One expert reveals the common conditions he treats in his clinic and the steps we can take to strengthen muscles and protect our joints.
For many of us, shoulder pain is an inevitable part of reaching middle age. Many adults will develop shoulder pain at some point in their lives, in many cases spontaneously and without warning. In my clinic, however, I’m increasingly seeing people who have brought on shoulder problems by taking up new exercise regimens without the correct guidance, and by trying to achieve too much, too quickly.
When it comes to shoulders, people in midlife have a lot going against them. Our bodies change when we reach our 40s and 50s: the blood supply to our tendons gets poorer and there is an increased chance of them tearing; our body’s collagen renewal slows down, so it takes longer for tissue to repair itself; and we experience sarcopenia (age-related muscle loss), which means we’re essentially trying to support our skeletons with reduced muscle mass.
We also undergo changes related to posture: we become kyphotic, where the upper spine curves forward. This causes scapular protraction, where your shoulder blades move away from the spine. In some cases, a bony protrusion called an acromial spur may also grow in the shoulder, narrowing the space in which our rotator cuff needs to move.
Unfortunately, this often coincides with people taking up new sports, prompted by the (very sensible) advice that we should all be weight-training to counteract natural age-related loss of muscle mass and bone density. So people lift heavy weights and train through injuries. They think, “I lifted 80kg over my head when I was in my 20s, so that’s my target.” Obviously, exercise is a good thing to do, but without the right technique or consulting a personal trainer, the result can be shoulder pain and, in some cases, the necessity for surgery.
What are the most common shoulder problems?
There are several different shoulder conditions, which are clearly and comprehensively explained in the website Shoulder & Elbow Club. These are the most common problems I see at my clinic.
Frozen Shoulder (Adhesive Capsulitis)
Frozen shoulder affects people aged between 40 and 60. It is often linked with other conditions that become more prevalent in midlife, such as heart disease and type 2 diabetes. Chronic autoimmune diseases like type 1 diabetes and thyroid conditions increase your likelihood of being affected. Women, for reasons that remain unclear, are far more likely to have frozen shoulder when they’re perimenopausal.
Your shoulder’s ball socket joint is surrounded by a capsule – a kind of lining. It’s very thin, but also very elastic. With a frozen shoulder your body suddenly decides (we think due to an autoimmune response) to attack the tissue of the shoulder capsule. It becomes inflamed, causing it to thicken and shrink, leading to a loss of movement.
Frozen shoulder happens in three stages. The first, which typically lasts between two and nine months, is the freezing phase, where it’s thickening and contracting. This stage is extremely painful. In phase two (lasting four to 12 months), the pain recedes, but your shoulder remains stiff. In phase three it thaws out and your range of motion comes back. Within two and a half years, almost everybody is fully recovered.
During phase one, when it’s really painful, we can offer an injection called hydrodilatation (or hydrodistension), where we pop a needle into the ball socket cavity and stretch it. This can essentially skip you straight to phase three.
The good news is that frozen shoulder rarely reoccurs in the same shoulder, and when people feel it coming on the other shoulder, they seek treatment sooner. The quicker you have the injection, the quicker you progress from phase one to phase two or three.
Shoulder impingement (subacromial impingement)
Shoulder impingement, which is particularly common in active people in their 50s, occurs when the tendons and soft tissues of the rotator cuff become compressed beneath the acromion, the bony roof of the shoulder.
Symptoms typically include sharp pain when raising the arm above shoulder height, and persistent discomfort that often disrupts sleep.
This condition often begins with irritation of the rotator cuff tendons (tendinopathy), progressing to inflammation of the subacromial bursa – the fluid-filled sac that cushions the tendons from the bone. In time, it can lead to partial or full-thickness rotator cuff tears.
Patients often mention an initiating event, such as trimming the hedge or lifting a suitcase into an overhead locker, when the pain suddenly began. In reality, these moments often reveal an underlying degenerative process that has developed over many years – they’re just the straw that broke the camel’s back.
Health professionals such as osteopaths, chiropractors and physiotherapists can help to reposition the shoulder blade, strengthen the muscles around the joint and improve rotator cuff function. For many patients, this type of therapy is enough to relieve impingement.
However, these treatments cannot overcome every problem. Some patients have a bony spur that prevents them from having a pain-free range of motion. In these cases, a minimally invasive procedure called subacromial decompression can remove the excess bone and create more space for the tendons.
