The Shoulder
Shoulder pain is a common complaint that can affect people of all ages, from athletes and manual workers to office-based professionals. The shoulder is a highly mobile joint, capable of an extraordinary range of motion, but that mobility comes at the expense of stability. It relies on a complex interplay of muscles, tendons, ligaments, and joint structures to function properly. Any imbalance, injury, or degeneration within these tissues can lead to pain, weakness, stiffness, or loss of function.
At The Injury Hub, we see shoulder pain caused by both acute injuries, such as sports trauma or falls, and chronic issues that develop over time through overuse, poor posture, or degenerative changes. Because the shoulder involves multiple joints and a network of muscles connecting the shoulder blade, collarbone, and upper arm, pain in this area can have many different sources. It’s also common for neck problems to refer pain into the shoulder, adding to the complexity of diagnosis.
Whether you are seeking a diagnosis, a tailored treatment plan, or a referral for further investigation, we are experts in identifying the exact cause of your shoulder pain. Using a detailed clinical assessment combined with onsite ultrasound imaging, we can give you a precise diagnosis and start your treatment without delay. Below, we will explore the most common shoulder conditions we see in clinic, how they present, and the most effective treatment options available today.
Shoulder Bursa
Subacromial–subdeltoid bursitis is one of the most common shoulder conditions we see at The Injury Hub. The bursa is a fluid-filled sac that reduces friction between the rotator cuff tendons and the overlying bone and soft tissue. When inflamed, it can cause significant pain, particularly when lifting the arm or lying on the affected side. Traditionally, bursitis was thought to be the primary source of pain; however, growing evidence suggests that in many cases the bursa is reacting to an underlying supraspinatus tendinopathy rather than being the main cause itself. The reason patients improve with strengthening programmes is often because these exercises target the rotator cuff muscles especially supraspinatus rather than directly treating the bursa.
Research using contrast dye injections into the subacromial bursa has shown that the fluid can leak and diffuse into the adjacent supraspinatus tendon. If the tendon is the actual driver of the pain, this diffusion means the steroid can also act on the tendon, which may explain why injections are sometimes effective even when the source of pain is not the bursa itself. Interestingly, some patients present with ultrasound findings that show marked neovascularity within the bursa itself, while the supraspinatus tendon appears completely normal on imaging—suggesting that in certain cases, the bursa can indeed be the primary pain generator.
At The Injury Hub, our approach is to address both possibilities. While injection therapy can be highly effective in reducing inflammation and pain, long-term resolution often comes from targeted rehabilitation. We run an in-house, tailored rotator cuff strengthening programme with our Strength & Conditioning coach, Neil, to restore optimal shoulder function and prevent recurrence.
Rotator Cuff Pathology
Rotator cuff tendinopathy and tears are among the most frequent causes of shoulder pain we see at The Injury Hub, and they often sit on a spectrum—starting with minor overload of the tendon, progressing to structural degeneration, and in some cases developing into partial- or full-thickness tears. The rotator cuff itself is a group of four muscles and their tendons—supraspinatus, infraspinatus, subscapularis, and teres minor—that surround the shoulder joint, keeping the ball of the humerus centred in the socket and allowing smooth, controlled movement.
Tendinopathy occurs when one or more of these tendons becomes overloaded or injured, leading to microscopic collagen breakdown, swelling, and sometimes neovascularisation within the tendon. Although supraspinatus is by far the most commonly affected, infraspinatus and subscapularis injuries are not uncommon—particularly in throwing athletes, tradespeople who work overhead, and individuals with poor scapular mechanics. Patients often describe a dull ache deep in the shoulder that worsens with reaching, lifting, or lying on the affected side. In early tendinopathy, pain may settle quickly after activity, whereas more chronic cases cause constant discomfort and disturbed sleep.
