Shoulder Pain—Is It Actually Your Shoulder?

Ah, the shoulder. It’s one of the most wonderfully complex joints in the body. And also one of the most misunderstood.

The shoulder is a ball and socket joint, and it happens to be the most mobile joint in the body. The joint itself consists of the head of the humerus and its interface with the “socket” of the scapula/shoulder blade. These two bones have a very intimate relationship and need to move and work smoothly together during all movements of the arm—the fancy term for this is coupled motion, or even better, scapulohumeral rhythm. For that to happen, the scapula also needs to move and adhere effectively on the rib cage, which in turn needs to have a good relationship with the thoracic spine, pelvis, and diaphragm. These movements are assisted by the many muscles surrounding your shoulder joint and thorax—muscles of your rotator cuff, biceps, deltoid, serratus, rhomboids, pecs, and even your core. In addition, you also have some pretty complex cartilage and ligaments going on there that serve to stabilize the joint. Not to mention, the shoulder has close proximity to the cervical & thoracic spine and associated nerves and blood vessels, which adds in a whole other degree of complexity. Whew! A lot going on here, yeah?

All that being said, shoulder complaints are one of the most common things I see in my office. Because of their complexity, they are one of my favorite things to treat. Each case is like a unique puzzle. And also because of their complexity (and with the advancement of medical imaging technology), injuries here are often misdiagnosed.

What if I told you that there is a good chance your shoulder pain isn’t even coming from your shoulder? Does your shoulder pain cause pain in/under your shoulder blade? Does it ever go into your neck or radiate down your arm? Does your neck or mid back ever feel stiff when your shoulder is acting up? Do you ever get numbness or tingling with your shoulder pain? These are all symptoms that indicate this could actually be a problem originating in your neck or mid-back! True shoulder injuries rarely (if ever) cause pain in the shoulder blade, and they certainly don’t cause numbness/tingling. But these are both extremely common things that neck/mid-back injuries do. And even if you don’t have any of those symptoms, it’s still a possibility that your shoulder pain is being generated from your spine.

Remember how I mentioned the close proximity of your shoulder to your cervical & thoracic spine? That’s why issues at the spine commonly manifest at the shoulder. This can even happen with ZERO neck or mid back pain. In fact, there have been recent studies showing the prevalence of this actually happening. In one particular study (linked here), 47% of isolated shoulder pain in the patients they studied was originating in the spine. That’s almost freaking HALF, people. (I’ve had the privilege of learning under one of the authors of this study, and he and his colleagues are trailblazers in some really cutting edge advancements in the rehab world.) So long story short, if you are seeking care for a shoulder complaint (or ANY extremity complaint, for that matter) and haven’t at least had your spine screened as a potential contributor to the problem, there is almost a 1 in 2 chance something is being missed/overlooked.

Let me tell you a little story.

I have a patient who was advised to get shoulder replacement surgery before ever coming to see me. He’s very active and has had his fair share of traumas to his shoulder throughout his life. He was now experiencing pretty severe pain, and his range of motion was also extremely limited, to the point he was having significant trouble doing simple daily tasks. He received an x-ray and MRI of his shoulder that showed quite a bit of anatomical wear and tear. Because of this, and because of his age (he’s in his 50s), he was advised to have a shoulder replacement surgery done. He even had the surgery scheduled. Luckily a friend (who happened to be a patient of mine) recommended he come to me to get a second opinion before going through with it. When I examined him, he could hardly reach his arm behind his back, and most movements were painful. Pretty life-altering stuff. I explained that it’s common for shoulder symptoms to be originating in the spine and asked if I could perform a couple screens to see if this was true for him or not—I wanted to make sure I didn’t miss anything.

Sure enough, during my screen of his neck, we started seeing rapid, dramatic changes in his shoulder. His pain started decreasing, and his range of motion started clearing up. By the end of treatment, he could reach fully behind his back and above his head pain free—something he hadn’t done in weeks. And the craziest part—I didn’t even touch his shoulder during treatment. I sent him home with the same neck exercises we had done during the appointment, told him to be diligent with them, and come back in a few days. Even when he returned, his symptoms had remained abolished, and they have remained abolished to this day. Full and free range of motion, no pain, and ability to do daily activities he was previously limited in. Long story short, we were both happy, and he ended up canceling his surgery. In my book, that’s a massive win.

But this wasn’t just a crazy, once-in-a-lifetime case. I’ve seen COUNTLESS patients at this point who have sought therapy for rotator cuff injuries, been referred for surgery, or even who have had “failed” shoulder surgeries, and the pain has ended up being generated from their neck or mid back. The reaction when we figure this out is almost always a mixture of sheer joy, relief, and also frustration at their previous misdiagnosis.

The purpose of these stories is not to throw any other profession or clinician under the bus. We are all humans who make mistakes every day with our patients—myself certainly included. But it does highlight the complexity and interrelatedness of the human body and the need for thorough assessments and diagnoses before recommending invasive and expensive treatment options like surgery. And as the research progresses, we are seeing a higher and higher prevalence of “false positives” with the premature utilization of imaging. A lot of the scary-sounding findings on x-rays or MRIs (arthritis, degenerative discs, rotator cuff tears, etc.) end up being completely normal, age-related findings that are often not primary drivers of pain. (For a more in depth look at that, I have an entire separate blog dedicated to that here).

Don’t get me wrong, sometimes in cases presenting almost identically to this, we screen the neck and mid-back and come up with absolutely nothing. In those instances—great! Then we can at least be fully confident it’s a shoulder injury we’re dealing with, and we can treat it accordingly. Shoulder injuries should be treated like shoulder injuries, and shoulder injuries coming from the neck should be treated at the neck. And sometimes surgery is needed! But I would never recommend surgery for a musculoskeletal complaint without a trial of rehabilitative/conservative care first.

All this to say, when seeking care for a muscle or joint related pain/injury, it’s important to see a professional who is able to assess and classify your specific condition, not just throw a blanket diagnosis at it, run you through a cookie-cutter treatment plan, or send you straight to get an MRI or surgery. Also, I’m not sure who needs to hear this, but this is also why you shouldn’t rely on Instagram or YouTube videos to diagnose and treat your pain. These can be awesome resources, but they should never replace a proper evaluation and treatment plan from a professional.

Hopefully this has been insightful, and if you’re someone who battles shoulder pain, my goal is that you feel more informed and empowered about making decisions when it comes to seeking care. You are ultimately in charge of all the choices regarding your body, and if you don’t feel comfortable with one professional’s opinion or recommendation, it’s never a bad thing to seek out a second perspective.

If you have any further questions, don’t hesitate to reach out! You can shoot me an email or give me a call via the contact tab. Thanks for reading, friends!