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The Grumpy Shoulder

Method Health
Oct 29, 2024
13 min read

Updated: Sep 18



Most cases of shoulder pain, where pain or symptoms occur only around the top and side of the shoulder and partially down the upper arm when the arm is lifted to any degree, can and should arguably be referred to as a grumpy shoulder, sprain, or strain. This article explains why we can group the diagnosis you might have been given for your shoulder pain with several other possible diagnoses, including:

  • Sprains or strains of the muscle or the shoulder “labrum” or joint lining,

  • “Subacromial” pain, 

  • “Anterior” shoulder pain,

  • Rotator cuff “tears,”

  • Shoulder, deltoid or rotator cuff tendinopathy/tendon pain,

  • Bicep tendon pain where the bicep muscles tendon attaches to the shoulder, 

  • Bursitis, 

  • “Calcification”-related shoulder pain,

  • Superior labral anterior to posterior labral (SLAP) pain,

  • The non-surgical management of shoulder osteoarthritis,

  • Shoulder “impingement,” 

  • A grumpy shoulder where multiple types of medical imaging have shown “nothing is wrong.”


Up to 65% of all causes of shoulder pain can be grouped into this category when it comes to their high quality management, saving time and confusion when seeking information and speeding up recovery of persistent grumpy shoulders (Shoulder pain: Can one label satisfy everyone and everything?). Around 15% of people will experience this type of general shoulder pain at least once during their lives (Patients' experience of shoulder disorders). All of these diagnoses can be managed initially (and mostly entirely) without imaging, injections, or surgery (Jeremy Lewis - Rotator Cuff Related Shoulder Pain & the athlete: Suggestions for management (youtube.com). 


How can we tell it is just a grumpy shoulder and not a medically serious condition? Can a physio or doctor tell you specifically from a single or multiple movement tests what specific part of your grumpy shoulder is sensitive? No. Movement tests cannot isolate a specific section of the shoulder that is causing pain, and many “special tests” yield mostly “false positives” (Podcast - Putting Special Tests for Rotator Cuff-Related Shoulder Pain out to Pasture). Movement tests you could perform can’t identify or isolate a specific irritated section of your shoulder. For that reason, as we use all parts of our shoulder when we move it, the management of these conditions is the same. So, be skeptical if a movement is used to “confirm” a specific sore site in the shoulder. Even imaging is unnecessary and unhelpful in identifying changes in a “pain generator” in the shoulder or directing how to manage your symptoms (Imaging Myths [Debunking Series: Episode 3] - YouTube). Imaging results often don't correlate with the severity of your symptoms, and images of both painful and non-painful shoulders appear similar (Bilateral magnetic resonance imaging findings in individuals with unilateral shoulder pain). Furthermore, imaging results don’t change while your symptoms improve. “Tears,” “degeneration,” or “bursitis” results are commonly found in people without pain, and often do not predict future pain either (What Imaging-Detected Pathologies Are Associated With Shoulder Symptoms and Their Persistence? + Magnetic resonance imaging of the asymptomatic shoulder of overhead athletes: a 5-year follow-up study - PubMed + Dynamic sonography evaluation of shoulder impingement syndrome - PubMed + The Duration of Symptoms does not correlate with Rotator Cuff Tear Severity or Other Patient Related Features). Many of the labels used for what could just be called a grumpy shoulder or other you might have been told not included above, are harmful in the long term due to leading to unhelpful pain beliefs/behaviour and predictable leads to unnecessary healthcare seeking and medical costs (Diagnostic Labels for Rotator Cuff Disease Can Increase People's Perceived Need for Shoulder Surgery + Diagnostic Labels for Rotator Cuff Disease Can Increase People's Perceived Need for Shoulder Surgery). Bursitis makes most think “rest is best.” Tendon “tears” make people think that exercise won’t be helpful and only surgery will help. “Impingement” makes people think lifting their arm above their head is bad. Hopefully by the end of this article, you can understand why the term “grumpy shoulder” is the most helpful term to help people recover from this type of shoulder pain.


