Shoulder Pain: Why It’s Often Misdiagnosed (And What Actually Needs Treating)

Written By Annmarie Maguire

Shoulder pain is often misdiagnosed due to the complex link between the shoulder, neck and upper back. Learn causes, diagnosis and physiotherapy treatment options.

Why Shoulder Pain Is So Complex

Shoulder pain is one of the most commonly misdiagnosed musculoskeletal conditions - and for good reason.

The shoulder is not just one joint.

It is a complex system involving:

  • The glenohumeral joint (ball and socket)

  • The shoulder blade (scapula)

  • The collarbone (AC joint & SC joint)

  • The cervical spine (neck)

  • The thoracic spine (upper back)

  • The rib cage

  • The surrounding muscles, tendons and nerves

Pain felt “in the shoulder” may actually be coming from the neck.
Or from the upper back.
Or from nerve irritation.
Or from load mismanagement.

Without a thorough assessment, it’s easy to label shoulder pain incorrectly, which often delays recovery.

Common Causes of Shoulder Pain in Active & Sporting Populations

In younger, active individuals and athletes, shoulder pain typically falls into several categories.

1. Rotator Cuff Tendinopathy

The rotator cuff muscles help stabilise and control the shoulder joint. In sports involving overhead or repetitive loading (swimming, CrossFit, gym training, throwing sports), these tendons can become overloaded.

Symptoms may include:

  • Pain with overhead movements

  • Pain during pressing or pulling exercises

  • Night discomfort

  • Weakness with lifting

Most cases are load-related, not structural tears.

2. Neck (Cervical Spine) Referral or Nerve Irritation

The cervical spine can refer pain into the shoulder and arm.

In some cases, mild nerve root irritation (often labelled “nerve impingement”) may present as:

  • Shoulder and arm pain

  • Tingling or pins and needles

  • Weakness

  • Pain with shoulder and/or neck movement

Treating the shoulder alone in these cases will not solve the problem - the neck must be assessed.

3. Muscle Spasm & Load Sensitivity

Sudden increases in training volume, contact sport impact, or high training stress can trigger protective muscle guarding and spasm around the shoulder.

This is common in:

  • Gym goers increasing pressing volume

  • CrossFit athletes during high-rep overhead work

  • Powerlifters during peak intensity phases

  • Contact sport athletes after collisions

Often, the issue is not damage, it’s load tolerance.

4. Labral Injuries, Dislocation & Impact Trauma

In contact sports or high-impact activities, shoulder injuries can include:

  • Labral pathology

  • Dislocation

  • Subluxation (partial dislocation)

  • Bony injuries

These are typically traumatic events rather than gradual overload problems.

Management depends on:

  • Severity

  • Stability of the joint

  • Sporting demands

  • Previous injury history

Rotator Cuff Tears: Age Matters

A common misconception is that shoulder pain automatically equals a torn rotator cuff.

In reality:

  • Younger athletes usually tear their rotator cuff due to trauma (heavy fall, tackle, sudden force).

  • Older adults are more likely to develop degenerative lesions over time.

Degenerative rotator cuff tears are very common over 50 and many people have them without pain.

Management depends on:

  • Location of the lesion within the tendon

  • Size of the lesion

  • Functional limitations

  • Irritability level

Understanding which lesions require structured rehab versus surgical opinion is something we are highly trained to assess and guide.

Imaging alone does not determine treatment - symptoms and function matter more.

The Shoulder Doesn’t Work Alone: The Role of the Arm & Upper Body

The shoulder is part of a kinetic chain.

The wrist, elbow, biceps, triceps, and forearm muscles all share load during pushing, pulling, throwing and lifting.

If:

  • The elbow isn’t tolerating load

  • The triceps are under-conditioned

  • The biceps tendon is overloaded

  • The forearm isn’t absorbing force

…the shoulder often compensates.

This is why isolated “shoulder rehab” often fails.

A full upper limb assessment is essential to distribute tissue load appropriately.

What About Shoulder Blade Position & Winging?

There is a strong myth that shoulder pain is caused by “poor scapular positioning” or “winging”.

Current evidence shows:

  • Scapular positioning varies widely between individuals

  • Many people without pain have winging

  • Forcing “perfect posture” does not fix shoulder pain

We no longer focus on rigid postural corrections.

Instead, we focus on:

  • Strength

  • Load tolerance

  • Movement variability

  • Capacity building

Your anatomy is not the problem. Capacity is.

Shoulder Pain in Specific Sports

Different sports create different stress patterns.

Swimmers

High repetition overhead loading can irritate rotator cuff tendons if recovery is insufficient.

CrossFit & Group Training

High-volume pressing, kipping, and fatigue-based lifting can overload tissues quickly.

Powerlifters

Heavy bench pressing and accessory volume can sensitise anterior shoulder structures.

Contact Sports

Impact, tackling and falls increase risk of labral injuries, instability and AC joint trauma.

Each athlete requires sport-specific load management - not generic exercises.

Why Shoulder Pain Is Commonly Misdiagnosed

Shoulder pain may be incorrectly labelled because:

  • The neck wasn’t assessed

  • The thoracic spine wasn’t considered

  • Load history wasn’t reviewed

  • Imaging findings were overemphasised

  • The whole upper limb wasn’t examined

Accurate diagnosis requires understanding whether the pain is:

  • Tendon-related

  • Joint-related

  • Nerve-related

  • Trauma-related

  • Load-related

Each has a different management pathway.

How Shoulder Physiotherapy Actually Works

Treatment is often more straightforward than people expect.

Step 1: We assess thoroughly
Step 2: We identify the true source of symptoms
Step 3: We build a progressive plan

Rehabilitation may include:

  • Progressive strength training

  • Load modification

  • Graded return to sport

  • Neck or thoracic mobility work (if relevant)

  • Targeted upper limb conditioning

Hands-on therapy may be used for:

  • Short-term symptom relief

  • Reducing muscle guarding

  • Assisting diagnosis

But long-term improvement comes from progressive loading.

The Bottom Line

Shoulder pain is rarely just “a bad shoulder”.

It is a complex interaction between:

  • The shoulder joint

  • The shoulder blade

  • The neck

  • The upper back

  • The arm

  • Your training load

Correct diagnosis makes treatment simple.

If you are experiencing persistent shoulder pain, especially with sport or gym training, early assessment can prevent chronic issues and recurring flare-ups.

Annmarie Maguire
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