How does physical therapy manage left shoulder pain in a patient?

Physical Therapy Management of Left Shoulder Pain

Physical therapy manages left shoulder pain through a structured, stepwise approach prioritizing range of motion exercises (especially external rotation and abduction), proper positioning, and progressive strengthening, while avoiding harmful interventions like overhead pulleys. 1, 2

Initial Assessment and Education

Physical therapy begins with evaluating muscle tone, strength, soft tissue changes, joint alignment of the shoulder girdle, pain levels, and orthopedic changes to identify the underlying pathology 2. The therapist should specifically assess for instability signs including pain during movement, decreased movement velocity or precision, and sensations of clicking or displacement 2.

Patient education forms the foundation of treatment, focusing on proper shoulder positioning techniques and the benign, self-limited nature of most soft tissue shoulder pain 1, 3. This reassurance reduces fear-avoidance behaviors and promotes active participation in rehabilitation 1.

Core Physical Therapy Interventions

Range of Motion Exercises (Primary Intervention)

Range of motion exercises—both passive and active-assisted—must be performed with the upper extremity positioned safely within the patient's visual field, emphasizing external rotation and abduction movements 1, 2, 4. These specific directions prevent frozen shoulder and shoulder-hand pain syndrome 1, 4. The exercises should progress from passive to active-assisted, then to fully active movements as alignment improves and scapular muscles strengthen 2.

Mobilization and Stretching

Gentle mobilization and stretching techniques concentrate on increasing external rotation and abduction 1, 2, 4. These movements address the most common mechanical restrictions that correlate with shoulder pain development—lateral rotation limitation being the factor most significantly related to pain onset 1.

Progressive Strengthening

Once acute pain is controlled, strengthening exercises targeting the rotator cuff and scapular stabilizers should be initiated 4. Active range of motion must increase progressively alongside restoration of proper alignment and strengthening of weak shoulder girdle muscles 2.

Critical Interventions to AVOID

Overhead pulley exercises must be avoided entirely, as they encourage uncontrolled abduction and have the highest incidence of developing shoulder pain 1, 4. This represents a common pitfall where well-intentioned therapy causes harm 1.

Adjunctive Physical Therapy Modalities

Electrical Stimulation

Functional electrical stimulation (FES) can improve shoulder lateral rotation and reduce pain, particularly in patients with spasticity-related shoulder dysfunction 1, 4. However, evidence for transcutaneous electrical nerve stimulation (TENS) and neuromuscular electrical stimulation (NMES) remains mixed, with the largest trials showing no significant pain prevention effects 1.

Physical Modalities

Ice, heat, and soft tissue massage provide symptomatic relief and can be incorporated as adjuncts to active treatment 1, 4. These modalities address pain and tissue inflammation but should not replace active exercise interventions 1.

Supportive Devices

Shoulder strapping or slings may prevent trauma and provide support during ambulation training, protecting the shoulder from traction injury 1, 4. However, evidence for strapping in pain prevention shows mixed results, with the largest trial (162 patients) demonstrating only non-significant trends toward improvement 1.

Advanced Interventions for Specific Pathologies

For Chronic Shoulder Pain (>3 months)

Stretching and strengthening exercises become particularly important for chronic presentations 3. Laser acupuncture or low-level laser therapy may be considered as evidence-based adjuncts 3.

For Spasticity-Related Pain

When spasticity contributes to shoulder pain, botulinum toxin injections into the subscapular and pectoral muscles can be used alongside physical therapy 2, 4. This medical intervention facilitates more effective participation in therapeutic exercises 2.

For Calcific Tendinitis

If imaging confirms calcific tendinitis, shock-wave therapy may be considered as an adjunct to physical therapy 3.

Orthotics and Adaptive Equipment

If pain during daily activities impedes function, orthotics (splints, braces, sleeves), assistive devices (canes), or ergonomic adaptations should be offered through occupational therapy referral 1. These devices support continued activity participation while tissues heal 1.

Stepped-Care Approach

Physical therapy follows a logical progression: 1

• Step 1: Education, self-management support, and basic exercises
• Step 2: Specialist physical therapy with individualized graded exercise or strength training if the patient cannot initiate activity independently
• Step 3: Multidisciplinary treatment if psychosocial factors (fear of movement, catastrophizing) underlie disability

Key Clinical Pitfalls

Delaying treatment of shoulder pain can mask motor function improvement, inhibit rehabilitation (limiting cane or wheelchair use), and contribute to depression, insomnia, and reduced quality of life 1, 2, 4. Early intervention is critical 1.

Aggressive passive range of motion, if performed improperly on the complex shoulder joint, can cause more harm than good 1. Technique matters significantly 1.

Continuing ineffective treatment beyond 12 weeks without improvement warrants referral back to the physician or orthopedic surgeon 5. Physical therapists should reassess patient status at each visit for worsening symptoms, new physical/mental/psychological symptoms, or satisfactory recovery 3.

Mechanism of Therapeutic Effect

Physical therapy addresses shoulder pain through multiple mechanisms: promoting motor learning and neural reorganization through proprioceptive feedback 1, preventing contractures that restrict movement and cause pain 1, maintaining joint mobility to prevent adhesive capsulitis 1, and facilitating functional recovery through task-specific practice 1. The repetitive, varied movement practice inherent in physical therapy drives neuroplastic changes that support long-term recovery 1.