Shouldering Shoulder Pain: Myths & Realities

You know what's wild? I've been training people for over 3 decades, and I can predict with scary accuracy what someone's going to tell me when they walk in with shoulder pain.

It goes something like this:

"My doctor said it's bursitis and I need a cortisone shot."

"The MRI showed bone spurs. They're impinging on something."

"I have a rotator cuff tear. Surgery might be next."

"I should probably stop lifting overhead. Maybe forever."

"My physical therapist said we need to 'turn my shoulder off' for a while." (Yes, someone actually said this. I'm still recovering.)

Here's what I've learned after watching hundreds of shoulders recover: almost all of that advice is wrong.

Your shoulder doesn't hurt because of bone spurs. It's not your bursa playing the villain. And that tear on your MRI? 62% percent of people over 40 have one, whether their shoulder hurts or not.

So what's actually happening? Buckle up. We're going deep.

The great Adam Meakins, Shoulder Rehab PT loves to say:

• Your shoulder is probably not being “pinched.” It is more likely irritated than trapped. • That scary MRI finding may be more about mileage than misery. • A painful shoulder usually needs better loading, not a lifetime ban on overhead movement. • Stop blaming every grumpy shoulder on bursitis, bone spurs, or a dramatic tear. • Shoulders are often sensitive, deconditioned, or overloaded, not ruined.

The Bursitis Myth: Blaming the Wrong Tissue

For decades, lateral shoulder pain, that annoying ache on the outside of your shoulder got labeled as "bursitis." The logic was simple: there's a bursa in there, the shoulder hurts, therefore the bursa must be inflamed. It's elegant. It's tidy. It's also usually wrong.

Yes, the bursa can get irritated. But in most cases, it's reacting to an unhappy neighbor the rotator cuff tendons. The bursa is like the guy who lives next door to the party house. He's not causing the noise. He's just suffering from it.

The real troublemaker? Rotator cuff tendinopathy. Your tendons are overloaded, irritated, and protesting loudly. The bursa just happens to be in the blast radius.

This is why cortisone shots into the bursa provide temporary relief but rarely fix the problem long-term. You're medicating the neighbor instead of shutting down the party.

Bone Spurs: The Scapegoat That Won't Die

Bone spurs those little calcium deposits that show up on X-rays—have been blamed for shoulder pain since the dawn of orthopedic imaging. They're still blamed today, despite overwhelming evidence that they're almost never the cause.

Think about it: We get tendinopathy all over the body; achilles, patellar tendon, tennis elbow, plantar fasciitis; and nobody blames bone spurs (unless you want to get out of Vietnam). Yet in the shoulder, somehow a little calcium deposit became public enemy number one?

Here's what actually happens: Bone spurs develop as a normal aging process. They're a sign your body has been doing stuff for a few decades. That's it. They're not pinching anything. They're not grinding anything. They're just...there.

Most people with bone spurs have zero pain. And many people with severe shoulder pain have zero bone spurs. The correlation is terrible.

So why does this myth persist? Because it gives patients a simple, structural explanation for their pain. And it gives surgeons something to "fix" during surgery. But shaving off bone spurs rarely solves rotator cuff tendinopathy because they weren't causing it in the first place.

Your MRI Is Lying to You (Sort Of)

Okay, the MRI isn't technically lying. It's showing you accurate images of your shoulder's structure. The problem is how we interpret those images.

A recent study published in JAMA Internal Medicine scanned the shoulders of adults aged 41-76 years old....regardless of whether they had pain. The findings?

Nearly 100% had rotator cuff "abnormalities" on MRI. 62% had a least one partial tear. Tendinosis. Partial tears. Full-thickness tears. Degenerative changes. Bursal fluid. All the scary words that make patients think their shoulder is falling apart.

But here's the kicker: these findings showed up in people with pain and people without pain at almost identical rates.

Translation: Seeing a tear on your MRI doesn't mean that's why your shoulder hurts. It might be. It might not be. The scan can't tell you that. Treat the pain not the scan.

