• Bryan Morrow

Ouch! Why does my shoulder hurt at night?

The shoulder is the most flexible joint in the body. The shoulder has a greater range of motion than any other joint. The shoulder is also the most complex joint in our body. It is capable of providing stable motion due to a delicate relationship of the muscles, tendons and bones which comprise the shoulder.

Many types of injuries can affect the shoulder due to the complex structure of the shoulder. Sports injuries, chronic repetitive stress or accidents, and falls can cause shoulder pain. Even simple repetitive tasks such as painting, housecleaning, and gardening can cause our shoulder to hurt.

The "rotator cuff" is the group of 4 muscles and their tendons responsible for keeping the shoulder joint stable. Injuries to the rotator cuff are common—either from accident or trauma, or with repeated overuse of the shoulder. Risk of injury can vary, but generally increases as a person ages. Rotator cuff tears are more common later in life, but also can occur in younger people. Athletes and heavy laborers are often affected; older adults can injure the rotator cuff when they fall on or strain the shoulder. When left untreated, a rotator cuff tear can cause severe pain and a decrease in the ability to use the arm.

Physical therapists help people with rotator cuff tears address pain and stiffness, restore movement to the shoulder and arm, and improve their activities of daily living.

People with chronic rotator cuff injuries often have a history of rotator cuff tendon irritation that causes shoulder pain with movement. This condition is known as shoulder impingement syndrome.

Rotator cuff tears also may occur in combination with injuries or irritation of the biceps tendon at the shoulder, or with labral tears (to the ring of cartilage at the shoulder joint). Your physical therapist will explain the particular details of your rotator cuff tear.

How Does It Feel? People with rotator cuff tears can experience:

  • Pain over the top of the shoulder or down the outside of the arm

  • Shoulder weakness

  • Loss of shoulder motion

  • A feeling of weakness or heaviness in the arm

  • Inability to lift the arm to reach up, or reach behind the back

  • Inability to perform common daily activities due to pain and limited motion

How Is It Diagnosed? To help pinpoint the cause of your shoulder pain, your physical therapist will complete a thorough examination that will include learning details of your symptoms, assessing your ability to move your arm, identifying weakness, and performing special tests that may indicate a rotator cuff tear. For instance, your physical therapist may raise your arm, move your arm out to the side, or raise your arm and ask you to resist a force, all at specific angles of elevation.

In some cases, the results of these tests might indicate the need for a referral to an orthopedist or other professional for imaging tests, such as ultrasound imaging, magnetic resonance imaging (MRI), or a computed tomography (CT) scan.

How Can a Physical Therapist Help? Once a rotator cuff tear has been diagnosed, you will work with your orthopedist and physical therapist to decide if you should have surgery or if you can try to manage your recovery without surgery.

If you don't need surgery, your physical therapist will work with you to restore your range of motion, muscle strength, and coordination, so that you can return to your regular activities. In some cases, you may learn to modify your physical activity so that you put less stress on your shoulder.

If you decide to have surgery, your physical therapist can help you both before and after the procedure.

Regardless of which treatment you have—physical therapy only, or surgery and physical therapy—early treatment can help you speed the healing process and avoid permanent damage.

If You Have an Acute Injury If a rotator cuff tear is suspected following a trauma, seek the attention of a physical therapist or other health care provider to rule out the possibility of serious life- or limb-threatening conditions. Once serious injury is ruled out, your physical therapist will help you manage your pain and will prepare you for the best course of treatment. If You Have a Chronic Injury

A physical therapist can help manage the symptoms of chronic rotator cuff tears as well as improve how your shoulder works. For large rotator cuff tears that can't be fully repaired, physical therapists can teach special strategies to improve shoulder movement. However, if physical therapy and conservative treatment alone do not improve your function, surgical options may exist.

