Chronic Shoulder pain? Rotator Cuff Injury?

Range of Motion Testing

Do you have undiagnosed chronic shoulder pain? Has someone suggested to you that it might be a rotator cuff tear? How do you distinguish between the two?

Magnetic Resonance Imaging (MRI) is an ideal means to identify the cause of shoulder pain. MRI uses a magnetic field, radio frequency pulses, and a computer to take detailed pictures of internal body structures. MRI gives clear views of tendon tears and damage to the glenoid labrum, the cartilage ring surrounding the shoulder socket. Swelling and bleeding can also be visualized.

In addition to MRI scanning, a physician or physical therapist can perform specific manual tests to obtain a diagnosis for chronic shoulder pain.


Shoulder pain is considered chronic when it has lasted more than six months. There are generally five major categories of causes:

  • Tendon Inflammation or Tear
  • Impingement
  • Joint Instability
  • Arthritis
  • Frozen Shoulder

TENDON INFLAMMATION – There are two types of tendon inflammation, bursitis and tendonitis.

Bursitis – A bursa is a sac containing lubricating fluid. It is found between bones, muscles, tendons, and skin. It serves as a cushion, and helps reduce friction and irritation. The bursae can become inflamed and swollen with repetitive activities or direct injury.

Tendinitis – A tendon is a band of tissue that connects muscle to bone. When the tendon is injured, it becomes inflamed. There are two types of tendinitis, acute and chronic. Acute tendinitis is caused by repetitive overhead activities during work or sports. Chronic tendinitis is the result of degenerative diseases, such as arthritis.

IMPINGEMENT – Impingement results when shoulder muscles are pinched between the upper arm and shoulder blade. This can lead to bursitis and tendinitis, causing pain and limiting movement. Over time, severe impingement can even lead to a rotator cuff tear.

INSTABILITY – Shoulder instability results when the head of the upper arm bone is forced out of the shoulder socket. There are four causes of shoulder instability:

  • ligament laxity
  • repetitive strain
  • shoulder subluxation and dislocation
  • “winging” of the shoulder blade

Ligament Laxity – A ligament is band of fibrous tissue that connects bone to bone. It holds joints together and keeps them stable. When the ligaments are loose, the stability of the shoulder becomes threatened.

Repetitive Strain – Repetitive overhead motion can also cause ligament laxity and shoulder instability. This can occur in the course of working and playing sports, such as baseball, tennis, and swimming.

Shoulder Subluxation and Dislocation – Subluxation occurs when the ball of the upper arm bone partially comes out of the socket. Dislocation means the ball completely leaves the socket. Shoulder dislocation is often caused by severe injury. When the upper arm pops out of the socket, the ligaments in the front of the shoulder are often injured. The cartilage ring around the socket, called the labrum, may also tear. Once the shoulder dislocates, it becomes susceptible to further episodes.

“Winging” of the Shoulder Blade – A winged shoulder blade is a condition where the shoulder blade abnormally protrudes from a person’s upper back. It causes considerable pain and muscle weakness. It may also be characterized by shoulder fatigue. Winging of the shoulder blade is caused by nerve injury due to major trauma.

Shoulder instability is best evaluated by MR arthrography. It involves the use of contrast material, and is a 2-part examination. The first segment is done with the assistance of an x-ray machine called a C-Arm. The second part is the MRI exam of the joint.

ARTHRITIS – Arthritis is a “wear-and-tear” disease of joint cartilage. Articular cartilage is a white, smooth tissue that covers the ends of bones within a joint. Healthy cartilage enables bones to glide over each other with minimal friction. When the cartilage becomes damaged, pain and swelling result. Bone spurs also develop where the ends of bones rub together. Age increases the incidence of arthritis. However, an injury such as shoulder dislocation can also cause arthritis in young people.

Symptoms of arthritis are:

  • Pain
  • Limited Range of Motion
  • Clicking or Grating Sounds
  • Muscle Weakness or Atrophy – a decrease in the mass of muscle

Arthritis is diagnosed with x-rays, MRI scans, blood tests, and analysis of joint fluid.

FROZEN SHOULDER – Frozen shoulder is medically known as “adhesive capsulitis.” It is a condition where the connective tissue around the joint, called the “capsule,” becomes inflamed and stiff. It is characterized by severely limited motion and chronic pain. The pain is typically constant and worse at night. Certain movements or bumps can result in sudden intense pain and cramping that can last several minutes.