Some people with dramatic MRI findings lift weights pain-free. Others with minimal findings can barely lift their arm. The imaging is information, nothing more. It doesn't predict your pain, your function, or your future. This is why I've been saying for over twenty years (long before it was comfortable to say out loud): very little of what we see on an MRI explains pain. I've seen people with MRIs that look like a war zone who lift pain free. And I've seen people with barely anything on imaging who can't raise their arm to shoulder height without wincing. Treat the person not the scan.

What's Actually Happening: Rotator Cuff Tendinopathy

Let's talk about what your rotator cuff actually does.

Most people think the rotator cuff lifts the arm. Not quite. The rotator cuff's primary job is stabilization; centering the ball of your shoulder in the socket while bigger muscles (deltoids, lats, pecs) do the heavy lifting. Think of a ball in a shallow dish being held in the middle by 4 small hands. The rotator cuff works to keep the ball (head of humerous) in the middle of the dish (shoulder socket).

That means your rotator cuff is working constantly. Every time you:

• Reach forward

• Press overhead

• Push open a door

• Type with unsupported arms

• Carry groceries

• Put on a jacket

  
  

...your rotator cuff is firing to maintain joint control.

Here's the problem: The rotator cuff muscles are small. Much smaller than the deltoids and pecs that power shoulder movement. Over time, those big muscles can overpower the cuff, leading to overuse, fatigue, and eventually, tendinopathy.

Tendinopathy is what happens when the load placed on a tendon exceeds its capacity to handle it. The tendon gets irritated, sensitive, and eventually starts screaming at you.

And just like gluteal tendinopathy at the hip (which I've written about before), rotator cuff tendinopathy:

• Can keep you up at night

• Makes everyday activities miserable

• Can hurt intensely without a significant tear

• Can show tears on imaging and cause zero pain

• Struggles when load exceeds capacity

• Responds best to progressive strengthening

• Can be affected by your metabolic health

That last point is huge. If you're perimenopausal, diabetic, or have thyroid issues, your tendons are more prone to getting cranky. We'll come back to that. Hint: it is not about 'wear and tear' so much as it is about metabolic health and bio chemistry.

How Rotator Cuff Tendinopathy Actually Feels

The pattern is remarkably consistent:

• Pain on the outside of the shoulder, sometimes radiating toward the upper arm (but rarely below the elbow)

• Sleeping on that side becomes torture

• Reaching overhead or behind your back aggravates it

• Lifting things away from your body hurts

• Putting on a jacket or reaching into the back seat feels like a Herculean task

  
  

What surprises most people is that there wasn't a dramatic injury. No pop. No fall. No obvious moment of "I wrecked my shoulder."

Just a gradual increase in irritation until normal activities started feeling abnormal.

That's how tendinopathies work. Tendons tolerate what they're accustomed to. When the load changes or when their capacity declines they get sensitive.

Why might capacity change?

• Activity increases (spring cleaning, painting a room, shoveling snow)

• Strength training fades over time

• You're sitting way too much

• Your metabolic health shifts (insulin resistance, menopause, thyroid dysfunction)

  
  

None of this should be mysterious. Like cars and homes, our tissues require maintenance. When they're not challenged appropriately and are exposed to an unfavorable metabolic environment (poor diet can also be a contributing factor), they lose the ability to tolerate normal loads.

Then you decide to reorganize the garage or play three sets of pickleball, and two days later your shoulder starts protesting. Ugh, but totally normal.

Why Rest Won't Fix It

When something hurts, the instinct is to rest it. And for acute injuries; like a sprained ankle or a muscle strain; a brief period of rest makes sense. But the data is showing that you can usually start moving the painful area sometimes hours if not a day later (isometrics are great).

But for tendinopathy? Rest is usually the wrong answer.

Here's why: Prolonged rest lowers tendon capacity even further. Your shoulder becomes less prepared for normal life demands, not more.

When you inevitably resume lifting, reaching, or overhead activity, the same problem returns; often worse than before; because your tendon's capacity has declined during the rest period.

This is why so many people feel temporarily better after "taking it easy," only to have symptoms flare up the moment they return to normal activities.

Tendons need load to heal. Let me say that again: Tendons need load to heal! They remodel in response to progressive, controlled stress. Take that stress away, and they atrophy. It's use it or lose it...literally.