If You Have Surgery If your condition is severe, you may require surgery to restore use of the shoulder; physical therapy will be an important part of your recovery process. The repaired rotator cuff is vulnerable to reinjury following shoulder surgery; working with a physical therapist is crucial to safely regaining full use of the injured arm. After the surgical repair, you will need to wear a sling to keep your shoulder and arm protected as the repair heals. Your physical therapist will apply treatments during this phase of your recovery to reduce pain and gently begin to restore movement. Once you are able to remove the sling for exercise, your physical therapist will begin your full rehabilitation program. Your physical therapist will design a treatment program based on both the findings of the evaluation and your personal goals. Your physical therapist will guide you through your postsurgical rehabilitation, which will progress from gentle range-of-motion and strengthening exercises to activity- or sport-specific exercises. Your treatment program most likely will include a combination of exercises to strengthen the rotator cuff and other muscles that support the shoulder joint. The time line for your recovery will vary depending on the surgical procedure and your general state of health, but return to sports, heavy lifting, and other strenuous activities might not begin until 4 months after surgery and full return may not occur until 9 months to 1 year after surgery.

Following surgery, your shoulder will be susceptible to reinjury. It is extremely important to follow the postoperative instructions provided by your surgeon and physical therapist.

Your rehabilitation will typically be divided into 4 phases:

  • Phase I (maximal protection). Phase 1 of treatment lasts for the first few weeks after your surgery, when your shoulder is at the greatest risk of reinjury. During this phase, your arm will be in a sling. You will likely need assistance or need strategies to accomplish everyday tasks, such as bathing and dressing. Your physical therapist will teach you gentle range-of-motion and isometric strengthening exercises, provide hands-on treatments (manual therapy), such as gentle massage, offer advice on reducing your pain, and may use techniques such as cold compression and electrical stimulation to relieve pain.

  • Phase II (moderate protection). This next phase has the goal of restoring mobility to the shoulder. You will reduce the use of your sling, and your range-of-motion and strengthening exercises will become more challenging. Exercises will be added to strengthen the "core" muscles of your trunk and shoulder blade (scapula), and the rotator-cuff muscles that provide additional support and stability to your shoulder. You will be able to begin using your arm for daily activities, but will still avoid heavy lifting. Your physical therapist may use special hands-on mobilization techniques during this phase to help restore your shoulder's range of motion.

  • Phase III (return to activity). This phase has the goal of restoring your strength and joint awareness to equal that of your other shoulder. At this point, you should have full use of your arm for daily activities, but you will still be unable to participate in activities such as sports, yard work, or physically strenuous work-related tasks. Your physical therapist will advance the difficulty of your exercises by adding weight or by having you use more challenging movement patterns. A modified weight-lifting/gym-based program may also be started during this phase.

  • Phase IV (return to occupation/sport). This phase will help you return to work, sports, and other higher-level activities. During this phase, your physical therapist will instruct you in activity-specific exercises to meet your needs. For certain athletes, this may include throwing and catching drills. For others, it may include practice in lifting heavier items onto shelves, or instruction in proper positioning for everyday tasks such as raking, shoveling, or doing housework.

Can This Injury or Condition Be Prevented? A physical therapist can help you reduce the worsening of the symptoms of a rotator cuff tear and may decrease your risk of worsening a tear, especially if you seek assistance at the first sign of shoulder pain or discomfort. To avoid developing a rotator cuff tear from an existing shoulder problem, it is imperative to stop performing actions that could make it worse. Your physical therapist can help you strengthen your rotator cuff muscles, train you to avoid potentially harmful positions, and determine when it is appropriate for you to return to your normal activities.

To maintain shoulder health and prevent rotator cuff tears, physical therapists recommend that you:

  • Avoid repeated overhead arm positions that may cause shoulder pain. If your job requires such movements, seek out the advice of a physical therapist to learn arm positions that may be used with less risk.

  • Apply rotator-cuff muscle and shoulder-blade strengthening exercises into your normal exercise routine. The strength of the rotator cuff is just as important as the strength of any other muscle group. To avoid potential harm to the rotator cuff, general strengthening and fitness programs may improve shoulder health.

  • Practice good posture. A forward position of the head and shoulders has been shown to alter shoulder-blade position and create shoulder impingement syndrome.

  • Avoid sleeping on your side with your arm stretched overhead, or lying on your shoulder. These positions can begin the process that causes rotator cuff damage and may be associated with increasing your pain level.

  • Avoid smoking; it can decrease the blood flow to your rotator cuff.

  • Consult a physical therapist at the first sign of symptoms.

