Shoulder Clinic

Support for shoulder pain, stiffness and reduced movement

Shoulder problems can make everyday activities such as reaching, dressing, lifting, sleeping, driving or exercising uncomfortable or difficult. Symptoms may begin after an injury, develop gradually through repeated activity or appear without one clear cause.

A shoulder assessment looks at how the joint moves, how the surrounding muscles are working and how your symptoms affect the activities you need or want to do. Physiotherapy may include exercise, movement advice and other treatment depending on the cause and presentation of the problem.

When a shoulder assessment may help

You may benefit from an assessment if you are experiencing:

• Shoulder pain during everyday movement
• Difficulty lifting your arm overhead
• Pain when reaching behind your back
• Shoulder stiffness or restricted movement
• Weakness when lifting or carrying
• Pain when lying on the affected side
• Pain during gym or sporting activities
• Symptoms following a fall or other injury
• A feeling that the shoulder is unstable
• Previous shoulder dislocation
• Recurring shoulder problems
• Reduced movement after surgery
• Difficulty returning to work, exercise or sport
• Pain that extends into the upper arm

Different shoulder conditions can produce similar symptoms, so assessment is useful for understanding how the problem is affecting movement and deciding which treatment approach may be appropriate.

Understanding shoulder pain

The shoulder allows a large amount of movement and depends on several joints, muscles and tendons working together.

Pain does not always come from one clearly identifiable structure. The way symptoms behave, how the shoulder moves, muscle strength, recent activity and previous injuries may all provide useful information during an assessment.

Some shoulder problems are mainly associated with pain and weakness, while others cause significant stiffness or a feeling of instability. Treatment therefore needs to reflect the individual presentation rather than using the same exercises for every shoulder problem.

What happens during your first appointment?

Your first appointment begins with a discussion about your symptoms and how they affect your daily activities.

The physiotherapist may ask:

• When the symptoms started
• Whether there was an injury
• Which movements cause discomfort
• Whether the pain affects sleep
• Whether you experience weakness or instability
• What work or physical activities you regularly perform
• Whether you participate in sport or gym training
• Whether you have had a previous shoulder injury
• Whether you have had injections, scans or surgery
• What activities you would like to return to

The physical assessment may look at:

• Shoulder movement
• Muscle strength
• Shoulder-blade movement
• Neck and upper-back movement where relevant
• Areas of pain or sensitivity
• Movement against resistance
• Lifting, reaching or carrying
• Sport or work-related movements where appropriate

The findings help guide the treatment plan and identify whether physiotherapy is suitable or whether further medical assessment may be needed.

What treatment may include

Treatment will depend on your symptoms and assessment.

Movement and mobility exercises

Exercises may be used to maintain or improve shoulder movement, particularly if stiffness is making everyday activities difficult.

The amount and type of movement will depend on the condition. For example, frozen shoulder rehabilitation commonly includes exercises aimed at maintaining or improving mobility and strength.

Strengthening exercises

Strengthening may focus on the muscles around the shoulder, shoulder blade and upper body.

Exercises usually begin at a manageable level and are gradually progressed according to symptoms and ability.

Movement control

Some shoulder problems involve difficulty controlling the position of the shoulder or shoulder blade during reaching, lifting or sporting movements.

Rehabilitation may therefore include exercises that focus on coordination as well as strength.

Manual therapy

Hands-on techniques may sometimes be used to help with stiffness or restricted movement. These are generally combined with exercises and active rehabilitation rather than being the only part of treatment.

Activity advice

You may receive advice on temporarily modifying movements that aggravate the shoulder while continuing with activities that remain manageable.

The aim is usually to find an appropriate level of activity rather than unnecessarily stopping all movement.

Home exercise programme

Exercises to complete between appointments are commonly included. These can be adjusted as your movement, strength and tolerance change.

Rotator cuff-related shoulder pain

The rotator cuff is a group of muscles and tendons that helps move and control the shoulder.

Problems involving this area may cause pain when lifting the arm, reaching overhead, carrying objects or lying on the affected side. Some people also notice weakness or discomfort during repeated movements.

Physiotherapy and exercise are commonly used in the management of rotator cuff-related shoulder problems.

Rehabilitation may focus on:

• Gradually restoring comfortable movement
• Building shoulder strength
• Improving control during reaching
• Increasing tolerance to lifting
• Gradually returning to work, gym or sport

The exercises used will depend on which movements are currently difficult rather than relying on one standard rotator cuff programme.

Frozen shoulder

Frozen shoulder is a condition where the shoulder becomes painful and significantly restricted in movement. Everyday activities such as dressing, reaching overhead or reaching behind the back can become difficult.

Symptoms can change over time, so the treatment approach may also need to change.

Physiotherapy may include:

• Advice on maintaining movement
• Gentle mobility exercises
• Strength exercises when appropriate
• Guidance on managing daily activities
• Gradual progression as movement improves

Recovery can take time, and exercises should generally be matched to how irritable and restricted the shoulder is rather than forcing movement aggressively.

Shoulder instability and dislocation

Shoulder instability can create a feeling that the joint is loose, unreliable or likely to move out of position.

For some people, instability begins after a dislocation or traumatic injury. Others may experience repeated instability without one major injury.

Physiotherapy often focuses on strengthening and improving the coordination of the muscles that help control the shoulder.

Rehabilitation may include:

• Shoulder strengthening
• Shoulder-blade control
• Balance and joint-position exercises
• Gradual reaching exercises
• Weight-bearing through the arm
• Sport-specific or overhead movements
• Preparation for returning to normal activity

If instability continues despite rehabilitation, further medical or orthopaedic assessment may sometimes be required.

