By Mark Howlin

Associate Physiotherapist, Musculoskeletal & Sports Injuries (BSc, MSc, GEMt) · Registered with the AHPRA (PHY0004060355)

Mark Howlin is an Associate Physiotherapist at Physio K, with a focus on sporting injuries and post-operative rehabilitation, with advanced dry needling training from Ireland and Sydney. Across six years of clinical practice in Ireland and Australia, he has developed particular experience in chronic conditions such as anterior knee pain and Achilles tendinopathy, and acute lower limb muscle strains, using an integrated approach combining manual therapy, dry needling, and progressive rehabilitation. He has also served as team physiotherapist to elite GAA athletes, including during a championship-winning run at Croke Park

Read more about Mark →

Last reviewed: 31 August 2026

Shoulder Pain: Causes, Diagnosis, and Treatment: What to Expect

Shoulder pain describes a range of musculoskeletal conditions affecting the shoulder joint, rotator cuff tendons, bursa, and surrounding structures. Most people experience pain with overhead movement, difficulty reaching, and night pain when lying on the affected side. The majority of shoulder problems respond well to structured physiotherapy and exercise-based rehabilitation.

Fast facts

Common symptoms: Pain with overhead movement, reaching behind, or lying on the affected shoulder; weakness or stiffness; difficulty with dressing, hair care, or lifting

Who it affects: Common across all age groups; rotator cuff and degenerative conditions more frequent in middle-aged and older adults; instability and acute injuries more common in younger, active populations

Typical recovery: Variable by diagnosis; many non-traumatic shoulder conditions show meaningful improvement within 3 to 6 months with structured rehabilitation; some conditions such as frozen shoulder may require 12 to 18 months

What is shoulder pain?

Shoulder pain is a broad term covering several distinct conditions causing discomfort and movement restriction around the shoulder. The shoulder is the most mobile joint in the body, made up of three true joints: the glenohumeral joint where your upper arm connects to your shoulder blade, the acromioclavicular joint where the shoulder blade meets the collarbone, and the sternoclavicular joint where the collarbone meets the breastbone. A fourth structure, the scapulothoracic joint, describes how the shoulder blade glides over the ribcage.

The most common shoulder problems include rotator cuff related pain, where the tendons that stabilise the upper arm become overloaded or torn; subacromial pain, involving inflammation of the bursa or compression of structures under the bony roof of the shoulder; frozen shoulder, characterised by capsular inflammation and stiffness; and osteoarthritis, where cartilage wears down. Less common causes include shoulder instability and referred pain from the neck.

When you reach overhead, the shoulder blade must rotate and tilt to keep the joint space open. If that coordination breaks down, often called scapular dyskinesis, the tendons and bursa can become pinched, leading to pain even when the structures themselves are relatively healthy. At Physio K, we assess not just where the pain is, but how the entire shoulder complex moves, because tightness in the mid back or altered movement patterns from the neck can drive shoulder symptoms.

"I always find myself correcting people referring to their shoulder pain diagnosis as 'impingement'. Impingement is an umbrella term for pain of a structure that is being impinged under the subacromial space, but the word 'impingement' doesn't give us much to work with as physios. It is important to find out what is causing the symptoms and what biomechanical and strength issues are present to correct this," says Mark Howlin, Associate Physiotherapist at Physio K.

What it feels like: symptoms and signs

Most people describe a deep ache or sharp pain around the top and side of the shoulder that worsens when you lift your arm or reach overhead. Lying on the affected shoulder at night is often impossible, and many patients report being woken repeatedly when they roll over. Everyday tasks such as reaching into the back seat of the car, doing up a bra strap, or washing your hair become frustrating or impossible.

Weakness is common, though it can be difficult to tell whether the arm feels weak because it hurts or because the muscles have lost strength. Some conditions, particularly frozen shoulder, cause marked stiffness where both you and the physiotherapist struggle to move the arm. Others, such as rotator cuff tendinopathy, show a painful arc: the arm moves freely at the start, hurts through a specific range, then eases again at the top.

