Written by Harry Carter - UPG Physiotherapist
This is true for clinicians, athletes and the general public. Between feeling tight, having aches, persistent clicking, spending more and more time at a desk or on our phones. If you've ever has more than just discomfort, and taken the first step to “sort out” your crook shoulder, you may have had a scan or spoken to your health professional, and come across these terms or diagnoses before;
subacromial shoulder pain
rotator cuff tendinopathy
painful arc syndrome
subacromial impingement
rotator cuff tendinosis
supraspinatus tendinitis
impingement syndrome
subacromial bursitis
and many more similar confusion labels,
These are what you call a ‘patho-anatomical diagnosis’. Meaning, we take a look a structures of your shoulder, observe any potential “wear” or abnormalities compared to what a perfect textbook shoulder would look like, while ignoring to look at the person attached to it.
Studies dating as far back as 2003, and reaffirmed as recent as 2024, would tell us that many structural findings on shoulder imaging are common in people without pain or dysfunction, making it somewhat unreliable in accurately diagnosing the cause for those with shoulder pain and those who are symptom free. More specifically, they collated scans between healthy and ‘subacromial impingement’ suffering 40 - 60 year olds, and found that many scans in the “healthy”/asymptomatic individuals looked the same as those with shoulder dysfunctions.
Now, that's not to discredit scans entirely. They can be an important component of diagnosing and managing certain injuries, particularly when there is a genuine concern for significant structural pathology. But when it comes to persistent, non-traumatic shoulder pain, imaging can sometimes muddy the waters.
Once we see a tendon that is “degenerative”, a bursa that is “inflamed”, or narrowing around the shoulder, it's very easy to fall into a trap of building a story around that finding: “that's what's causing your pain, so that's what we need to fix.”
The problem we have found is that these findings are often present in people without pain, too. The scan can therefore inadvertently narrow our thinking, rather than broaden our understanding of why this particular person is struggling.
So, instead of asking “which structure is causing the pain?”, we can ask a much more useful question: “what is contributing to this person's experience, and what can we change?” As such, contemporary research would recommend using that “patho-anatomical” information as a piece of the puzzle, and to zoom out and look more holistically at the body and daily loads the individual undertakes.
While that sounds great, what does that actually mean? Lets add the other pieces of the puzzle;
What movements do you struggle with? What limits you? Is it pain or something else?
How do your usual positions and postures affect your symptoms?
Are your tight muscles weak? or overburdened with compensation?
Is this a recent change, or has your capacity to tolerate a particular load gradually changed over months?
Is your restriction actually coming from elsewhere? And your shoulder has finally hit its limit for compensating for neck or back stiffness
We know that age-related changes and degeneration is normal, but living with persistent pain and loss of function shouldn't be dismissed as inevitable. This is where Physiotherapy can be really valuable, as it can oftentimes be too hard to objectively “zoom-out” and check our own biases to see where our fundamental issues are coming from.
A physiotherapist can help break down your “meaningful movements”, find the broken links in your chain of daily activities, and help pave the way forward into better physical health.
The end-goal really is not to try and find a single structure to blame, but to rather understand the whole picture. This is where using Google to self-treat with a generic cookie-cutter protocol can fail to understand the full picture.