Rose Mary has been an occupational therapist since 1987. She has extensive experience treating conditions of the hands and arms.
Shoulder Expert From Both Sides of the Table
You could say I’m an expert on shoulder pain. I have injured both of my shoulders— thankfully, not at the same time. As an occupational therapist, I have also treated a lot of shoulder pain in clients referred by primary care providers as well as clients referred for post-operative therapy by orthopedic surgeons.
I’m proud to report that I have succeeded in many cases where other therapists have failed. I believe the key to success when dealing with severe shoulder pain is to make the client’s pain the number one priority. This may sound like a no-brainer, but you’d be surprised. A lot of therapists often jump in with exercises that may be too rigorous—and this certainly works against the client's recovery.
In this article, I will discuss two effective recovery strategies:
- Ice for pain management
- Gentle, passive exercises to regain full functionality and range of motion
1. Ice for Pain Management
My experience with clients has convinced me that ice is the single best pain management tool for shoulder pain. Clients have repeatedly reported the effectiveness of ice for reducing their pain, whether they are taking over-the-counter pain relievers, powerful prescription drugs, or even no meds at all.
I instruct my clients to start out with a goal of 20-30 minutes of ice, 3-5 times a day. Initially, most clients have to be convinced to use ice because they think heat feels better. Although it may feel better, heat does not help you recover in the long run. Heat dilates blood vessels, or opens them up, and can actually increase pain. Cold constricts blood vessels, or makes them smaller, and is a powerful pain management tool. The consensus of my clients is that ice is their single best and most reliable tool for managing shoulder pain.
The Best Types of Ice Packs
Alcohol Ice Packs
I like to mix alcohol and water to make “ice slushy” ice packs. Shoulder pain tends to radiate and span a large area, so I prefer using a gallon bag.
- Pour three cups of water and one cup of alcohol into a gallon ziplock bag.
- Then, double bag it to prevent spills.
- Store in the freezer.
I like the alcohol ice packs because they stay therapeutically cold for a longer time than water-based ice packs. If the pain is severe, you can ice 30 minutes on and 30-60 minutes off. Place a pillowcase or thin towel between the ice pack and your skin to prevent frostbite.
Corn Syrup Ice Pack
You can also make a cold pack by pouring corn syrup into a ziplock bag, and double bag. Store in the freezer. You may need to take it out of the freezer for 10 minutes before use, depending on your freezer. You want it to be soft and ready to conform to the area. Karo corn syrup (a popular trade name used in cooking) has a very soothing texture when used in cold packs—similar to commercial cold packs used in therapy clinics.
Frozen Peas or Corn
Many therapists pitch the classic use of frozen peas or corn. While this may be inexpensive and convenient, I don’t recommend this option. Most clients will be icing several times a day for days and possibly weeks. The vegetables may get a bit disgusting.
Direct Ice Massage
Another option for ice treatment is a direct ice massage. This is best for concentrated (smaller) areas of pain.
- Fill Styrofoam cups ¾ full with water and freeze.
- Peel the bottom of the cup off when ready to use.
- Holding the top of the cup, rub the ice over the area of pain, keeping it constantly moving.
- Apply direct ice to the shoulder area for about 7-10 minutes.
2. Gentle, Passive Range of Motion Exercises
For severe shoulder pain, I avoid active range of motion exercises (using your shoulder muscles to move your arms) and strengthening exercises until the pain has significantly subsided. Instead, I introduce passive range of motion exercises, with a large emphasis on "passive." The arm on the painful side should be fully relaxed, as though it were paralyzed and incapable of moving. Movement, therefore, must come from another source, such as the non-injured arm.
I recommend pendulums and cane exercises. Exercises should be done so as not to significantly increase pain above baseline pain, on a scale of zero to ten. If the pain is 6 of 10, exercises should only be done to a pain level of about 7 of 10.
I bring clients into the clinic to teach them the exercises and verify they are using correct form. Some clients may not be able to perform the exercises, themselves, and may need clinical therapy, which may include other pain modalities.
For pendulum exercises:
- Lean over, hinging at the waist. Support your body by holding onto a table or chair with the unaffected hand.
- Let the arm on the painful side hang limply.
- Create slow, gentle movements forward and back, side to side, and in small circles by moving at the hips and knees.
There are plenty of videos demonstrating this movement, but many of them use fast or forceful movements. Even worse, some use active movements in the arms and shoulders rather than passive movements caused by swaying the body. The video below does a good job of showing how the exercise should look when done properly.
Cradle and Rock
Another way to provide gentle, controlled, passive movements is to cradle the affected arm like a baby.
