Charlotte Physical Therapy: The Ultimate Guide to Solving the Root Cause of Shoulder Pain

Today we’re diving deep into a topic that’s incredibly relevant for athletes of all types – shoulder pain. Whether you’re a professional baseball player, weightlifter, CrossFit athlete, or someone who’s simply active and enjoys working out, shoulder injuries can be a huge roadblock to performance. But fear not – in today’s article, we’re going to break down the causes of shoulder pain, how to identify the root of the issue, and provide you with strategies and tips to prevent and treat shoulder injuries.

Why The Shoulder Is So Easily Injured

Shoulder injuries are incredibly common among athletes and ranks as one of the most frequent issues we see in our clinic—second only to lower back pain. But why is the shoulder so prone to injury, and how can we better understand it?

The shoulder is a highly complex region made up of four joints:

• Glenohumeral (GH) joint: the ball-and-socket joint we often think of as the “shoulder.”
• Scapulothoracic (ST) joint: where the shoulder blade (scapula) glides over the ribcage.
• Acromioclavicular (AC) joint: the connection between the acromion (part of the scapula) and the clavicle.
• Sternoclavicular (SC) joint: the link between the clavicle and the sternum.

Here’s the wild part: your entire shoulder—and your entire arm, for that matter—connects to your body solely through the clavicle. Even more surprising, the scapula (shoulder blade) rests on the ribcage without any direct bony attachment at all! This inherently unstable environment is what often leads to shoulder injuries. The shoulder relies heavily on scapular position and muscular coordination, timing, sequencing, and recruitment, particularly the scapular muscles (not the rotator cuff muscles!), to move in a pain-free healthy manner. When these muscles aren’t functioning properly, injuries can occur, whether from overuse or improper movement patterns.

When we talk about the shoulder, we’re really referring to a system of joints and muscles working in concert. The glenohumeral joint, a ball-and-socket joint, offers exceptional mobility. Unlike the hip joint, which is also a ball-and-socket joint but designed to bear weight, the shoulder functions as an open-chain joint. This means it isn’t anchored to the ground, which gives it unmatched range of motion—but at the cost of stability. This inherent instability is why the shoulder is so prone to injury. Stability in the shoulder relies heavily on the coordination and timing of muscle firing, particularly the rotator cuff and scapular muscles.

Understanding the Scapula and Its Impact on Shoulder Health

A stable scapula is the foundation for healthy shoulder movement. It serves as the base for numerous shoulder-stabilizing muscles, including all four rotator cuff muscles. When the scapula doesn’t function properly, neither do the rotator cuff muscles. This dysfunction disrupts the relationship between the humerus and the glenoid, often leading to shoulder pain.

Believe it or not, 17 muscles attach to the scapula, each playing a role in controlling its position and movement. If the scapula isn’t moving well, the rotator cuff muscles can’t perform their job effectively. That’s why focusing solely on strengthening the rotator cuff is an inadequate approach to treating shoulder pain.

Addressing scapular mobility and strength is absolutely essential before targeting the rotator cuff. By first ensuring the scapula moves properly and provides a stable base, we create the foundation needed for the rotator cuff to function efficiently and for the shoulder to move pain-free.

The Role of the Rotator Cuff in Shoulder Health

Most people have heard of the rotator cuff, but do we truly understand what it does? The rotator cuff consists of four muscles: the supraspinatus, infraspinatus, subscapularis, and teres minor. Their primary job is to stabilize the glenohumeral joint by keeping the humeral head (the ball) centered in the shallow socket of the scapula as you move your arm. If the rotator cuff isn’t doing its job properly, the ball can move around too much within the socket, leading a disrupted PICR (path of instantaneous center of rotation), and pain and injury. But this isn’t the whole story. The rotator cuff doesn’t work in isolation – it requires a coordinated effort from other muscles, particularly those attached to the scapula, which has a largest influence on healthy shoulder movement and stability.

The Myth of Rotator Cuff Strengthening

What sets the shoulder apart from the hip isn’t just the muscles themselves, but the requirement of recruitment, coordination, and timing of those muscles to produce smooth movement. When this system is disrupted, it leads to reduced synchronization, unhealthy shoulder movement, and ultimately, pain.