When degeneration progresses, the tendon can develop partial-thickness tears (either on the bursal or joint side) or full-thickness ruptures. These may result from a sudden injury, but many are degenerative—occurring gradually over time, especially in people over 50. Interestingly, research shows that not all tears cause pain; some are found incidentally on scans in completely asymptomatic patients. The challenge lies in identifying when a tear is truly the source of symptoms versus an incidental finding.
At The Injury Hub, diagnosis involves both a thorough clinical assessment and high-resolution ultrasound imaging. Ultrasound is particularly useful for dynamic testing—allowing us to watch the tendon move in real time and identify subtle mechanical issues such as impingement under the acromion. If a more complex tear is suspected, or surgical planning is required, we can arrange an MRI the same day.
Treatment depends on the severity and functional demands of the patient. In most cases, the best results come from a targeted rehabilitation programme focused on strengthening the rotator cuff and scapular stabilisers, improving posture, and optimising biomechanics. We refer patients in-house to our strength and conditioning coach, Neil, for tailored progressive loading. Hands-on manual therapy, shockwave, and TECAR therapy can complement rehab in cases of persistent pain. For degenerative tendinopathy, regenerative injection therapies such as prolotherapy or platelet-rich plasma (PRP) can help stimulate repair. Steroid injections, while effective for pain relief in some cases, are used sparingly due to their potential to weaken tendon tissue over time.
Surgical intervention—usually arthroscopic repair—is considered for large, acute tears in active individuals, or when non-surgical management fails after a dedicated rehab period. Research shows that partial- or full-thickness tears in younger, active patients tend to do well following surgical repair, but similar pathology in individuals over 50 often has less favourable outcomes, with structured exercise rehabilitation frequently achieving better long-term results. Post-surgery, when indicated, a carefully phased rehabilitation programme is critical for regaining strength, restoring full range of motion, and preventing recurrence.
Frozen Shoulder
Adhesive capsulitis, more commonly known as frozen shoulder, is a condition that causes a progressive restriction in shoulder movement, often accompanied by significant pain. It is far more common in women than men, and typically presents in individuals between the ages of 40 and 60. In many cases, the onset is idiopathic, meaning there is no clear trigger, although it can develop following shoulder injury or surgery, and is seen more frequently in people with certain medical conditions such as diabetes, thyroid disorders, and cardiovascular disease.
The hallmark feature is a gradual loss of both active and passive range of motion, particularly with external rotation and abduction. In some individuals, the pain can be severe enough to disturb sleep and daily activities, while others may experience more stiffness than pain. The condition often follows a self-limiting course, but this can last 18 months to two years, progressing through the classic stages of freezing (painful loss of movement), frozen (stiffness with less pain), and thawing (gradual recovery).
Diagnosis is made clinically, supported by imaging to rule out other causes such as rotator cuff tears or arthritis. Ultrasound often shows thickening of the coracohumeral ligament and capsule, along with loss of the normal glide between structures.
Management focuses on maintaining as much movement as possible, reducing pain, and optimising function. At The Injury Hub, we use a combination of manual therapy, targeted stretching, and joint mobilisation to maintain joint play, alongside referral to our in-house strength and conditioning coach for controlled mobility exercises. Shockwave therapy can also be particularly effective in this condition, helping to release tension in both the anterior and posterior joint capsule and improve range of motion when combined with mobilisation techniques. Corticosteroid injections into the glenohumeral joint can help in the early painful stage, particularly when combined with a structured exercise programme. In resistant cases, hydrodilatation (fluid distension of the joint capsule under ultrasound guidance) can be effective in improving range of motion. Surgery, in the form of manipulation under anaesthesia or arthroscopic capsular release, is reserved for the most persistent cases where conservative management has failed.
Acromioclavicular Joint (ACJ) Arthritis
The acromioclavicular joint sits at the very top of the shoulder, where the collarbone (clavicle) meets the highest point of the shoulder blade (acromion). It’s a small but critical joint, playing an important role in the fine-tuned movements of the shoulder, particularly when lifting the arm overhead or across the body. Because of its position, it absorbs significant compressive and shearing forces, especially in activities involving repetitive overhead lifting, pushing, or contact sports.