Real Life Experiences from Joe Q., 40

One morning I woke up and my right arm/shoulder were in pain. I shrugged it off to just another one of those, you just turned 40 and getting older pains. Well this one didn’t go away and it became worse. I went to the doctor and found out I had tears in my labrum and rotator cuff. Surgery was strongly recommended followed by a long 6-12 month recovery. A second opinion agreed, but also suggested we try PT first to see if that would provide relief and postpone surgery given how busy our lives are.

My shoulder and for that matter, all of my muscles were very weak. I had let myself go. 30lbs over weight. Barely any working out. A high stress job, a family with 3 kids under 12 all with sports and homework, a house to keep up and seemingly no time during any day of the week allowed the excuse not to take care of myself. “I will get to me when the kids get older and things calm down.” Things never calm down.  Well, off I went to PT. I made a promise to take it seriously, although I was very skeptical. I was a former college athlete and knew my body. These little exercises weren’t going to do anything for me. Surgery was a forgone conclusion. Treatment 1 - After my initial consult, I showed up Monday morning at 8am to start my 3 times a week for 8 weeks treatment with Cecily. Cecily is a vibrant and funny PT who can hold a conversation with anyone who walks through the door. She makes you feel welcome. Like you are part of her extended family. She is tell it like it is and direct. Just what I need. Someone who isn’t going to let me half ass it. So Day 1 hurt. Not necessarily my shoulder although it was certainly tested, but my ego. I was more than weak. I was feeble. I was having trouble dealing with the lightest resistance. After my session as I drove to work, I was emotional. My ego was broken. What had I done to myself over the years? How could I have let myself go the much? Treatment 2 through Treatment 23 - I came back to my second appointment with a renewed spirit. I had made the decision that this was going to be my turning point and I was going to do everything that was asked of me. No excuses. The early sessions sucked. They hurt. Physically and emotionally. You do think about quitting or at least mailing it in with a half effort, but Cecily is right there to keep pushing you. After about the 5th session, the scale begins to tip to the other side. You move up in resistance bands. The little red one become the medium green one. A small victory. The 2lb weight becomes a 5lb. Another battle won. With these successes come increases in mood and most importantly hope. I remained dedicated. It actually got to the point where I was looking forward to each session and would get upset at the prospects of missing for some reason. Speaking of rescheduling, iPT made it so easy for me to reschedule. Cecily would even show up an hour early if I had a meeting that I had to get to for work. In a world where good customer service almost non-existent, iPT has customer service figured out. Treatment 24 - Graduation Day. I learned that the # of sessions or the end date that is given for treatment is arbitrary. Everyone responds differently and treatment can be shortened or extended. My timeline happened to be spot on. I will never forget this day. We would end each session with shoulder exercises and stretching where Cecily would use her own resistance. On Day 1, I could barely budge her arm. It was embarrassing. I had previously been called weak by one of the orthopedic doctors I had a consult with. I couldn’t budge him on my resistance test. He shook his head and reminded me that he was more than 20 years older than I was. So here I was again, trying to do the same thing and having no success. At least Cecily didn’t call me weak. She didn’t have to. My last day was a little different though. We went through the normal routine. I felt strong. My shoulder didn’t hurt at all. I had just broken my record on the kettle bell hold. I was using the max weight and resistance bands for my other exercises. We had come to the final few resistance exercises and right in the middle we stopped. Cecily said, “Well, I think we are done treatments now. You almost pulled me across the table.”

The next 120 days and beyond - I was not going to let this fresh start fade away. My health was not taking a backseat any longer. I bought a universal weight machine and a treadmill. The family and I had an unspoken rule that 8pm every night was “Joe Time.” I downloaded the myFitnessPal app and tracked everything I ate and all of my workouts. I worked hard and watched my weight drop 25lbs, my BMI to get into the healthy range, my “skinny” clothes were all fitting again. I was getting full nights of sleep. My stress levels were more than manageable. I was healthy and happy again. To top the all off, no shoulder surgery needed! Physical Therapy saved my health. Specifically, Innovative PT and Cecily saved my health. They gave me the spark and patiently fanned it into a roaring fire! Thank you. Joe


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