Shouldering the burden of how to treat shoulder pain

Shoulders are, in many ways, a marvel. One shoulder has four separate joints, packed with muscles, that allow us to move our arm in eight different major ways, giving us the most degrees of freedom of any joint in the body. We can swim, toss, hug, and even punch because of the movement our shoulders enable.

But the same complexity that allows us such motion also presents opportunities for pain when something goes wrong. Another complication: shoulders change as we age, and new types of injuries come with it. Clinical practitioners face the daunting task of keeping up on the latest developments to treat a range of injuries as wide as Michael Phelps' wingspan.

“It’s not that shoulder problems are unique to one particular age or for one particular group of individuals, but rather that they can arise throughout our lifetime,” said Paul Salamh, visiting associate professor of rehabilitation sciences at Tufts University School of Medicine. “Because we ask our shoulders to do so much, they’re vulnerable to a wide range of issues.”   

It can also be a challenge for health care providers to keep up with all of the latest evidence-based research on treating shoulder injuries. That’s why Salamh served as the lead author on two recently published papers, the research for which was conducted while he worked at the University of Indianapolis, about efforts to help coalesce this information and make it easier for everyone to understand.

In a paper published recently in the International Journal of Sports Physical Therapy, Salamh and other researchers conducted a systematic review of 19 papers on shoulder injuries. That review included four studies encompassing 7,802 athletes in baseball, handball, swimming, tennis, cricket, American football, and also multi-sport athletes and people in the military. The reason to focus on athletes, Salamh said, was because the rate of shoulder and elbow pain in athletes in these “overhead” sports is increasing. A 2022 study estimated that nearly 11% of athletes between the ages of 5 to 18 years old experience a shoulder injury. 

Overall, the research team found five risk factors for athletes developing shoulder pain, two that can’t be changed (local and regional musculoskeletal pain) and three that can (range of motion, strength, and training load).  

These findings are supportive of a drilling-down approach to risk factors specific to body region, sport, and where applicable, position played in that sport, said Salamh, who also serves as director of research for the Doctor of Physical Therapy Phoenix program at the School of Medicine. “There is a lot that can be looked at specifically in each sport. For example, the range of motion that would predispose a swimmer to a shoulder injury is different than that for someone playing lacrosse,” he said, adding that the same is true with strength of muscle or muscle groups within a particular sport. 

In a paper published recently in the Journal of Manual and Manipulative Therapy, Salamh and a team of researchers addressed a decade’s worth of research on the risk factors, etiology, diagnosis, and management of frozen shoulder, an inflammatory condition that causes unrelenting stiffness and pain in the shoulder that can last for years.

For this paper, 14 international experts discussed and identified possible risk factors for the condition and symptoms that most often lead to a diagnosis. They also examined 33 different treatment options and categorized them into effectiveness for treating frozen shoulder in its earlier stages when pain is more prominent than stiffness, and later stages, when stiffness is a bigger problem than pain. 

“The treatment we would intervene with varies significantly depending on the stage of the condition,” Salamh said. “Depending on where they are in this process, we could be doing something that could be more painful and create more problems for individuals than be helpful.”

Overall, Salamh hopes that these types of papers and future research can lead to better understanding of what this unique joint requires to stay healthy along the course of our lives. “We want to take the complexity of the shoulder and not simplify it but make it more manageable and digestible for patients, clinicians, and researchers,” he said.

Complete information on authors, methodology, limitations and conflicts of interest is available in the published papers.