ACJ arthritis occurs when the cartilage lining the joint gradually wears away, allowing the bone surfaces to rub directly against each other. This leads to pain, swelling, and in many cases the development of small bony growths (osteophytes) that can further restrict movement and contribute to impingement of the rotator cuff beneath. While it is often an age-related process, it can be accelerated by a previous injury such as an AC joint sprain (commonly seen in rugby players, cyclists who fall onto the shoulder, or anyone sustaining a direct blow).
Patients typically report pain directly over the top of the shoulder, which may radiate into the neck or upper arm. Discomfort is often aggravated by bringing the arm across the body (as in fastening a seatbelt), performing press-ups, bench presses, or lifting objects overhead. On examination, pressing over the joint reproduces symptoms, and provocative tests such as the cross-body adduction test can confirm the diagnosis.
At The Injury Hub, diagnosis is made through a combination of clinical assessment and high-resolution ultrasound imaging, which can visualise joint space narrowing, osteophytes, and sometimes associated swelling. Ultrasound also allows us to guide targeted injections directly into the ACJ with pinpoint accuracy.
Treatment starts conservatively with activity modification, hands-on therapy to improve surrounding shoulder mechanics, and a strengthening programme to optimise scapular and rotator cuff function — reducing unnecessary load on the ACJ. Our in-house strength and conditioning coach, Neil, designs tailored rehabilitation programmes to achieve this. In persistent cases, ultrasound-guided cortisone injections can provide significant short- to medium-term relief, allowing patients to progress with rehab. For advanced arthritis unresponsive to conservative measures, surgical options such as distal clavicle excision (Mumford procedure) may be considered.
Biceps Tendon
Biceps tendinopathy, particularly involving the long head of the biceps (LHB) tendon, is a common source of anterior shoulder pain. The LHB tendon originates from the top of the shoulder socket (supraglenoid tubercle) and runs through the bicipital groove at the front of the humerus before joining the biceps muscle. As well as contributing to elbow flexion and forearm supination, it acts as a dynamic stabiliser for the shoulder joint.
The tendon can become irritated or degenerate over time due to repetitive overhead activity, poor shoulder mechanics, or secondary to other shoulder conditions such as rotator cuff tears or labral injuries. Symptoms often include a deep, aching pain at the front of the shoulder that may radiate into the upper arm, sometimes accompanied by clicking or snapping during movement.
Ultrasound imaging is highly effective in assessing the LHB tendon for thickening, swelling, partial tears, or instability. It can also detect fluid or inflammation within the tendon sheath and identify associated shoulder pathology.
A progressive loading programme aimed at improving tendon capacity and correcting underlying mechanical issues is the preferred treatment approach. In more chronic cases where symptoms persist, regenerative medicine such as prolotherapy or PRP may be considered. Surgical referral is occasionally required for complete ruptures or severe instability.
Shoulder Labrum
Labral tears are injuries to the ring of fibrocartilage (the labrum) that lines the rim of the shoulder socket (glenoid). The labrum deepens the socket, improving stability and allowing smooth movement of the ball-and-socket joint. Damage to this structure can compromise shoulder stability, cause pain, and lead to mechanical symptoms such as catching, locking, or clicking.
One of the most common patterns we see is a SLAP lesion (Superior Labrum Anterior to Posterior), where the upper part of the labrum is torn. This region also serves as the anchor point for the long head of the biceps tendon, so SLAP tears often occur alongside biceps pathology. They are typically caused by repetitive overhead activities, falls onto an outstretched hand, or sudden traction injuries.
Another frequent finding is a Bankart lesion, usually linked to shoulder instability following a dislocation. This tear occurs in the lower front portion of the labrum and may be accompanied by stretching or tearing of the surrounding capsule, predisposing the shoulder to further dislocations.