When is it not a grumpy shoulder? A good chat and response to a movement exam or exercise (in one health care session or over weeks of time) with an evidence-based healthcare professional can increase confidence that a rarer diagnosis is not likely, where seeking imaging, injections and surgery might have more benefits than harm. Those rarer conditions include: 

   

Why is my shoulder grumpy but not “damaged”? Most of the time, pain makes you feel weaker, which can lead you to believe you have “damaged” something. However, it's better to think of your shoulder as having tendon pain (The role of tendon and subacromial bursa) or a joint “headache” or “flu”, which, like a cold, is a temporary nuisance, affecting your mood and sense of well-being. Still, it will improve over time without requiring excessive medical care, such as surgery (An Open Letter to You, a Unique Individual Living with Shoulder Pain). This might seem too simple or not very “specific” considering how much pain you may be experiencing, but it is honest, evidence-based physiotherapy advice. 


Sometimes symptoms occur “randomly,” after doing a “single harmless” movement like an exercise you’ve done a thousand times in the gym or after sleeping “wrong”. Those scenarios point to an unhealthy joint “neuro-immune” system and an overfilled “cup” (What? Pain is complex - the overflowing cup analogy of pain) or an “overreaction” from your joint's immune system, which has the well-intended purpose of speeding up adaptation to a sudden increase in shoulder use in the last couple of days to weeks, such as spending a weekend painting the house or playing in a tennis tournament. 


“Ok, why is it not resolving?” or “Why has this reoccurred?” Even when managed well, it is normal for a shoulder to be grumpy for multiple weeks to months (Living with a symptomatic rotator cuff tear 'bad days, bad nights': a qualitative study + Predicting response to physiotherapy treatment for musculoskeletal shoulder pain). When symptoms are persistent past this point, it is likely, rather than “something has been missed” or “not healed,” that instead, beliefs of poor shoulder confidence or “my shoulder is damaged” have led you to daily behavioural changes and “neuro-immune adaptations, that are prolonging your symptom resolution. If you maintain long term beliefs of “my shoulder is damaged,” “sleeping wrong is bad for my shoulder,” "I have pain due to my age,” “I actually need a joint replacement” or “I need massage and acupuncture before I begin exercise,“ or “painful movement is bad for my shoulder due to impingement,” it is common sense that your nervous system will adapt to reduce the threshold before you feel symptoms during what were previously harmless movements (Psychological factors are associated with the outcome of physiotherapy for people with shoulder pain + Fear-Avoidance Model - an overview + The influence of cognitions, emotions and behavioral factors on treatment outcomes in musculoskeletal shoulder pain). Also, lifestyle factors such as persistent negative social stress (family stress or death of a close one) or work dissatisfaction, reduced sleep, reduced physical activity, being overweight, smoking, or a recent sickness or illness often increase joint symptoms, resulting in a vicious cycle of more pain, less movement, less sleep due to pain and ongoing symptoms (Is there an association between metabolic syndrome and rotator cuff-related shoulder pain? + The effect of obesity on pain and disability in shoulder pain + Association between alcohol consumption and rotator cuff tear + Comorbidities in rotator cuff disease). Some lifestyle factors are less under your control, and/or previous shoulder sprains and strains, perhaps years ago, may have created a “neuro-immune” adaptation that has not entirely resolved, explaining why recurrence of a grumpy shoulder is common (A systematic review of the histological and molecular changes in rotator cuff disease).


What can I do about it? The goal of high-quality grumpy shoulder management is to:

  • Temporarily modify your valued but sensitive shoulder movement activities to allow you to continue them. 

  • Improve modifiable lifestyle factors to improve your “neuro-immune health.”

    • Prioritise high-quality sleep (Sleep Health and Habits).

    • Either reduce daily mental stress or increase participation in “stress-relieving” coping strategies like exercise, active hobbies, or social activities. 

    • Improve body composition (Fat Loss Myths).

