a lack of supporting evidence.” What does this mean? Simply, the biomedical mechanisms is that exercise promotes an anti-inflammatory capacity (stops inflammation), an anti-oxidant capacity (to try to reverse a degenerative joint disease into a healing mode) and to strengthen muscle to prevent mechanical stress and tearing. Sounds good. But something is stopping the exercise from working.
Must the failure of physical therapy be a signal to your doctor that you must have a surgery?
Two of the main rationale for having physical therapy are, first, the patient may have a physically demanding line of work, are active in sports, or are the primary caregivers for an ailing family member or spouse. Physical therapy may hold the promise to helping these people avoid a surgery that they do not have the time, energy or desire for. Secondly, your doctor may not be able to recommend a surgery through your insurance until physical therapy has failed.
Favorable exercise outcomes from a good exercise program. Just as good as rotator cuff surgery?
This is not to say physical therapy for shoulder pain typically fails. Many people have very successful outcomes. One study suggests that physical therapy and exercise are just as good as a surgery.
Doctors at Aarhus University Hospital in Denmark published August 2022 findings on the feasibility of progressive shoulder exercises for patients with glenohumeral osteoarthritis or rotator cuff tear disease. In this study (2) the team investigated whether 12 weeks of progressive shoulder exercises provided beneficial changes in shoulder function and range of motion.
- Twenty patients were included.
- Eighteen patients (11 women, 15 with osteoarthritis), mean age 70 years (range 57-80), performed 12 weeks of progressive shoulder exercises with one weekly physiotherapist-supervised and two weekly home-based sessions.
- Feasibility (is this program designed well enough that patients are willing to adhere to this program) was measured by dropout rate, adverse events, pain, and ability to stay with the exercise program.
Results: Two patients dropped out and no adverse events were observed. Sixteen of the eighteen patients (89%) had a high adherence (more than 70%) to the physiotherapist-supervised sessions. Acceptable pain levels were reported; in 76% of all exercise sessions. Shoulder and disability function improved.
The researchers found among this group that progressive shoulder exercises are feasible, safe and may relieve shoulder pain, improve function and range of motion in patients with glenohumeral osteoarthritis or rotator cuff problems. The patient-experienced gains after progressive shoulder exercises seem clinically relevant and should be compared to arthroplasty surgery in a rotator cuff setting.
One of the reasons your physical therapy may fail is the same reason your shoulder replacement may fail. Unusual muscle activity and imbalance.
When being prescribed physical therapy or an exercise program to strength the shoulder, you may have it explained to you that the exercises are to strengthen the Teres muscles, Supraspinatus muscle, Infraspinatus muscle, and Subscapularis muscle. More commonly these are the muscles of the rotator cuff. Further the the powerful deltoid muscles and the Trapezius and Rhomboid muscles of the upper back and the biceps and triceps of the arm will also be included.
The problem of failed physical therapy is the inability to increase muscle strength and function. A reason an ultimate shoulder replacement may fail is not because of the hardware, but rather your shoulder’s inability to hold the hardware in place and provide muscle strength to function your arm normally.
The caption of the image reads: Shoulder joint instability causes more force pressure on the rotator cuff tendons. Rotator cuff tendons are designed to move the shoulder joint, not stabile it. This causes the tendons to degenerate and become weaker which makes them care easier. The rotator cuff tear is the symptom of shoulder joint instability, the underlying cause as why physical therapy does not help shoulder pain in many people.
Cortisone injections and physical therapy in the case of a frozen shoulder
In December 2020 doctors at the University of Glasgow wrote in the JAMA network open from the Journal of the American Medical Association (8) about the positive effect cortisone injections could have on helping patients with Frozen Shoulder. In this study, the doctors recommend the use of cortisone injections in patients who developed frozen shoulder but who had symptoms of less than one year. They recommend an accompanying home exercise program with simple range of motion exercises and stretches.
This article focuses on why physical therapy may not have helped your shoulder pain or helped you avoid a shoulder arthroscopic procedure or eventual shoulder replacement. This article also discusses treatments that may help the shoulder physical therapy work better.
For physical therapy to be effective, the tendons, which hold the muscle to the bone must be strong so that the muscle can get the resistance it needs to “work out.”
