Where To Start With Shoulder Treatment & Rehab

Posted By: Andy Barker

Where To Start With Shoulder Treatment & Rehab

The shoulder can be challenging to deal with.

It is a complex joint, with many structures.

It is well evidenced that many shoulder special tests have poor sensitivity and reliability, meaning it can be hard to pin-point a patient’s specific cause of shoulder pain.

The result…

…it is hard to make a diagnosis.

…and without a diagnosis many New Grad therapists struggle to know where to start with their treatments and rehab.

Often this means therapists try and treat everything.

You give rotator cuff exercises, stretches, scapula stability work…

…because you are not sure where you should be focusing your attention.

This blog post will show you how you can simplify your shoulder assessment to find the main cause of shoulder pain, even without a diagnosis.

Then you will know what to focus your efforts on with your hands-on treatment techniques and rehab and NOT fall into the common pitfall of trying to treat everything!

Why Is The Shoulder Hard To Assess?

Many therapists dread dealing with shoulder pain patients.

Finding a specific diagnosis can be tough, particularly given the problems of poor sensitivity and specificity with many shoulder special tests.

Many structures can give the same pain and present in the very same way, so where do you start?

Firstly, it is important to recognise that special testing is just part of your assessment and it should not dictate your ability to help your shoulder pain patients out of pain and back to full health.

One aim of the assessment is to identify a diagnosis.

Another aim is to find out problems that you can fix.

The problems you can help your patients with, like reduced range of movement or reduced strength.

So, whilst you may be unable to tell your patient exactly what structure is causing your patient their pain…

…you will be able to identify the problems that are contributing or have resulted from their injury.

These problems are your interventions, your treatments, and your rehab exercises.

Many New Grads struggle with the treatment and rehab of shoulder injuries.

You may think this is because you do not know what you are dealing with…

…but you do!

If you can identify what problems a patient has, the fact that you have a diagnosis or you do not have a diagnosis, might not matter as much as you might think.

Most problems with rehab and knowing what treatment techniques to use are the result of a poor assessment.

Special testing is just one part of your assessment.

Just because you cannot distinguish exactly what structure is causing your patients shoulder pain does not mean you can NOT have a great outcome with shoulder pain patients.

So, how do you do this?

Keep It Simple

Everything I do in my work is aimed at making my life simpler.

The way I teach New Grads to assess patients on my courses and in my New Grad Physio Membership is no different.

I use the same techniques in my own practice that I teach those therapists I work with.

The shoulder is no different.

There are some limitations to testing as we have already discussed.

This just means you must use the other parts of your assessment to find out what is contributing to your patient’s shoulder pain.

In short, if you fix this and their pain reduces, and their function improve does it really matter if their anterior shoulder pain is coming from their long head of biceps, the rotator cuff, or the bursa?

I simplify the shoulder by breaking it down into 3 parts.

1) The Glenohumeral Joint (GHJ)
2) The Scapula (including the Scapulothoracic Joint)
3) Everything Else (including the Sternoclavicular Joint & The Acromioclavicular Joint)

Focus On The Big Problem

There are easy ways to assess which of these 3 parts if having the biggest impact on your patient’s shoulder symptoms.

Once you can attain this, then you can focus your attention on this area.

Some patients may have more than 1 area contributing to their pain, but almost all will have one primary problem.

This is the problem that is contributing most to their symptoms and the area of the shoulder that will then in theory cause the biggest change in symptoms if you treat it.

For those patients with more complex problems you will often find that by fixing the big problem you will often see that the other problems also improve, without you having to treat them.

You may have a patient for example that complains of anterior shoulder pain when they are reaching above their head or lifting something above head height.

They might enjoy going to the gym and tell you that they get pain with exercises like a shoulder press or lateral raises, but other pressing exercises like the bench press are ok.

This information is gold-dust.

Your patient is telling you the answer…

In this example, the patient is telling you that when their scapula is stabilised, i.e. when they lay on their back and press weight, with their shoulder blade fixed to the bench, their symptoms are much better.

They are using similar muscles to the other exercises but when they stabilise their scapula, their symptoms are much improved.

So, might the scapula be a great place to start?


Simplifying, the shoulder is NOT as complicated as you might think.

Just because it may be more difficult than other joints to assess does NOT mean that you cannot still do a good assessment.

You will always be able to identify some problems that you can help your patient fix both with your hands-on treatment techniques and your rehab and this is where you should focus your attention.

Key Points

Why Is The Shoulder Hard To Assess: The shoulder is a complicated joint and many of the shoulder special tests are poor meaning gaining a diagnosis is harder to attain

Keep It Simple: By breaking the shoulder into 3 parts – The Glenohumeral Joint, The Scapula + Everything else (ACJ/SCJ) makes it easier for you to focus your attention on ONE area

Focus On The Big Problem: Pick the biggest issue and spend your time there. You will notice that once the BIG problem starts to improve so do the other problems a patient may have.

Andy Barker

The New Grad Physio Mentor

PS. Want to know more about the shoulder and how to better manage upper limb injuries.
Then you will find these blogs and podcasts helpful.

Rotator Cuff Rehab: Are We Getting It Wrong?
Blog Link: https://newgradphysio.com/rotator-cuff-rehab-are-we-getting-it-wrong/
Podcast Link: https://newgradphysio.com/podcast/episode-30/

Shoulder Dislocation To Grand Final Winner In 7 Days
Blog Link: https://newgradphysio.com/rotator-cuff-rehab-are-we-getting-it-wrong/
Podcast Link: https://newgradphysio.com/podcast/episode-20/