In the acute stage, pain is often intense and reactive. Subacute presentations settle into more localised pain, developing weakness, and emerging stiffness. Chronic shoulder pain tends to present as persistent aching, reduced function, and compensatory movement patterns where you start hiking your shoulder or twisting your body to avoid using the painful arm properly.

If you experience unexplained weight loss, fever, night sweats, a history of cancer, severe pain after significant trauma, marked weakness or numbness in the arm, or signs of infection such as redness and heat around the joint, seek urgent medical assessment.

What causes it and who is at risk

Shoulder pain arises from a combination of structural changes, biomechanical overload, and movement dysfunction. Rotator cuff problems typically develop when the tendons are asked to do more than they can tolerate, whether that is a sudden increase in overhead work, repetitive lifting, or gradual wear with age. Subacromial bursitis often coexists with tendon problems, as the bursa sits in the same space and becomes irritated when the tendons thicken or the shoulder blade does not move properly.

Frozen shoulder, where the joint capsule becomes inflamed and then fibrotic, is more common in people with diabetes, thyroid disease, or a previous shoulder injury. Osteoarthritis develops as cartilage wears down, typically in older adults or following previous trauma. Instability is more common in younger people, particularly those who have dislocated the shoulder or participate in contact or overhead sports.

Modifiable risk factors include high volumes of overhead work in trades such as painting or electrical work, repetitive manual handling, prolonged desk work with poor posture, and participation in overhead sports such as swimming, cricket, tennis, or throwing codes. Smoking, low physical activity, obesity, and inadequate rehabilitation after a previous injury all increase the risk of chronic shoulder pain or slow recovery.

For overhead athletes, the shoulder is under constant demand. Swimmers can perform thousands of shoulder rotations per week, and

if the rotator cuff or scapular muscles are not strong enough to control that load, pain is common. Tradespeople who work with their arms above shoulder height face similar challenges, and office workers who sit with rounded shoulders gradually lose mid back mobility, which forces the shoulder to compensate.

A systematic review published in the Scandinavian Journal of Rheumatology (2004) found that shoulder pain affects between 7 and 26 per cent of adults at any one time, with lifetime prevalence reported as high as 67 per cent in some populations, making it one of the most common musculoskeletal complaints in primary care.

How it is treated and what recovery looks like

Physiotherapy is typically the first line of treatment for shoulder pain. The initial assessment involves a detailed history to understand what triggered the pain, how it behaves, and what you have already tried. We then assess your movement, strength, and scapular control, looking not just at the shoulder itself but at the neck, mid back, and posture.

Treatment centres on progressive exercise to restore strength, control, and range of motion. For rotator cuff and scapular muscles, this usually starts with low-load exercises to build endurance and control, then progresses to heavier resistance as the tendons adapt. Range of motion work is essential, particularly in frozen shoulder or after surgery. We also retrain functional movement patterns so you learn to use your shoulder blade, mid back, and shoulder joint together properly.

Manual therapy, including joint mobilisation and soft tissue techniques, is used to reduce pain, improve joint and capsular mobility, and optimise movement of the shoulder blade and thoracic spine. Dry needling may be used by trained practitioners to address muscle tension and pain. Taping can provide feedback and support during rehabilitation, though it is always used alongside active exercise.

A clinical guideline published in Musculoskeletal Care (2021) recommends that shoulder pain be classified as acute or chronic, traumatic or spontaneous, with red flag screening followed by analgesia plus rehabilitation including exercises as the core treatment, reserving imaging and specialist referral for specific indications.

Most people are prescribed simple pain relief such as paracetamol or non-steroidal anti-inflammatory drugs by their GP to help them engage in rehabilitation. Corticosteroid injections into the subacromial space or glenohumeral joint can provide short-term pain relief in selected patients, especially where pain is limiting exercise.