  • Seek high-quality education and advice to reduce negative beliefs about your ability to recover (An Open Letter to You, a Unique Individual Living with Shoulder Pain + The Shoulder Physio Podcast). Many in Western Australia do not receive high-quality care or education (Exploration of the Usual Care Pathway for Rotator Cuff Related Shoulder Pain in the Western Australian Workers’ Compensation System). We have seen high-quality education be as helpful for shoulder pain as exercise (see the table below). Stay optimistic during your recovery and educate yourself about the risk factors that can prolong the persistence of your shoulder pain. Ask us for validated, up-to-date information, as there is a lot of unhelpful physio fluff out there. See the “Myth” section later. 

  • Increase full-body or shoulder-specific exercises to improve your tolerance for the positions and movements you frequently perform. Movement, improving shoulder confidence, and patient optimism are beneficial for resolving shoulder pain (“Restoring That Faith in My Shoulder”: A Qualitative Investigation of How and Why Exercise Therapy Influenced the Clinical Outcomes of Individuals With Rotator Cuff–Related Shoulder Pain). Exercise advice can include:

    • Make sure you continue to meet the (Australian activity guidelines) for your active hobbies and overall health. Maintaining general health keeps your immune system healthy, helping it improve immune reactions occurring in your shoulder, contributing to unpreventable symptoms. 

    • Incorporating weekly upper-body strength, power, or activity-specific exercises to improve tolerance to activities affected by shoulder pain. Don’t be too worried about finding the “best exercise.” You can’t isolate all the muscles, tendons, labrum, and/or shoulder ligaments with one movement anyway (Direction-specific recruitment of rotator cuff muscles during bench press and row). The progressive movement that involves pushing, pulling, and lifting your arms to the side strengthens all the shoulder muscles comprehensively. A general shoulder strength routine will “isolate” the shoulder muscles as much as any fancy shoulder exercise (Specific versus general exercise program).

    • When your shoulder is grumpy, pain during arm use is safe, but it's wise to keep to tolerable pain levels to avoid sleep deprivation or entry into the pain worry cycle. Remember, this type of shoulder pain is not caused by measurable tissue changes, and more pain does not necessarily equal more tissue damage.  However, when in a sensitive state, your immune and nervous systems are more sensitive or “ready to go,” and the threshold for a flare-up is lower, which can affect sleep and lead to negative thoughts during shoulder movement.  



All of these strength training movements are great options for the health of your shoulders.


How long will it take to resolve? If you are optimistic, have clear expectations and education about what shoulder pain means (e.g. more shoulder pain does not equal more shoulder damage), and follow realistic, up-to-date advice, many can feel much better within 2 weeks to three months. Sometimes, it takes more than 12 months to feel better (Role of physiotherapy). Don’t be too concerned; just having symptoms for longer does not mean you will not improve when following good advice. Continue doing the things that are beneficial for your shoulder tendon and muscle health, such as improving sleep, physical activity, and stress management, while your symptoms resolve over the next couple weeks to months. You can effectively self-manage this common form of shoulder pain without medication, injection or surgery (Terminating Corticosteroid Injection in Tendinopathy? Hasta la Vista, Baby + Platelet-rich plasma (PRP) for shoulder pain: science or science fiction? + Surgery or conservative treatment).

 Busting Shoulder Pain Myths?



What can Physiotherapy or Exercise Physiology at Method Health offer? 

  • We can offer individual advice to help you modify your activities to manage life with shoulder pain. Shoulder pain should not stop you from doing the things you love. This might involve incorporating strength exercises for your shoulder and upper body into your weekly routine, which we can coach you through or help support you in resuming the activities you enjoy, which you may have reduced or avoided due to your beliefs about what will alleviate your shoulder pain. 

  • We can be your support team to encourage lifestyle changes that can improve your overall health, such as coaching you on sleep, guiding you through ways to reduce stress, or introducing activities to help you better cope with stress. 

  •  If you have had persistent shoulder pain and are very confused about the “specific” diagnostic labels you have been given that might be unhelpful, including shoulder “degeneration,” “tears,” “bursitis,” or “impingement,” and why you still have shoulder pain persistence, we can help you make sense of the pain, highlight areas of management to prioritise or be more optimistic about, and give you individual guidance to assist in managing and resolving it. 

  • Exercise physiology and physiotherapy can offer high-quality exercise-based management for general shoulder pain.

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