Understanding Shoulder Pain: Why the Labels Are Changing
In my early years of practice, I frequently used diagnostic labels like rotator cuff tear, subacromial impingement, and bursitis when assessing shoulder pain. I would often refer for imaging to help confirm the suspected diagnosis. However, over the past few years, my approach has significantly changed.
This shift came about as I deepened my understanding of the research around shoulder pain—particularly the evidence showing that imaging can sometimes lead to unnecessary interventions or even surgeries.
Despite knowing that posture is not strongly correlated with shoulder pain, and that imaging is often unhelpful, that tears are usually asymptomatic and that movement is often the best medicine, I’ve been guilty of continuing to use the old terminology when discussing shoulder pathology. A recent discussion with our fellow pain-nerd Osteopath, Kieren Jamieson, prompted me to look further into the evolving terminology in this area, and this blog is a reflection of that research and the latest clinical guidelines.
At the heart of these changes is a desire to move away from overly pathoanatomical or nociceptive explanations—that is, assuming that pain always means something is structurally damaged. Instead, the focus is shifting toward function, recovery, and pain management, particularly for non-traumatic cases.
Language matters and is a powerful tool to help promote, or conversely hinder, recovery – so I thank Kieren for giving my words a kick in the pants!
Why are the old terms being reconsidered?
Traditionally, shoulder pain has been diagnosed using terms like subacromial impingement, rotator cuff tear, or bursitis. While these labels may sound specific, they often don’t accurately reflect the cause of someone’s pain.
For example, bursitis is frequently an incidental finding on imaging—commonly seen in people without any symptoms. Likewise, degenerative rotator cuff tears are a normal part of aging and are present in a large proportion of asymptomatic individuals over 50.
The term impingement implies a mechanical compression of structures under the acromion, but this theory has come under heavy scrutiny. Surgical decompression procedures, once common, have been shown in multiple trials to offer no benefit over placebo surgery or exercise-based care.
Evolving terminology: a more helpful approach
In light of this, the clinical community has begun moving away from these structural labels. More recent terminology includes:
Subacromial Pain Syndrome (SAPS)
Rotator Cuff-Related Shoulder Pain
These terms better reflect the fact that shoulder pain is often non-specific, with no single identifiable structure responsible. They also help reduce the reliance on structural imaging and the assumption that tissue changes are always pathological.
These are proposed terminology, and there is still some scrutiny because, whilst somewhat more vague, these labels still carry the inference that one tissue is the culprit of the patient’s pain. Watch this space, as it seems there will continue to be an evolution in the language we use to diagnose shoulder pain.
When is imaging or referral appropriate?
Current clinical guidelines provide clear recommendations around the use of imaging in shoulder pain:
Acute, traumatic injuries—such as a fall with immediate weakness or functional loss—do warrant early imaging and potential referral for surgical opinion.
For chronic, degenerative, or atraumatic shoulder pain, imaging is generally not recommended unless symptoms persist beyond 12 weeks or fail to respond to conservative treatment.
This approach reduces the risk of over-diagnosis and unnecessary surgical intervention, both of which are associated with increased healthcare costs and poorer long-term outcomes.
What does best-practice management look like?
Most cases of shoulder pain are self-limiting and respond well to conservative care. Key management principles include:
Maintaining movement through gentle, pain-free range-of-motion exercises
Avoiding aggravating positions, particularly those that reproduce sharp or persistent pain
Progressive strengthening and functional exercise, once acute pain has settled
- Potential cortisone injection if conservative care (Osteo/Physio/Exercise) has not improved symptoms.
At Chadstone Region Osteopathy, our treatment approach reflects the latest evidence and guideline-based care. We focus on patient education, active rehabilitation, and restoring function.
If you’re dealing with persistent or limiting shoulder pain, we’re here to help guide your recovery with a personalised, evidence-informed approach.
References:
Choosing Wisely Australia. Recommendations for imaging in musculoskeletal conditions. https://www.choosingwisely.org.au/recommendations
American Academy of Orthopaedic Surgeons (AAOS). Clinical Practice Guidelines on the Management of Rotator Cuff Injuries. https://www.aaos.org/quality/quality-programs/clinical-practice-guidelines/
RACGP. Chronic shoulder pain: Diagnosis and management. https://www1.racgp.org.au/ajgp/2023/november/chronic-shoulder-pain
OrthoDiv. Rotator Cuff-Related Shoulder Pain Clinical Practice Guidelines. https://www.orthodiv.org/wp-content/uploads/2023/08/ODCU-August-2023-RCRP-EN.pdf