For physical therapy to be effective, the tendons, which hold the muscle to the bone must be strong so that the muscle can get the resistance it needs to “work out.” If the tendons or ligaments are damaged, as depicted in the above illustration where a Supraspinatus tendon tear is depicted as well as a ligament tear, the resistance may be non-adequate or may even be non-existent. The muscle cannot build. In some instance there is an imbalance in the way shoulder muscles are strengthening and at the same time atrophying. This creates another incidence of shoulder instability
Let’s explore a June 2022 paper from researchers at Northwestern University and the University of Pittsburgh published in the journal Clinical orthopaedics and related research.(4) Here is the introduction to that paper:
“When nonoperative measures do not alleviate the symptoms of glenohumeral osteoarthritis, patients with advanced osteoarthritis primarily are treated with anatomic total shoulder arthroplasty (total shoulder replacement). It is unknown why total shoulder replacements performed in patients with eccentric (or unusual) (asymmetric glenoid wear) compared with concentric (even or typical) (symmetric glenoid wear) deformities exhibit higher failure rates, despite surgical advances.”
In other words, there are two types of wear and tear. The first mentioned is an unusual or eccentric wear and tear that is wear away at the shoulder in uneven unexplainable patters. The second wear and tear type is the concentric or even wear and tear type of “bone on bone” developing patterns. So you have abnormal, unexplainable wear and tear and the regular typical wear and tear. A concern the researchers are pointing out is the unusual wear and tear patterns are also causing total shoulder replacements to fail. Returning to the research:
“Persistent disruption of the posterior (front) -to- (back) anterior rotator cuff force couple resulting from posterior rotator cuff intramuscular degeneration in patients with eccentric (unusual) deformities could impair external rotation strength and may contribute to eventual total shoulder replacement failure. Pain and intramuscular fat within the rotator cuff muscles may impact external rotation strength measures and are important to consider.”
In simplest terms the researchers are suggesting an imbalance of the muscles. In examining their study group, the researchers made these observations:
“Patients with eccentric (unusual muscle) deformities demonstrated higher variability in strength compared with patients with concentric (standard wear and tear) deformities. This increased variability suggests patients with potential subtypes of eccentric wear patterns . . . may compensate differently for underlying anatomic changes by adopting unique kinematic or muscle activation patterns.” In other words you are overcompensating and your muscles are strengthening and weakening in unusual ways that do not support the strength of the shoulder.
The researchers conclude: “Our findings highlight the importance of careful clinical evaluation of patients presenting with eccentric deformities because some may exhibit potentially detrimental strength deficits. Recognition of such strength deficits may allow for targeted rehabilitation.” Rehabilitation post-surgery and pre-surgery).
Exercise and physical therapy for subacromial pain syndrome
A July 2022 study on the effects of exercise on clinical pain and pain mechanisms in patients with subacromial pain syndrome comes to us from Aalborg University in Denmark, published in the European journal of pain. (6)
This study examined:
- If 8-weeks of exercise could modulate clinical pain or temporal summation of pain (this is a condition where the same arm movement causes an increase in pain intensity, if you lifted your arm above your head, it hurts worse the more you do it), conditioned pain modulation (the patient was given a treatment to lessen the pain), and exercise-induced hypoalgesia (exercise decrease pain intensity) and
- If any of these parameters could predict the effect of 8-weeks of exercise in patients with un this stuyd of 37 patients, ilateral subacromial pain syndrome.
In this study of 37 patients , the researchers findings suggested reduction in pain and improved sleep quality after 8-weeks of exercise. Furthermore, the results suggests that low pain intensity and high temporal summation of pain scores (indicative for pain sensitization) may predict a lack of pain improvement after exercise.
- The reason for physical therapy and exercise not being successful in some subacromial pain syndrome is that the patient suffers from a greater sensisity to pain and they have a lower tolerance for pain.
The ligaments of the shoulder – Once these structures are stretched or loosened, no amount of exercise will strengthen the shoulder joint enough to permanently hold it in place.
Another reason that physical therapy may not be helpful is because the ligaments that hold the shoulder together are weakened and cannot provide the stability the joint needs to build strength. The ligaments, muscles and tendons all work together to stabilize the shoulder.
In the medical publication StatPearls (5) part of the National Center for Biotechnology Information internet library doctors offered this assessment of the problem of multidirectional instability in the shoulder.
