Why the shoulder hurts
The glenohumeral joint has a very large range of motion and a small area of bony contact. Its stability comes from the rotator cuff muscles and from the scapula working properly. When that balance is disturbed – because the muscles are overloaded or weak, or because the scapula cannot keep up with the arm – the tendons stop tolerating the load put on them, and they start to hurt. This used to be explained by a lack of space under the acromion; today we talk instead about subacromial pain syndrome, because what decides the symptoms is the tissue tolerance to load, not the space in the joint.
The most common scenario is not dramatic: there is no injury, only a load that went up too fast. A new training plan, painting the flat, a week of work with the arms overhead. The tendon did not have time to adapt.
The second group is people coming out of a period of immobilisation – after a wrist fracture, after surgery, after a few weeks in a sling. The shoulder loses mobility faster than most people expect, and getting it back takes systematic work on range of motion before we move on to loading at all.
What we assess at the first visit
We check at what height the pain appears and whether passive movement is better than active – that difference often settles whether we are dealing with a tendon problem or a restriction of the joint capsule. We assess the strength of the individual rotators, the scapulohumeral rhythm and the mobility of the thoracic spine. We also check the neck, because shoulder pain can be referred – and then we manage it as we would neck pain.
How you react at night matters too. Pain that wakes you when you lie on the affected side is typical of rotator cuff irritation, and in itself does not mean damage requiring surgery – more often it tells us how irritated the tissue is.
Therapy and loading
The first phase is about reducing the symptoms and regaining mobility – manual work, soft tissue techniques, modifying the movements that are currently irritating the shoulder. That, however, is only the preparation.
The real work is done by medical training. Rotator cuff tendons rebuild their tolerance to load only when they are loaded – gradually, in controlled ranges and regularly. The progression usually takes from several to a dozen or so weeks, and it is the most common reason why treating a shoulder takes longer than treating a spine.
How long it takes
With a recent overload, usually 6–10 visits spread over several weeks, with exercise done in between. Symptoms that have lasted months, and frozen shoulder in particular, need longer work and realistic expectations – here improvement is measured in months, and the pace depends largely on how consistent you are with the exercises. At every visit we check how the shoulder responded to the previous dose of load, and set the next step on that basis – which is why the plan changes as we go, rather than being fixed at the start.