Surgery is considered when there is significant structural damage, such as a full thickness rotator cuff tear causing loss of function, recurrent instability, or advanced osteoarthritis, or when a well-delivered physiotherapy programme over several months has not achieved acceptable improvement. However, research continues to show that outcomes after surgical intervention and conservative management are often very similar, sometimes better in the strength rehabilitation group, particularly for rotator cuff related pain. As Mark explains, "Rotator cuff related pain patients often ask if they will require surgery. This topic is very case dependent, but research continues to show that outcomes after surgical intervention and conservative management and rehabilitation are very similar, sometimes better in the strength rehab group. Some full thickness tears resulting in a loss of function may benefit from surgical repair, but if function isn't affected, a lot of the time conservative management is the way to go."

Recovery timelines vary by diagnosis. Many non-traumatic shoulder pain conditions respond well to structured rehabilitation over 3 to 6 months, though some, such as frozen shoulder, can take 12 to 18 months to resolve fully. Early physiotherapy is generally associated with better outcomes and a lower risk of chronic pain.

For people who participate in overhead or upper limb dominant sports, the question is almost always about when they can get back. At Physio K, we work with you to manage symptoms while maintaining as much participation as possible, using a graded return to training based on symptom control and progressive re-loading.

Different approaches at Physio K

At Physio K, we offer both physiotherapy and massage therapy for shoulder pain, and the two approaches complement each other well.

Physiotherapy focuses on assessment, diagnosis, and active rehabilitation. Your physiotherapist will assess your movement, strength, and scapular control, identify the contributing factors behind your pain, and design a progressive exercise programme to restore function and build resilience. Treatment typically includes manual therapy, dry needling where appropriate, and education about load management and activity modification.

Massage therapy addresses muscle tension, pain, and soft tissue restrictions around the shoulder, neck, and upper back. Your massage therapist will use techniques such as deep tissue massage, trigger point release, and myofascial release to reduce tightness in the rotator cuff, scapular muscles, and upper trapezius. Massage can be particularly helpful in the early stages when pain and muscle guarding are high, or as part of ongoing management to maintain tissue health.

The two approaches work well together: massage therapy can reduce pain and muscle tension, making it easier to engage in the strengthening and movement work your physiotherapist prescribes, while physiotherapy addresses the biomechanical and strength issues that contributed to the problem in the first place.

What the research shows

Current clinical practice guidelines emphasise early assessment, red flag screening, and structured rehabilitation as the foundation of shoulder pain management. A systematic review of clinical practice guidelines published in the Archives of Physical Medicine and Rehabilitation (2024) synthesised recommendations from multiple international guidelines and found that history, clinical examination, and red flag screening are central to diagnosis, while paracetamol, oral non-steroidal anti-inflammatory drugs, and exercise-based rehabilitation are commonly recommended treatments across shoulder pain disorders, with limited routine need for MRI.

The review noted that imaging such as MRI is not required before starting physiotherapy in most cases, and can sometimes be unhelpful, as many people without any shoulder pain show rotator cuff tears or degenerative changes on scans. What matters is the clinical picture: how you move, what hurts, what you can and cannot do, and how the problem responds to treatment.

Exercise therapy is consistently recommended as the core treatment for most shoulder conditions. A large body of evidence supports progressive resistance training for rotator cuff related pain, with studies showing that strengthening the rotator cuff and scapular muscles reduces pain and improves function over 3 to 6 months. The key is that the exercises are tailored to your current capacity and progressed gradually as your tendons adapt.

Manual therapy, including joint mobilisation and soft tissue techniques, is supported as an adjunct to exercise, particularly in conditions such as frozen shoulder where capsular stiffness limits movement, and in subacromial pain where improving thoracic and scapular mobility can reduce compression. The evidence generally supports manual therapy working best when combined with exercise.

