Referred pain and tenderness

"Shoulder treatment" very often means treatment of joints in the neck and upper back.

It’s very often possible to cure shoulder and arm pain only by including this, even if a possible cause is found in the area of the pain.

It is common for us to feel just one pain when there are multiple places contributing to it.

I retest for the painful arc immediately after treating any stiff joints in the cervical and thoracic spine.

If this is reduced (over a smaller angle of arc, less painful) the spine was contributing to the shoulder pain. Sometimes this is all that is needed. More commonly scapular muscle stretches need to be included in your shoulder therapy.

painful arc on shoulder abduction

Shoulder treatment of the rotator cuff mechanism

If imaging has shown any abnormality in the rotator cuff and you have severe pain, your doctor will probably offer you a cortisone injection.

Cortisone is a dirty word. Many people will refuse this treatment because of the perception that toxic effects will be dangerous.

This is not the case here, however. The cortisone injected will have precious little effect on your body generally.

It will speedily relieve your shoulder joint pain by reducing shoulder tendonitis. I recommend it often, even though I lean towards natural remedies.

I mix the cortisone with local anaesthetic. By the time the person has got their shirt back on, their pain should be relieved.

This confirms that the cortisone has been injected into a satisfactory space. Shoulder treatment injections without imaging to guide the needle, are often not in the actual joint space¹, but this was found not to matter in the study quoted.

The effect of the anaesthetic will wear off before the 1-2 days needed for cortisone to work.

Acupuncture is very effective in shoulder treatment, regardless of the actual state of the tendons.

Glyceryl trinitrate can be applied to the skin over the affected part of the rotator cuff.

This is to improve repair mechanisms, so should work well with any nutritional support for repair, such as zinc and vitamin C.

Unlike its use in angina, no nitrate-free interval is needed. It should be applied over the full 24 hours each day.

In angina, the blood vessel dilating effect is wanted. Our body becomes resistant to this effect with continuous application. Workers in munitions factories during the second world war got headaches only for their first week, from the nitro glycerine.

The effect being used for tendon injury repair, is stimulation of the fibroblast cells which do this job.

One little known cause of rotator cuff pain is vitamin B 12 deficiency². This dates from observations published in 1953 by I.S.Klemes MD. It is described in Dr. Jonathan Wright’s “Book of Nutritional therapy” and I've seen it occasionally.

This is a possibility when the X-ray shows calcification of the rotator cuff.

Treatment is with vitamin B12 injections, daily initially for about ten days, then progressively less often over a period of months.

The pain is relieved within days, and the calcium deposits eventually are removed by this treatment.

Examples of this are detailed on the case histories pages of this site.

Aspiration of calcium deposit.

If during an ultrasound examination the probe can deform the calcium deposit, showing it to be liquid, pain can rapidly be relieved by aspiration.

Surgery can relieve pain well. The edge of the acromion is often trimmed back and torn tendons can be reattached.

Recovery is quicker with keyhole surgery, but still takes months. It does not give one a normal shoulder.
Preoperative assessment may include MRI in long standing pain, as the scapular muscle may be withered and fatty.

Treatment of causes in the scapulo humeral joint - the shoulder joint proper

Osteoarthritis here is uncommon, but can be severe enough to require joint replacement surgery.

Recurrent dislocation is also very well treated by the surgeons.

Adhesive capsulitis (frozen shoulder,) is covered on the next page.


As soon as your pain allows, assess your scapular muscles.

Any of the three main muscles may be tight and sore, and need stretching as part of your shoulder treatment.

This may be so even if imaging has shown a tear. I figure that if there is enough tendon intact to allow testing to hurt, there is enough to contribute to your pain.

These tendons tear because of attrition and pathological weakness, so there is a theoretical risk that stretching may increase or cause a new tear.

I have not seen this happen. Presumably most times any potential tear has already happened from day to day activities. I can't remember right now, anyone knowing exactly when a tear occurred.



Sit facing along the side of a table. Hold the table edge. Hold your elbow closely to your side, then slide your bottom forward on the chair without rotating your body, so that your hand is left behind.

As this swings your forearm backwards, note any pain. You could turn around and do the same test on the other arm, to compare both discomfort and range of movement.

This comparing of your two sides is a basic principle to use for most examinations.

This manoeuvre can also be done standing, with the hand against a wall at a doorway


Now face the table, resting your elbow on it in front of your other shoulder. Bend down to get the other shoulder as close to the elbow as you can.

This may already be painful, but if not, use your other hand to push the wrist away from you. Do not shift the elbow, and keep it bent at a right angle (90 degrees.) Your forearm is being used as a lever to cause your upper arm to rotate.


Put your hand over your other shoulder. Raise your elbow to just under your chin. Use your other hand to push on the elbow, so your hand goes further over your other shoulder.
Dig the fingers of this hand in, and walk them over your shoulder and down your back, to help by pulling the arm further.

An alternative is to lean your raised elbow against a wall and push your body closer to the wall to force your hand over the shoulder.

These tests of pain on stretch and range of movement, are done with the arm passive, not resisting the movement.

Exactly the same actions are used to stretch each of the muscles, in treatment.

Keep any sore muscle stretched, only enough to cause minimal pain, and just wait. The muscle is likely to take a couple of minutes before even the tightest fibers relax.

More on this.

Another infraspinatus or subscapularis stretch is done laying on your back along the edge of your bed with arm out at a right angle to your body and elbow just over the edge.

Bend your elbow to a right angle, and let your hand fall forwards to stretch infraspinatus, backwards for subscapularis.


You can use the same actions for testing isometric (not shortening) contraction and also for strengthening. Subscapularis and infraspinatus often need strengthening as part of shoulder treatment.

Here you get into position, and use your arm to resist the movement described above.


1. Hegedus EJ, Positive outcomes with intra-articular glenohumeral injections are independent of accuracy.
J Shoulder Elbow Surg. 2010 Sep;19(6):795-801

2. Use of Vitamin B12 in treatment of acute subdeltoid bursitis. Klemes I S, Industrial Medicine & Surgery 1953 August; vol 22 (8), pp 352-4

Vitamin B12 in acute subdeltoid bursitis. KLEMES IS, Industrial Medicine & Surgery 1957 Jun; Vol. 26 (6), pp. 290-2

Shoulder treatment for frozen shoulder

Back to shoulder anatomy from this shoulder treatment page

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