What About Stretching?

When something hurts, people often want to stretch it. (full disclosure, I think most stretching is overrated). With rotator cuff tendinopathy, aggressive stretching; especially in positions that compress the tendon under the acromion can make things worse in the early phases.

This doesn't mean flexibility is unimportant. It means that when the tendon is already irritated, repeated compression and strain can perpetuate the sensitivity.

Early on, strength and controlled loading outperform stretching for tendon rehabilitation.

As tolerance improves and the tendon becomes more resilient, range of motion work can gradually expand. But trying to stretch your way out of tendinopathy in week one is like trying to run a marathon the day after a hamstring strain. Premature and counterproductive.

The Treatment: Progressive Loading (Not Magic)

Eventually, all roads lead back to load. Tendons remodel in response to demand. They require progressive, repeatable loading to reorganize, heal, and strengthen. This process is not quick. It can take months. But appropriate progressive strengthening consistently outperforms passive treatments like rest, ice, ultrasound, and stretching.

Here's the roadmap:

Phase 1: Isometrics (Weeks 1-3)

Start with isometric holds, muscle contractions without joint movement. These reduce pain without aggravating the tendon and prepare the tissue for loaded movement.

Isometric External Rotation: Stand next to a wall. Elbow bent 90 degrees at your side. Press the back of your hand against the wall. Hold for 30-45 seconds. Rest 1 minute. Repeat 6-8 times per side, multiple times daily if severe pain allows.

Isometric Abduction: Face the wall with your arm straight at your side. Push the back of your hand against the wall, keeping the elbow straight. This isolates a different portion of the rotator cuff. You can also turn your palm against the wall to load yet another area.

Don't skip this phase if your shoulder is very irritated. Isometrics are boring, but they work.

Phase 2: Light Loading (Weeks 3-8)

Progress to I-Y-T exercises with light dumbbells (2-5 pounds) or TRX straps. The goal is controlled movement through range with manageable resistance.

• I: Lying face down, arms straight overhead in an "I" position. Lift arms off the ground, hold 5 seconds.

• Y: Arms at 45-degree angle forming a "Y." Lift, hold 5 seconds.

• T: Arms out to the sides forming a "T." Lift, hold 5 seconds.

• 
  

Start with 2 sets of 10-12 reps, 3-4 days per week.

Add external rotation with resistance band or light dumbbell. Keep elbow at your side, rotate arm outward against resistance. This targets the infraspinatus and teres minor directly.

Exercise to the point of muscle fatigue, not exhaustion, but enough to create stimulus. If pain significantly increases the next day, you pushed too hard. Back off and rebuild tolerance.

Phase 3: Building Capacity (Weeks 8-16)

Add rows, farmer carries, and supported overhead positions. Your shoulder is gaining tolerance. You're building capacity to handle normal life demands.

Increase load gradually: 1-2 pounds every 7-10 days, not every session. Tendons adapt slower than muscles. Patience prevents setbacks.

Phase 4: Return to Full Function (Months 4-6)

Controlled overhead pressing, push-ups, full range movements, sport-specific activities. You're not protecting the shoulder anymore....you're using it fully while continuing to strengthen progressively.

This timeline assumes consistent work. Miss a few weeks, and the process extends. Push too hard too fast, and you might restart from Phase 1.

When Injections Are Useful (And When They're Not)

Corticosteroid injections can help if pain is severe enough to prevent any exercise. That's the primary use case: reducing inflammation enough to allow you to start loading the tendon.

An injection is not a treatment by itself. It's a tool to open a window for rehabilitation.

If you get an injection but don't do the strengthening work, you've wasted the temporary relief it provides. The injection may give you 6-12 weeks of reduced pain. Use that window to build capacity. Otherwise, when it wears off, you're back where you started.

The Risk of Repeated Injections

One or two corticosteroid injections spaced months apart? Rarely a problem.

Three, four, five injections into the same area? That's where tendon weakening becomes a real concern.

Corticosteroids reduce inflammation, but they also impair collagen synthesis and can weaken tendon structure over time. Repeated injections increase the risk of tendon rupture, particularly in heavily loaded tendons.