Acromioclavicular (AC) joint arthritis
This is a degenerative wearing away of the cartilage lining the joint where the collarbone (clavicle) meets the shoulder blade. All joints degenerate with age, but if you’ve done a lot of weight-lifting or contact sports, then you have a greater risk of these joints degenerating faster. Some people may have caused some damage when they were younger, then they start doing weights at the age of 50, and the joint flares up.
AC joint arthritis is treated with rest and anti-inflammatories, usually resolving itself within four to eight weeks. If the problem persists, we can administer a steroid injection under ultrasound. If it continues to cause a problem, the next thing would be a small keyhole operation to shave away the end of the collarbone.
Shoulder (glenohumeral joint) arthritis
Shoulder, or glenohumeral joint, arthritis differs from AC joint arthritis because it affects the main ball-and-socket joint rather than the smaller joint at the very top of the shoulder.
I’m increasingly seeing patients in their 40s with well-established shoulder arthritis that you would normally see in 70-year-olds, which is a significant concern. This progressive condition occurs when the protective cartilage that lines the ball-and-socket joint wears away, causing bone-on-bone friction, pain and stiffness.
Symptoms can often be managed temporarily with steroid or hyaluronic acid injections, but severe cases may eventually require shoulder replacement surgery. Modern shoulder replacements typically last 15 to 20 years, so surgeons generally avoid performing them in younger patients whenever possible.
What are the most common causes of shoulder conditions in midlife?
New exercise regimens
A significant number of my patients are former high-flying professionals who retired in their 50s. Some take up triathlons, others enter HIIT and Crossfit competitions, and many head to the gym. Unfortunately, their focus is often on building strength or muscle rapidly rather than protecting joints and the skeleton. When they develop pain, they often ignore it.
I’m also seeing patients who have recently started taking weight-loss medications such as GLP-1s. Weight loss drugs often cause an individual to lose muscle as well as fat – so, quite rightly, well-informed people are training more to counteract this. Wanting to progress quickly, they are developing shoulder injuries, including impingement and acromioclavicular (AC) joint arthritis.
Additionally, there’s an increasing number of people in their 50s injuring their shoulders through more esoteric exercises like calisthenics, which is similar to gymnastics. Positions like the “planche”, where you hold your body up from the floor, put a huge amount of pressure on the shoulder joints. If you couldn’t perform advanced gymnastics moves at 18, it’s unrealistic to expect to do them at 55 without years of progressive training.
Ignoring previous injuries
I see many male patients who played contact sports when they were younger and have spent years weightlifting. They may have dislocated their shoulders in the past – a rugby injury, for example – which can tear the labrum and ligaments, leaving a permanent weak point in the joint. Having strong muscles has helped keep their shoulder joints stable and centred, but as they age, those muscles weaken, making it harder to maintain stability.
This is rather like opening a gate in a sheep pen: eventually, one sheep will find its way out. Unless that “gate” is surgically repaired, people who continue to play contact sports are very likely to dislocate the shoulder again and again, which can eventually lead to arthritis.
The genetic factor – and associations with autoimmune conditions
There is a strong genetic component to shoulder conditions. Some people develop severe tendon tears in their 40s, while others maintain perfect tendons into their eighties, despite having played contact sports. Similarly, shoulder arthritis often runs in families.
There is a strong correlation between frozen shoulder with autoimmune-related conditions. Type 1 diabetes is one of the strongest risk factors, making an individual three times more likely to develop frozen shoulder. Thyroid disorders, including hypothyroidism, hyperthyroidism, thyroiditis and Graves’ disease, are also strongly associated.
How can I avoid developing shoulder pain?
Consult a professional before embarking on a new fitness regime
If you’re returning to the gym after a prolonged absence or starting weight-training for the first time, the best way to avoid injury is to book some sessions with a qualified personal trainer to ensure good technique from the outset. Building strength should be a gradual process, with progressive loading rather than explosive movements.
Strengthen your core
Going to the gym is about more than just gaining strength in the upper body. Cross-training – incorporating a range of different activities into your regimen – is highly recommended. Regular stretching, combined with things like Pilates, yoga and swimming, builds core stability, which improves overall movement and reduces the risk of shoulder injury.
Stop smoking and maintain a good diet
Smoking is strongly linked to rotator cuff pathology and the ability to heal from injuries, because it reduces blood supply. Eating a nutritious diet with plenty of fruit and vegetables will also be beneficial. There is limited evidence that taking collagen and vitamin C aids the repair of ligaments or tendons but I don’t advise taking it. If you’ve got a full thickness rotator cuff tear, it won’t heal without surgery, however many supplements you take.