Injury or trauma can lead to a frozen shoulder. When a person tries to avoid the pain of injury by not moving the shoulder, the capsule “freezes up.”


What is the rotator cuff? – The rotator cuff is a group of muscles and their tendons that form a “cuff” over the shoulder joint. These muscles raise and rotate the arm. They also stabilize the ball of the upper arm within the socket of the joint.

What causes a tear? – A rotator cuff tear may be caused by acute injury, such as a fall. Improper lifting of a heavy object can tear tendons. Injury can be the result of chronic wear and tear of the tendons. In people over 40, impingement is the major cause. Repetitive overhead movement can impact the rotator cuff, causing inflammation and tear. Bone spurs that develop with arthritis can irritate and fray tendons.

What are the symptoms of a tear? – The primary symptom is pain over the top and front of the shoulder and the side of the arm. The pain can radiate from the shoulder through the arm. Muscle weakness is present, which makes it difficult to perform overhead motions or reach behind the back. You may hear crackling of the shoulder with certain movements. Sleeping is often difficult, limited by pain.


For all the above shoulder conditions, physical therapy is the ideal approach to treatment. It involves the use of the following methods:

  • Applications of Heat and Cold
  • Electrical Stimulation
  • Ultrasound
  • Range of Motion Services
  • Massage
  • Stretching
  • Strengthening Exercises
  • Dry Needling

Applications of Heat and Cold – Heat works to warm up muscles, reduce stiffness, and promote flexibility. It also increases blood flow to injured areas, providing them with nutrients and oxygen, which speeds healing. Application of an ice pack decreases swelling and pain.

Electrical Stimulation – Transcutaneous Electrical Nerve Stimulation is a treatment that uses electricity to relieve pain. The TENS modality involves placing electrode pads on the skin over a painful body part. The electrodes are connected to a machine that emits small waves of electricity, sending comfortable electrical impulses to the injured area. The impulses interrupt pain messages sent from the nerves to the brain. Consequently, the brain doesn’t register pain. The current also stimulates the body to produce its own pain-relieving chemicals known as “endorphins.”

Ultrasound – Ultrasound creates high-frequency, inaudible sound waves that are directed deeply into tissues. The vibrations of the sound waves warm and increase blood flow to the shoulder.

Range of Motion Services – Your physical therapist will take measurements of how far you can move your arm independently. This gives him a benchmark for evaluating your future progress. Knowing your starting point enables him to set goals for treatment. Toward this end, he will perform “Passive Range of Motion.” This involves gently moving the arm beyond the point where you can. “Active Assistive Range of Motion” is done by you with some help from the therapist or equipment, such as a pulley. “Active Range of Motion” is performed by you without any assistance. The end result of all three methods is increased flexibility and movement. Range of Motion Services are vital in preventing a frozen shoulder.

Massage – Deep tissue massage realigns deeper layers of muscles and connective tissue. It utilizes some of the same strokes of classic massage therapy. However, the movement is done more slowly. The pressure is also deeper. It smooths the fascia, which is a sheath of fibrous tissue that covers a muscle. The fascia provides a gliding surface for muscles. When the fascia is injured, its collagen fibers become rigid bands known as “adhesions.” These adhesions and scar tissue impair free muscle movement. Deep tissue massage eliminates these restrictive tissues.

Stretching – This increases flexibility in the shoulder. It facilitates the ability to perform normal activities. It prevents scar tissue from forming. Stretching differs from Range of Motion Services in that it moves a joint beyond the point of limitation by degrees. It is important to perform this both in physical therapy and at home.

Strengthening Exercises – Strengthening of the shoulder muscles promotes joint stability and protects you from re-injury. Strengthening exercises are a core component of the Home Exercise Program your physical therapist will design for you.

Dry Needling – This procedure utilizes very fine needles, like those of acupuncture. The needles are introduced into areas called “trigger points.” These are tiny, tender knots that form in muscles which are overworked or injured. When touched, these hypersensitive knots cause pain to intensify and spread. Dry needling releases the tension in muscle fibers. This facilitates movement and relieves pain.


Now you have an understanding of the causes of chronic shoulder pain, including rotator cuff tears. Armed with this information, you can obtain the vital care needed to return to your normal activities. Won’t that be great!

For further information about Range of Motion Physical Therapy, Lucan Village, Dublin, Ireland, please click here:

Proof Preferred, based out of Venetia, Pennsylvania, is a supplier of wireless devices for range of motion and muscle testing, as well as associated integrated software modules. These devices are used by physical therapists to develop their treatment plans.