“Multidirectional instability is characterized as an imbalance between shoulder mobility and stability. The glenoid, glenoid labrum complex, glenohumeral ligaments as well as the negative pressure (the pressure of the lubricating synovial fluid at the ball and socket of the shoulder joint) created within the (shoulder) joint, all play roles as static stabilizers. The rotator cuff, long head of the biceps, periscapular muscles as well as the deltoid muscle, are all dynamic stabilizers. The interplay between the static and dynamic stabilizers is responsible for overall stability. ultidirectional instability is recognized as a continuum in which the static and/or dynamic stabilizers are no longer sufficient to maintain the congruence (the basic function of a pain free) glenohumeral joint.”
As documented in Caring Medical publications: Shoulder ligaments are strong bands of connective tissue that connect bones to bones. To treat shoulder joint instability, the ligaments and shoulder capsular structures (muscles, labrum and tendons) must be strengthened. The main shoulder capsular structure involved in the stability of the shoulder is the glenoid labrum, which holds the humerus bone to the glenoid cavity of the scapula. Other common reasons for shoulder joint instability involve weakness in the supraspinatus tendon, acromioclavicular ligament laxity, a weakened glenohumeral ligament, and weakness of the structures that attach to the coracoid process. A shoulder is usually unstable because these structures are torn or stretched. Once these structures are stretched or loosened, no amount of exercise will strengthen the shoulder joint enough to permanently hold it in place.
Ross Hauser, MD discusses the Prolotherapy treatment results that were published a few years ago on part of our article series on the use of Hackett-Hemwall dextrose Prolotherapy, as well as shows a treatment demonstration from a Prolotherapy symposium he taught in 2021. The treatment addresses ligament laxity or ligament weakness caused by degenerative wear and tear or injury.
Please see our article: The different shoulder problems that can be treated with Prolotherapy as well as a general introduction article on Prolotherapy treatments.
To help physical therapy work better, the ligament and tendon attachments should be strong or made stronger to help supply the resistance the muscles need to strengthen.
I am going to discuss one of our own research papers that assessed Prolotherapy treatment on 94 patients with received Hackett-Hemwall dextrose Prolotherapy injections to the main areas we treated ligaments and tendons of the shoulder. The glenohumeral ligament, the bicep tendons and the rotator cuff tendons. Many of these patients had the common problems of the shoulder caused by shoulder instability.
- Shoulder osteoarthritis
- Shoulder impingement
- See our article: Subacromial shoulder pain treatment for discussions on exercise and physical therapy.
- Snapping scapula
- See our article: Snapping Scapula Syndrome – Non-surgical options. In this article is a discussion why physical therapy may have failed you
- Shoulder bone spurs
- Shoulder labral tears
- Rotator cuff tear
- Rotator cuff tendonitis
The treatment begins at 3:30 of the video: Click on the image to watch the treatments at this point.
Prolotherapy Research Shoulder Osteoarthritis, Tears and Chronic Pain Disorders
- We assessed quarterly Prolotherapy injection outcomes in 94 patients with an average of 53 months of unresolved shoulder pain.
- 60% of the patients were female
- Average age 54 years old
- They had previous consulted at least three doctors before they had Prolotherapy injections
- An average of 20 months following their last Prolotherapy session, patients were contacted and asked numerous questions in regard to their levels of pain and a variety of physical and psychological symptoms, as well as activities of daily living, before and after their last Prolotherapy treatment.
- The results of this study showed that patients had a statistically significant decline in their level of pain, stiffness, and crunching sensations (crepitation) level with Prolotherapy, including the 39% of patients who were told by their medical doctors that there were no other treatment options for their pain and the twenty-one percent who were told that surgery was their only option.
- Over 82% of all patients experienced improvements in sleep, exercise ability, anxiety, depression, and overall disability with Prolotherapy. Ninety-seven percent of patients received pain relief with Prolotherapy.
Summary and contact us. Can we help you?
When traditional treatments such as physiotherapy, medications, electrical stimulation, manipulation, exercise, rest, or massage do not work, then consider that you may have ligament and tendon weakness.
We hope you found this article informative and it helped answer many of the questions you may have surrounding your shoulder problems and shoulder instability. If you would like to get more information specific to your challenges please email us: Get help and information from our Caring Medical staff
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