If you've had multiple injections and the pain keeps returning, the injection is not the solution. The underlying capacity issue hasn't been addressed. More injections won't fix that. Loading will.

What About PRP?

Some practitioners offer platelet-rich plasma (PRP) or other biologic injections. The evidence for PRP in rotator cuff tendinopathy is...decent. Not overwhelming, but decent.

They're expensive, not covered by insurance, and research doesn't consistently show superiority over progressive loading alone. That said (and this could be placebo) I've personally know a few people who had PRP injections for tendon issues and found them useful. Your mileage may vary. Don't expect miracles.

Physical Therapy: What It Should Look Like

A good physical therapist does more than give you exercises. They:

• Assess movement patterns

• Identify compensations

• Modify loading based on your response

• Progress you systematically

• Educate you about what's happening and why

  
  

The goal is to make you independent and able to manage your shoulder without ongoing treatment.

If your PT just applies ice, ultrasound, and passive stretches for weeks without progressive loading, find a different therapist. Those passive modalities have limited long-term benefit for tendinopathy.

Look for someone who understands tendon rehabilitation, emphasizes active loading, and can explain the rationale behind each exercise. You want a coach who helps you rebuild capacity, not someone treating you like a passive recipient of interventions.

Activity Modification: Don't Avoid, Adjust

Most people don't need to stop activities entirely. They need to modify based on discomfort, not fear.

• If overhead reaching hurts, lower the range temporarily.

• If lifting heavy groceries aggravates symptoms, split the load or make two trips.

• If sleeping on that side is miserable, sleep on the other side for now.

  
  

These are temporary adjustments, not permanent limitations. As capacity improves, these activities become tolerable again.

The fear of "making it worse" often leads to excessive avoidance. Unless you've ruptured the tendon (uncommon and usually obvious), using your shoulder won't cause structural harm. It might increase discomfort temporarily, but discomfort and damage are not the same thing.

Use pain as a guide:

• Sharp, severe pain that persists for days? Modify.

• Mild discomfort that settles within hours? Probably acceptable.

Your tendon is irritated, not fragile. Continue normal activities that don't significantly aggravate symptoms. Keep using your arm for daily tasks. The goal is graded exposure...gradually increasing what you ask the shoulder to do as tolerance improves.

Prolonged avoidance of all overhead activity, all lifting, all reaching creates a different problem: your shoulder becomes deconditioned, loses tolerance for normal demands, and every attempt to resume activity feels impossible because capacity has declined further.

The Metabolic Connection (Yes, Again)

I know. I talk about this all the time. But it matters. If you have insulin resistance, type 2 diabetes, or are perimenopausal, your tendon healing is affected. These conditions:

• Alter collagen metabolism

• Increase systemic inflammation

• Reduce tendon resilience and capacity

  
  

"Fixing" your shoulder might require fixing your metabolic health. That means addressing diet, sleep, activity levels, and metabolic dysfunction, not just doing shoulder exercises.

While this rotator cuff episode might subside, if we don't address your metabolic health, you're at risk for it recurring or developing issues elsewhere (the other shoulder, your hip, etc.).

This is why some people respond quickly to rehabilitation while others struggle for months with the same injury. The tendon exists in a metabolic environment. If that environment is hostile to healing, progress will be slow regardless of how perfectly you execute exercises.

Let's Wrap This Up

Lateral shoulder pain is common, frustrating, and almost never as structurally catastrophic as the MRI report suggests. Most cases are rotator cuff tendinopathy responding to overload in a system that has lost capacity.

The solution is rarely:

• Rest

• Stretching

• Repeated injections

• Bone spur removal surgery

  
  

The final and best is solution is usually progressive loading that rebuilds what the tendon needs to tolerate normal life.

If you're dealing with this:

✓ Start the work

✓ Be patient with the timeline

✓ Address your metabolic health if it's compromised

✓ Remember that imaging abnormalities are nearly universal after 40...they don't determine your outcome. Your response to rehabilitation does.

Now go press something against a wall and hold it there. Your shoulder will thank you later.

Want more evidence-based content that doesn't insult your intelligence? Check out more at www.joachimstraining.com/