Using your unaffected arm, rock the affected arm gently from side to side and up and down.
For cane exercises, use a cane or dowel to gently move the arm. These are generally done while standing, but they can be done seated or even while lying down.
- Hold onto one end of the cane with the hand on the painful side.
- Push the injured arm in different directions, rotating at the shoulder joint, by moving the cane with the non-painful arm.
Strictly speaking, most would consider cane activities to be active, assistive range of motion. I don’t disagree, but I stress trying to relax the painful arm as much as possible—as though the arm was paralyzed, and the hand had to be secured to the end of the cane with Velcro.
Start with small, gentle movements in a short range. If you don't notice any discomfort, gradually increase movement. Start by working in a forward direction, then to the side. Only go until you feel a gentle stretch; you should not feel a significant increase in pain.
You will not be pushing to achieve your full range of motion each session—at least not in the beginning. The idea is to increase your range over time. With my first shoulder injury, the physical therapist told me that I absolutely had to push with the cane to reach my full range right away. This was excruciating, and I wound up with pain so severe that I had to take maximum doses of Motrin and Tylenol daily for months. The high doses of Motrin, along with the pain, drove my blood pressure up. Knowing what I know now—I was a pediatric therapist at the time, and not yet experienced with shoulder therapy—I would give that therapist a swift kick in the pants.
Dr. Erin Ducat Demonstrates PROM with Dowel
Unweight the Shoulder
Clients with shoulder pain often develop secondary muscular pain in the neck and upper back muscles. This is because our body tends to tense up around the area of pain as a coping mechanism. Over time, this can cause muscle imbalances that alter your posture and the way you move. Poor posture and the inability to move freely and properly lead to pain in other areas and can hinder daily movements like walking and dressing.
To relax the muscles of the neck, back, and shoulders, I recommend periodically using pillows or a sling to take the weight off those muscles. While seated, lift your arm up and place it on top of a couple of pillows. The goal is to put some slack in the muscles that support the shoulder. Alternatively, you can use an arm sling. Whichever method you use, relax into the support. I recommend unweighting the arm one to three times a day for 30-90 mins at a time.
Orthopedic surgeons are often opposed to the use of slings except during the acute phase immediately after an injury or surgery. Their reasoning is that they want the client to use the arm to prevent muscle wasting. My philosophy is that if the shoulder hurts so badly that you are unlikely to use the arm anyway, why not use the sling to reduce the pain, help you recover, and get you to the point of being able to use your arm again.
3. Pain Management Modalities
Sometimes, it is necessary to use a physical agent modality (PAM) for assistance with pain management. Your options include modalities such as TENS (transcutaneous electrical nerve stimulation), iontophoresis, IFC (interferential current), ultrasound, or phonophoresis. These modalities are usually administered by a physical or occupational therapist. Home units are also available but are often not as effective as models used in a clinic. Home modality options should also be used under the supervision of your therapist.
I Don't Feel Anymore Pain—What Now?
As pain decreases through icing and passive range of motion exercises, I begin to focus more on increasing range of motion. Once passive motion increases, I start clients on more aggressive range of motion exercises and very gentle strengthening exercises. I may have clients come to the clinic for range of motion exercises performed by therapy assistants, as well as physical agent modalities, like interferential current (IFC).
Strengthening exercises start with submaximal, isometric exercises and progress as tolerated. I may then begin short-range flexion/extension, abduction/adduction, and internal/external rotation of the shoulder joint with a 1-2-lb weight.
Shoulder stabilization exercises are also important. Finally, I start clients on Rockwood exercises, or rubber band exercises, to further increase strength.
This last bit of information is just an example of how I would proceed with the recovery process for my clients. Discuss your recovery goals and strategies with your doctor or therapist.
This article is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Consult your doctor, physical therapist, or occupational therapist.
This content is for informational purposes only and does not substitute for formal and individualized diagnosis, prognosis, treatment, prescription, and/or dietary advice from a licensed medical professional. Do not stop or alter your current course of treatment. If pregnant or nursing, consult with a qualified provider on an individual basis. Seek immediate help if you are experiencing a medical emergency.
© 2018 rmcrayne
Peggy Woods from Houston, Texas on February 28, 2018:
I have a good friend who is suffering from shoulder pain. I will forward this to her and also pin to my health board. Thanks for writing this informative article.
Tom Cornett from Ohio on February 25, 2018:
Bookmarking this Hub. Have used ice many times over the years. I have to be in extreme pain to take any kind of pill. I didn't know there were exercises. I will give them a try. Thanks Rose Mary. :)