One of the most common issues we see in the treatment of shoulder injuries is the use of isolated exercises like external rotations or banded four-way cuff rotational drills. They’re not only inadequate, but often feed into the underlying root cause of the injury, prolonging recovery. Consider this – all 4 of the rotator cuff muscles originate from the scapula. If the scapula isn’t moving in the way it’s designed to move, it creates length-tension deficits in the rotator cuff muscles decreasing their ability to adequately activate, which leads to instability, and the inability to do their primary job – keep the ball centered in its socket. That’s why ensuring proper scapular mobility and stability should always come first in treatment. Without a stable and mobile scapular base, strengthening the rotator cuff muscles is ineffective (I mention important concept over and over for a reason). I honestly can’t remember the last time I gave an external rotation exercise to an athlete, and my shoulder outcomes are unmatched.

For a deeper dive, check out this blog: The Myth of Rotator Cuff Strengthening

Type of Injuries Caused from a Poor Scapular Base

An immobile or unstable scapular base is one of the most common movement impairments we see in both athletes and sedentary individuals with shoulder pain. This single issue can lead to a wide variety of injuries, including:

• Impingement Syndrome: When the rotator cuff tendons become pinched or irritated.
• Bursitis: Inflammation of the subacromial bursa, a small fluid-filled sac that reduces shoulder friction.
• Rotator Cuff Tendinitis/Tendinopathy: Inflammation or degeneration of the rotator cuff tendons.
• Biceps Tendon Issues: Inflammation of the tendon connecting the biceps muscle to the shoulder.
• AC Joint Dysfunction: Problems with the acromioclavicular joint at the top of the shoulder.
• Subscapularis Bursitis: Inflammation of the bursa beneath the subscapularis muscle.
• Levator Scapulae, Upper Trap, and Rhomboid Strains: Strains in muscles that stabilize the shoulder blade.
• Cervical Pain (especially between the scapulas): Since many muscles connect the scapula to the neck, shoulder pain often coincides with neck discomfort.
• Thoracic Outlet Syndrome: Compression of nerves or blood vessels between the neck and shoulder, causing pain, numbness, or tingling.

The reason this single issue can lead to so many different injuries or pain presentations lies in the many factors influencing shoulder health: your daily activities, what you do for work, the sport you play, your lifting program, and even your body size, height, and weight. Finally, the scapula’s role isn’t limited to shoulder health. Proper scapular function significantly impacts the health and performance of other areas in the body as well, making it a critical element of overall movement and stability.

For a deeper dive into Upper Trap Tightness, check out this blog: The Myth of Upper Trap Tightness

The Root Cause of Shoulder Pain in Athletes – The RMPPs

While shoulder injuries can result from acute events like a fall or a direct blow, most shoulder pain develops gradually over time. This happens when the cumulative effects of your daily habits include more negative influences than positive ones. We refer to these habits as the RMPPs—Repeated Movements and Prolonged Postures. If no specific injury event caused your pain, it’s a clear sign that changes need to be made to your daily RMPPs.

Consider a baseball pitcher, for example. He might throw hundreds of pitches during practice, placing significant strain on his shoulder. Afterward, he spends hours lounging on the couch, hunched over his phone. Later, he heads to the gym for an upper body workout focused on chest and back—muscle groups that can reinforce poor scapular and shoulder joint mobility. Finally, he goes to bed and sleeps on his throwing side. Do you see the pattern here? Over time, these poor RMPP choices compound, creating the perfect storm for injury. This example highlights how habits outside of your sport—such as training, daily activities, and even sleep positions—can directly impact athletic performance and lead to pain.

Importance of a Balanced Gym Routine

Earlier I mentioned that the scapula is essentially a free-floating bone, with a tremendous influence on movement and performance from the muscles that surround and attach to it. Therefore, whether these muscles are in balance or not (ex: weak, strong, long, short) plays a critical role in healthy, coordinated shoulder movement. More than any other joint in the body, your training regime and balance of your shoulder workouts plays a tremendous role in whether or not you experience shoulder pain. What you decide to do or not do in the gym makes a huge difference.

If You Don’t Use It, You Lose It

Another important thought here is the age old saying: “if you don’t use it, you lose it,” just applied to shoulder range of motion. If you never reach overhead throughout your day, how could you expect to be mobile and strong in that position in the gym? If you decide to paint the ceiling, but then develop crazy shoulder pain – would you be surprised? You shouldn’t be. If you’re arms are more or less by your side throughout the day, certain muscles will stiffen up, making movements like reaching end range overhead difficult. Your body adapts to the stimulus it provided.

