Shoulder pain is one of the problems I see very often in my practice. A patient points to the painful area, has difficulty lifting the arm, or feels pain when reaching behind the back, putting on a jacket, or sleeping. Naturally, we start by looking for the problem in the shoulder itself. The rotator cuff, tendons, muscles, joint capsule, long head of the biceps tendon, and the acromioclavicular joint all need to be considered.
But what if these structures have been assessed and treated properly, yet the improvement is minimal or there is no improvement at all? This is the moment when I start looking beyond the place that hurts.
The shoulder is not just one joint
When we raise an arm, the glenohumeral joint does not work alone. The movement involves the scapula, the acromioclavicular joint (AC), the clavicle, and the sternoclavicular joint (SC). The clavicle is particularly important because it connects the scapula to the sternum and, through the SC joint, provides the only bony connection between the entire upper limb and the axial skeleton.
During arm elevation, the clavicle does not remain still. It elevates, retracts, and rotates around its long axis, while the scapula changes its position at the same time. We can therefore look at the shoulder girdle as one connected mechanism:
sternum → SC joint → clavicle → AC joint → scapula → glenohumeral joint → arm
If one part of this system is not moving properly, the other parts have to adapt. This is why a restriction somewhere along this chain may influence movement and symptoms in another part of the shoulder complex.
What I see in clinical practice
I have repeatedly seen patients with shoulder pain or a clear restriction in movement where local treatment had already been performed. The structures directly related to the painful area had been assessed and treated, yet the problem remained. In these situations, one of the areas I check is the sternoclavicular–clavicular–shoulder complex.
Very often, mobilisation of this area produces a noticeable change. Sometimes the improvement is small, but there are also cases where pain decreases and the range of movement increases immediately after mobilisation.
For me, this is valuable diagnostic information. It does not mean that “the clavicle was the cause of the whole problem.” The human body is rarely that simple. What it tells me is that the place where pain is felt is not necessarily the place where the most important restriction is located.
Why can mobilisation change shoulder movement?
The scapula provides the foundation for the glenohumeral joint. The glenoid, which forms the socket for the head of the humerus, is part of the scapula, but the scapula itself also has to move freely during arm elevation.
Its movement is closely connected to the clavicle through the AC joint, while movement of the clavicle relative to the sternum occurs through the SC joint. If mobility within this system is restricted, the mechanical conditions under which the entire shoulder operates may change.
This means that we can sometimes spend a long time treating the painful area while an important mechanical restriction is located somewhere else. Restoring mobility in the SC or AC joint can change the way the clavicle and scapula move, and this can also change the conditions under which the glenohumeral joint functions.
That is why, after mobilisation in a completely different area, a patient may suddenly say: “Now I can lift my arm.”
This is not only my clinical observation
A similar phenomenon has also been described in the medical literature. A published case report described a patient with a large supraspinatus tear whose improvement in pain and shoulder mobility had reached a plateau after several physiotherapy sessions. During a subsequent session, mobilisation of the sternoclavicular joint was introduced, and immediately afterwards improvements were reported in pain, active range of motion, and shoulder function.
Of course, this was a single case report, so it cannot be used to claim that SC joint mobilisation will solve every shoulder problem. However, it illustrates something that is easy to forget in clinical practice: shoulder movement is the result of several joints working together, not just the glenohumeral joint.
Biomechanical research also shows that movement at the sternoclavicular and acromioclavicular joints contributes to scapular movement relative to the thorax during arm elevation. From a mechanical point of view, it therefore makes sense to assess the entire shoulder girdle rather than concentrating exclusively on the painful structure.
Don’t treat only the place that hurts
This is one of the most important principles I follow in my clinical work. If treating the painful area works, that is exactly what we want. But if appropriate local treatment has been performed and the patient still has the same pain or restriction of movement, repeating the same treatment again and again may not be the best approach.
Sometimes we need to look further. The relevant restriction may involve the scapula, the clavicle, the sternoclavicular joint, or another structure influencing the mechanics of the shoulder complex. And sometimes the important factor may be located even further away from the place where the patient feels pain.
That is why, at Fysiomas, assessment does not end with the question “Where does it hurt?” A much more useful question is: “Why is this particular area the one that has become painful?”
The shoulder may be the place where the problem appears, but it is not always the place where the problem began.