For frozen shoulder specifically, the evidence supports a combination of manual therapy to restore capsular mobility and progressive stretching and strengthening exercises. Corticosteroid injections can provide short-term pain relief and may help in the early inflammatory stage, but the long-term outcome depends on rehabilitation.

The research also highlights the importance of load management, particularly for overhead athletes and manual workers. Tendon pain is fundamentally a load tolerance problem: the tendon is being asked to do more than it can currently manage. The solution is not complete rest, which weakens the tendon further, but a carefully graded increase in load that allows the tendon to adapt and build capacity over time.

When to seek urgent help

Most shoulder pain is not an emergency, but certain symptoms require prompt medical assessment. Seek urgent help if you experience severe pain after a fall or direct blow to the shoulder, particularly if the shoulder looks deformed or you cannot move it at all, as this may indicate a fracture or dislocation. Unexplained weight loss, fever, night sweats, or a history of cancer require investigation to rule out serious underlying disease.

Marked weakness or numbness in the arm, particularly if it came on suddenly, may indicate nerve compression or a neurological problem. Redness, heat, and swelling around the shoulder joint, especially if accompanied by fever, may indicate infection and requires immediate medical attention.

If you are unsure whether your symptoms require urgent assessment, contact your GP or present to an emergency department.

Common questions

What is causing this pain in my shoulder?

Shoulder pain is usually caused by overload or irritation of the rotator cuff tendons, subacromial bursa, or joint capsule, often driven by repetitive overhead movement, poor scapular control, or reduced mid back mobility. At Physio K, we assess not just the painful area but the whole shoulder complex, because the problem is often not where the pain is. We look at how your shoulder blade moves, whether your mid back is stiff, and whether the muscles around the shoulder are strong enough to control the loads you are asking them to manage. Once we identify what is being overloaded and why, we can design a clear treatment plan to reduce pain and restore function.

Do I need a scan to find out what is wrong?

Most of the time, no. A thorough clinical assessment, including your history, how the pain behaves, and how you move, gives us the information we need to diagnose the problem and start treatment. Scans such as MRI can be helpful when we suspect a full thickness rotator cuff tear, significant structural damage, or if the problem is not responding to treatment as expected, but they are not required before starting physiotherapy. In fact, scans often show degenerative changes or small tears in people who have no pain at all, so what shows up on an image does not always match what you are feeling. We focus on the clinical picture: what hurts, what you can and cannot do, and how the problem responds to treatment.

Will I need surgery, or can physiotherapy fix this?

The majority of shoulder problems respond well to structured physiotherapy and exercise-based rehabilitation, and surgery is rarely the first option. Research shows that outcomes after surgical intervention and conservative management are often very similar, sometimes better in the strength rehabilitation group, particularly for rotator cuff related pain. Some full thickness tears that cause a loss of function may benefit from surgical repair, but if function is not significantly affected, conservative management is usually the way to go. At Physio K, we work with you to build strength, restore movement, and manage your load so you can get back to what you need to do. If surgery does become necessary, the rehabilitation work you do beforehand can support a better outcome afterwards. Always speak to your treating practitioner and get a second opinion if you are unsure.

How long will it take to get better?

Recovery timelines vary depending on the diagnosis and how long the problem has been there. Many non-traumatic shoulder conditions show meaningful improvement within 3 to 6 months with structured rehabilitation, though some, such as frozen shoulder, can take 12 to 18 months to resolve fully. For overhead athletes, the question is almost always about when they can get back to training or playing. At Physio K, we work with you to manage symptoms while maintaining as much participation as possible, using a graded return based on symptom control and progressive re-loading. The timeline depends on how well your symptoms settle and how your tissues respond to load, so it is different for everyone, but we will give you a realistic expectation and adjust the plan as you progress.

This article is for general information only and is not a substitute for personal medical advice. If you have concerns about your health, please consult a qualified clinician or your GP.