Shoulder Pain: It's Not Always the Rotator Cuff

The shoulder is one of those joints that people think they understand — until it starts playing up, and suddenly nothing makes sense. Pain at the front, pain at the back, can't lift your arm, can't sleep on it, can't remember doing anything to it. And almost always, the assumption is: "must be my rotator cuff."

Sometimes it is. But a lot of the time, it isn't — and even when the rotator cuff is involved, it's rarely the whole story.

Let me explain why the shoulder is such a complicated beast.

Unlike the hip, which is a deep, well-contained ball and socket joint, the shoulder is more like a golf ball sitting on a tee. The socket is shallow, which is exactly what gives your arm such an impressive range of movement — you can reach behind you, above you, across your body in ways your hip simply can't. But that mobility comes at a cost. There's far more room for things to get weak, imbalanced, or just move inefficiently. And when the shoulder moves inefficiently, things start to hurt.

One of the most talked-about causes of shoulder pain is something called scapular dyskinesis — essentially, the shoulder blade not moving the way it should as you lift your arm. If you've ever been told you have it, the name alone tends to cause alarm. It sounds serious. Clinical. Like something that needs urgent fixing.

But the research is increasingly telling a different story.

Studies have found that 60-70% of both painful and completely pain-free populations show signs of scapular dyskinesis — which raises a pretty important question about whether we should even be calling it a problem at all. A 2023 systematic review went as far as asking whether it's time to normalise scapular dyskinesis entirely, given how prevalent it is among people with no symptoms whatsoever — with researchers raising concerns that it's being over-medicalised, with people being told they need treatment for something that may simply be normal movement variation.

One particularly interesting study found that scapular dyskinesis was no more common in people with shoulder pain than in people without — and, tellingly, when clinicians didn't know whether a patient was in pain, they rated dyskinesis far less frequently than when they did. Knowing someone had pain made clinicians more likely to find a problem. That's a significant bias, and it's worth being aware of.

A study of professional basketball players found scapular dyskinesis in nearly 30% of completely asymptomatic shoulders — suggesting it may in some cases simply be a sport-specific adaptation rather than a pathology.

The nuanced picture is this: scapular dyskinesis on its own isn't a diagnosis, and finding it doesn't automatically mean it's causing someone's pain. Where it becomes worth addressing is when genuine movement imbalances are contributing to loading issues — and that's a clinical judgement call, not a one-size-fits-all verdict.

The shoulder blade also doesn't move in isolation. It glides across the back of the ribs, and if those posterior ribs are stiff or restricted, the whole shoulder mechanism gets compromised. This is why I'll often assess and treat the thoracic spine and ribs in someone who comes in with what looks like a straightforward shoulder problem.

The neck is another piece of this that often gets ignored. Nerves that supply the shoulder and arm exit from the cervical spine, and stiffness or joint restriction in the neck can refer pain directly into the shoulder, mimic rotator cuff symptoms, or simply reduce the shoulder's ability to move freely. Treating the shoulder in isolation when the neck is the issue is a bit like fixing a leaking tap without turning the water off first.

Then there's the labrum — the ring of cartilage that deepens the shoulder socket and helps keep the joint stable. Labral tears, often the result of a fall, a high-speed impact, or repetitive overhead loading, can cause pain that's deep in the joint, a feeling of clicking or catching, or a general sense that the shoulder "isn't right." Altered scapular movement can contribute to labral tears, particularly in people who do a lot of overhead movement — worth knowing if you play racket sports, swim, or do any kind of throwing.

And when it is the rotator cuff? The picture is often more nuanced than people think. The rotator cuff is made up of four muscles — supraspinatus, infraspinatus, teres minor, and subscapularis — and they work together to both move and stabilise the joint. A problem with one doesn't mean the others are fine, and the size of a tear doesn't always predict how much pain someone's in or how well they'll respond to treatment. A recent review found that for partial tears and smaller injuries, conservative treatment produced comparable outcomes to surgery — which matters, because surgery on the shoulder is not a quick fix and comes with its own significant recovery demands.

The research is also increasingly pointing to movement quality and muscle balance as key factors. A 2025 systematic review found that targeted exercise therapy meaningfully reduced pain and improved function in people with rotator cuff related shoulder pain — not rest, not injections alone, but actually retraining how the shoulder moves and loading it properly.

This is where chiropractic comes in. A good shoulder assessment isn't just prodding the joint and assuming rotator cuff. It's looking at how the neck moves, how the ribs and thoracic spine are functioning, how the shoulder blade tracks, where strength and control are letting things down — and then building a plan that addresses all of it. That might include adjustments to the neck, thoracic spine and ribs, targeted rehab for the shoulder stabilisers, and hands-on work to the shoulder itself.

The shoulder is complicated. But most shoulder problems, assessed and treated properly, respond well. Don't assume the worst — and don't assume it's the rotator cuff until someone's actually had a proper look.