Shoulder pain after an injury

A shoulder injury may occur after a fall, collision, sudden pull, heavy lift or sporting movement.

Depending on the injury, symptoms may include:

• Pain
• Swelling
• Reduced movement
• Weakness
• Difficulty lifting the arm
• Instability
• Difficulty sleeping on the shoulder

The early stages of rehabilitation may focus on protecting the injured area while maintaining appropriate movement. Exercises can then progress towards restoring mobility, strength and normal use of the arm.

More significant injuries, suspected fractures or dislocations require appropriate medical assessment before routine rehabilitation.

Rehabilitation after shoulder surgery

Physiotherapy commonly forms part of recovery following procedures such as rotator cuff repair or shoulder stabilisation surgery. Rehabilitation needs to follow the restrictions and timescales provided by the surgical team.

Early rehabilitation may focus on protecting the surgical repair while maintaining movement within an appropriate range.

Later stages may include:

• Restoring shoulder movement
• Rebuilding strength
• Improving control
• Increasing lifting tolerance
• Returning to work
• Returning to gym activity
• Sport-specific rehabilitation

The progression can vary considerably depending on the procedure, so rehabilitation after surgery should not follow the same timeline as a non-surgical shoulder problem.

Shoulder pain at night

Shoulder pain can sometimes become more noticeable at night, particularly when lying on the affected side.

You may need to experiment with sleeping positions or use pillows to support the arm in a more comfortable position. Managing the underlying shoulder problem through appropriate movement and rehabilitation may also help as symptoms improve.

Persistent night pain should be discussed during your assessment, particularly if it is severe, unexplained or accompanied by other symptoms.

Work-related shoulder problems

Shoulder symptoms may affect people whose work involves:

• Repeated reaching
• Working overhead
• Lifting and carrying
• Manual handling
• Repetitive arm movements
• Prolonged use of tools
• Desk-based work

The assessment can consider the specific movements required for your job.

Rather than simply avoiding these activities, rehabilitation may focus on gradually improving your ability to tolerate them through strengthening, movement practice and temporary changes to workload where appropriate.

Shoulder problems during sport and exercise

Different sports place very different demands on the shoulder.

Swimming, tennis, cricket, gym training and other overhead activities require repeated movement and control through larger ranges. Contact sports may place additional demands on shoulder stability.

Rehabilitation may therefore progress beyond basic exercises towards movements that reflect the activity you want to return to.

This could include:

• Overhead strengthening
• Pressing or pulling
• Throwing movements
• Weight-bearing through the arm
• Gym exercises
• Repeated reaching
• Faster or more powerful movements

The progression should reflect your symptoms, strength and the demands of the activity.

Returning to lifting and gym training

If shoulder pain has interrupted gym training, returning to previous weights immediately may be difficult.

Rehabilitation may begin with movements that are comfortable and easier to control before gradually increasing resistance and range.

Depending on your goals, this may involve progressing towards:

• Rows
• Pressing movements
• Overhead exercises
• Pulling exercises
• Push-ups
• Carrying
• Sport-specific strength exercises

The aim is to gradually rebuild the shoulder’s ability to tolerate the amount of work you need it to perform.

Recurring shoulder problems

If shoulder pain repeatedly returns, the assessment may look at what happens around each episode.

This could include:

• Sudden increases in activity
• Repeated overhead movement
• Strength changes
• Previous injuries
• Incomplete rehabilitation
• Changes in gym or sporting activity
• Work demands

Treatment may then focus on building a longer-term exercise programme rather than only settling the current episode.

Do I need a scan?

Not every shoulder problem requires an X-ray, ultrasound or MRI scan.

A healthcare professional will normally begin by considering your symptoms and examining the shoulder. Imaging may be arranged when it is expected to provide useful information or when another condition or significant injury needs to be investigated.

It is also possible for scans to show changes in shoulder tissues that are not necessarily responsible for a person’s symptoms. Rotator cuff tears, for example, can sometimes be identified on scans in shoulders without pain.

The decision to investigate further therefore needs to be considered alongside the clinical assessment.

When to seek further medical assessment

Some shoulder problems require medical assessment rather than routine physiotherapy alone.

Seek appropriate medical advice following a significant injury if:

• You cannot move the arm
• The shoulder has changed shape
• You think it may be dislocated
• There is significant swelling after trauma
• You develop sudden major weakness
• You experience persistent numbness or loss of sensation
• Pain is severe or rapidly worsening

If concerns are identified during your physiotherapy assessment, you may be advised to seek further investigation or review by another healthcare professional.

Treatment based on what you need to do

Shoulder rehabilitation should reflect the activities that matter to you.

Your goal may be to:

• Dress comfortably
• Sleep without shoulder pain
• Reach into a cupboard
• Lift your child
• Return to manual work
• Exercise in the gym
• Swim
• Play an overhead sport
• Return after surgery
• Feel confident using the arm again

The exercises and rehabilitation plan can be progressed towards these activities rather than focusing only on pain levels.

How many sessions will I need?

The number of appointments depends on the type of shoulder problem, how long symptoms have been present and the level of activity you want to return to.

Some shoulder problems may improve with a relatively short period of advice and rehabilitation. Conditions involving significant stiffness, instability, surgery or a substantial loss of strength may require treatment over a longer period.

Your progress can be reviewed throughout rehabilitation so that the programme changes as your shoulder improves.