Shoulder Pain Won’t Go Away? Your Sleep Position Might Be to Blame

Your sleeping position also plays an important role in shoulder health, yet it’s almost always overlooked—especially by athletes. If you’re a thrower, weightlifter, CrossFitter, or any kind of overhead athlete, and you sleep on your shoulder, you’re shooting yourself in the foot. It not only can severely delay recovery, but cause that annoying shoulder pain to come again, and again, and again.

Think about it: sleep is supposed to be your body’s time to recover and repair. But if you’re lying on your shoulder—whether your arm is stretched straight out, overhead, or even tucked under you—you’re preventing that from happening. Sleeping in these positions can literally cut off blood flow to your rotator cuff tendons, impairing their ability to heal and recover. This isn’t just an issue for overhead athletes; anyone who spends long hours in poor sleeping positions can experience similar problems. If you spend 7-9 hours in a harmful position every night, it’s no wonder you wake up with shoulder pain.

To protect your shoulders, avoid sleeping:

• On your side, especially with your arm directly under you.
• On your back with your arms overhead.
• On your stomach, where your arms are awkwardly positioned.

The best option? Sleep on your back with your arms resting comfortably by your sides or on your hips. This neutral position minimizes strain, promotes blood flow to your shoulder tendons, and supports recovery during sleep. It might feel unfamiliar at first, but adopting this habit can save you countless days of frustration and reduce your risk of shoulder injuries down the road. Sleep matters—especially for shoulder health. Making these adjustments to your sleeping position is a simple yet powerful way to prevent pain and improve recovery, no matter your activity level.

Tips to Prevent Shoulder Injuries

Preventing shoulder injuries requires a combination of proper training, daily habits, and recovery practices. Here are some tips that can help keep your shoulders healthy:

For even more tips, check out this blog: Top 8 Reasons Why Athletes Suffer From Shoulder Pain

The Charlotte Athlete’s Treatment Approach

As with all injuries, the sports physical therapists at The Charlotte Athlete always conduct a thorough evaluation, and create a customized treatment plan based on the individual’s specific injury presentation and goals. In general, when it comes to treating shoulder injuries, we utilize a combination of manual therapy, strengthening exercises (and a few mobility drills), and education.

1. Manual Therapy: Manual therapy is typically the first step in treating shoulder pain, and it is VERY effective. This includes soft tissue work, joint mobilizations, joint manipulations, mobilizations with movement, muscle energy techniques, and dry needling to improve mobility and reduce pain. Improving the ability of your shoulder to move in a pain-free, healthy manner is essential for athletes to be able to perform strengthening exercises more effectively.
2. Strengthening Exercises: Strengthening the shoulder, especially the muscles that promote scapular upward rotation, scapular external rotation, and scapular posterior tilt is critical. However, it’s important to do so in a functional way: Minimize isolation exercises as much as possible; Focus on training the serratus anterior and lower trap above 140 degrees; Focus on exercises that mimic the movements you’ll be doing in your sport or daily life. All exercises should be 100% pain free!
3. Education: Education is a huge part of the healing process. We work with patients to address their RMPPs including their daily habits and training routines. By understanding the root cause of why their shoulder pain occurred in the first place and how to prevent it in the future, athletes are empowered to take control of their recovery and are set up for long term success.

Final Remarks

Shoulder injuries can be complex, but with the right approach, they’re preventable and treatable. Whether you’re an athlete or just someone who uses your shoulders regularly, it’s crucial to understand the anatomy and biomechanics of the shoulder to prevent pain and dysfunction. By focusing on scapular mobility, thoracic spine mobility, functional strength, and recovery practices, you can protect your shoulders and keep them healthy for years to come.

The Charlotte Athlete is a group of fellowship trained sports physical therapists. We work with athletes all the time both local and around the globe with their shoulder injuries. If you’ve seen other physical therapists or medical professionals before without long term success, we’d love for the opportunity to help you. Living with pain isn’t living at all. We can help! Just email us at [email protected] to learn more, or set up a free 20 minute phone consultation below to get started!

All the best,

Dr. Andrew