At The Injury Hub, high-resolution ultrasound enables us to identify many superior labral tears and associated paralabral cysts in real time, as well as assess for biceps tendon involvement. While ultrasound excels in detecting superior labral pathology, we can arrange same-day MRI when a more detailed view is needed particularly for complex tears, recurrent dislocations, or suspected structural instability.
Treatment depends on the type and severity of the tear, as well as the patient’s activity demands. Many respond well to a progressive shoulder stability and strengthening programme aimed at improving rotator cuff and scapular control. In more persistent or unstable cases, referral to an orthopaedic surgeon may be required, particularly for young athletes or recurrent dislocations.
Shoulder Osteoarthritis
Shoulder osteoarthritis (OA) is a degenerative condition where the smooth cartilage covering the joint surfaces gradually wears away, causing the bones to rub against each other. This leads to pain, stiffness, and reduced range of motion, which often worsens with activity and improves with rest. Unlike the hip and knee, shoulder OA is less common, but it can still significantly impact daily activities such as dressing, reaching overhead, or lifting.
Patients often present with deep, aching pain in the shoulder, sometimes radiating down the upper arm. Morning stiffness is common, and the joint may produce creaking or grinding sounds (crepitus) during movement. OA can develop gradually due to age-related wear and tear, or it can occur secondary to previous injuries, instability, or surgery. Because it can mimic the presentation of frozen shoulder, a detailed clinical examination is essential for accurate diagnosis.
Diagnosis is made through clinical assessment and confirmed with imaging. Ultrasound can show osteophytes (bone spurs), joint space narrowing, and associated soft tissue changes, while X-ray or MRI may be used to assess the full extent of degeneration.
Management typically focuses on maintaining mobility and strength through targeted exercise, manual therapy, and activity modification. In more advanced cases, injection therapies such as corticosteroids (for pain relief) and hyaluronic acid (for lubrication and cushioning) can be considered. For severe cases that fail to respond to conservative measures, referral to an orthopaedic surgeon for joint replacement may be recommended. Encouragingly, recent research shows that modern shoulder replacement techniques can restore excellent function and significantly reduce pain, meaning your restriction does not have to be permanent.
Shoulder Pain – Frequently Asked Questions
1. Do I need to remove my shirt for a shoulder assessment?
No. In most cases, we can simply roll up a short-sleeve T-shirt or use loose clothing to access the area — there’s no need to be undressed from the waist up unless we’re assessing posture or other areas for contributing factors.
2. Why does my shoulder pain get worse at night?
Night pain is common with shoulder issues such as bursitis, rotator cuff tendinopathy, and frozen shoulder. Lying on the affected side or certain sleeping positions can compress inflamed structures, leading to discomfort and waking you from sleep.
3. How quickly can I get a scan if needed?
At The Injury Hub, most patients receive an ultrasound scan as part of their initial assessment. If further imaging is required, such as MRI, we can often arrange this on the same day, ensuring you get answers — and a plan — without long delays.
4. Will a frozen shoulder get better on its own?
It often does, but the process can be slow — typically lasting 18 months to two years. Early intervention with joint mobilisation, manual therapy, and sometimes shockwave treatment can speed recovery and help restore range of motion.
5. My GP said I have “wear and tear” in my shoulder. Am I stuck with it?
Not at all. Many people with osteoarthritis on scans have no significant symptoms. Progressive exercise, manual therapy, and in selected cases injections can help you maintain or even improve movement and reduce pain. Joint replacement surgery is reserved for more severe, resistant cases — and outcomes are increasingly encouraging.
6. Are steroid injections safe?
When used selectively, steroid injections can provide excellent pain relief, particularly when symptoms are preventing you from starting or progressing with rehab. Around the shoulder, the tendons are non-weight-bearing, meaning there is a lower risk of rupture compared to weight-bearing tendons such as those in the ankle — although this risk still exists. For that reason, we only recommend steroid injections in more severe cases and always as part of a broader treatment plan.