Most people think the choice is simple: rehab or surgery.
But with shoulders, that’s often the wrong question.
The real choice is usually rehab—or surgery plus rehab.

We can see from the anatomy of the region that to maintain a normal pain free shoulder, we need the health of a wide range of structures in the shoulder complex.

These structures–muscles, tendons, ligaments–can be affected by acute injury, chronic stress, repetitive injury, or degenerative changes over time.

The following categories includes the most common shoulder problems that may require surgery.

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Pain at the tip of the shoulder, pain down the arm, pain around the shoulder blade, can all point us in different directions.

But here’s the important part: the location of pain is just a clue. It is not the whole story.

It’s 2:00 AM, and you’re awake again.

You’ve flipped the pillow six times. You’ve tried propping your arm up, hanging it off the edge of the mattress, and rolling onto your other side—but the deep, throbbing ache in your shoulder just won’t stop. During the day, the pain was a manageable background hum that you could totally ignore. Now, in the dark—when you’re desperate for a good night’s sleep—it feels like a raging toothache inside your shoulder.

If you’re reading this in bed, exhausted and frustrated, take a deep breath. You’re not alone, and your shoulder isn’t playing tricks on you out of spite.

Over my 40 years as a physiotherapist rehabilitating thousands of shoulders, night pain is the number one reason patients finally walk through my clinic door. It’s exhausting, it drains your energy, and it makes you feel like your shoulder is failing. Surgery starts to sound like a welcome alternative.

But here is the good news: you do not have to just “live with it,” and you don’t necessarily need surgery to get a good night’s sleep. To start the fix of the sleep problem, we first need to look at exactly what happens inside your shoulder the moment your head hits the pillow.

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Where you feel shoulder pain matters.

Pain at the tip of the shoulder, pain down the arm, pain around the shoulder blade,

can all point us in different directions.

But here’s the important part: the location of pain is just a clue. It is not the whole story.

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The shoulder is easily the most amazing joint in the human body. If you don’t believe me, watch international level gymnastics sometime and take notice of the incredible things that athletes do with their shoulders.

The shoulder has the largest range of movement of any joint in the body, and yet with the right training and fitness people can walk on their hands or carry out amazing manoeuvres on Roman rings at gymnastic competitions.

Analysing these abilities of the shoulder, we can see that the shoulder has mobility, strength and stability. These three are often seen as being mutually exclusive, but the shoulder manages all three in its optimum state.

So how does the shoulder girdle manage this? Because it comprises a complex of joints which are stabilised by a complex arrangement of muscles and ligaments:

◆ The glenohumeral joint (GHJ) is the “ball and socket” joint between the humerus (upper arm bone) and the scapula (shoulder blade). The socket is deepened by a ring of cartilage—the glenoid labrum. The glenoid labrum provides better stability.

◆ The acromioclavicular joint (ACJ) is the joint between the acromion (part of the scapula) and the clavicle (collar bone).

◆ The scapulothoracic articulation is not actually a joint but an area where the scapula moves across the ribs under the control of several muscles.

These joints are moved by and stabilised by a range of muscles. The most important group of muscles for the GHJ is the Rotator Cuff—the Supraspinatus, Infraspinatus, Subscapularis and Teres Minor muscles. These muscles attach the scapula to the head of the humerus and stabilise the GHJ. Their tendons form a cuff around the head of the humerus, providing both movement and stability.

Without a functioning rotator cuff, we are actually unable to raise our arm past horizontal. At the very least we experience shoulder pain on overhead activities, as the humeral head can rise compressing the subacromial/subdeltoid bursa. Damage to the rotator cuff is one of the most common reasons for shoulder surgery.

The GHJ is surrounded by a joint capsule, a sleeve of ligamentous type tissue strengthened by several ligaments. A potential complication of shoulder surgery is “frozen shoulder”, where the capsule becomes inflamed and ultimately thickened and tight. This can cause restricted and painful movement and delayed recovery.

So in summary the glenohumeral joint:

◆ is a large ball sitting in a small shallow socket,

◆ is held together by a loose joint capsule (to allow a large range of movement),

◆ has a capsule strengthened by several ligaments,

◆ is stabilised by the rotator cuff group of muscles and their tendons, and

◆ is moved by many muscles travelling between the spine, thorax, scapula and upper arm.

In this way the shoulder meets our requirements of mobility, stability and strength. It does however leave the shoulder susceptible to any injury or degenerative changes of these structures.

Although a rehabilitation exercise program can achieve a lot, there will be times where surgical help is required.

If you want to see how all these structures move together, I suggest other shoulder anatomy resources at:

www.theshoulderphysio.com/anatomy.

Episode 1 introduces the importance of this information.

Freedom Fridays

Freedom Fridays are short (3 to 5 minute) videos where Bruce Paulik shares tips and tricks (gleaned from 40 years experience) in restoring your shoulders to ultimate strength and health. The goal? You can build your knowledge base to help your gradual return to healthy shoulders.

How to Recover from Shoulder Surgery

Chapter 1: A Tale of Two Shoulders

Let me tell you the story of two patients with the same surgery on the same day who ultimately had very different recovery paths.

It was 1997. The young orthopedic surgeons in the medical center where my clinic was located were well-trained and using the latest techniques in shoulder surgery. On a Wednesday in mid-July two men presented for their first rehabilitation session 5 days after rotator cuff shoulder surgery—let’s call them Bill and Jim.

Jim was 39 years old, fairly fit, but irritated that this process was taking him away from his work. He had had a moderate size rotator cuff tear repaired. Bill was 82 years old, fit and keen to get on with his rehabilitation. He also had a moderately sized rotator cuff tear repaired by the same surgeon with the same technique on the same day. At this point most clinicians would expect that Jim, being 40 years younger, would make a faster recovery than Bill. This was not to be the case.

Jim had done no preparation for his surgery. He was unaware of the details of his shoulder surgery and had read none of the printed materials supplied by the surgeon. He had not taken the surgeon’s advice to see me for an exercise program prior to the surgery. Since the operation he was struggling at home with simple daily activities such as washing and dressing.

Bill, on the other hand, was well prepared for the surgery. He had in fact been to see me three weeks earlier and started a simple exercise program. He had read everything he could lay his hands on, so knew the post-operative process and how to manage at home, despite living alone.

From this point on, the differences between Jim and Bill increased further. Jim often missed review sessions with me, and at these sessions admitted to going at times several days without doing his simple home exercise program. His unspoken attitude was that if the surgeon had done an expert job, he shouldn’t need to do any more. In contrast, Bill kept appointments, did a few minutes of exercise every day as instructed, but was careful not to over-stress the shoulder, and so protecting the repairing rotator cuff from injury.

And so how did Jim and Bill progress in their recovery? It would be great if I could report that with an excellent orthopedic surgeon and the latest modern surgical techniques that they both had the same progress! Obviously, this wasn’t the case, otherwise I wouldn’t be telling the story, I wouldn’t need to write this book, and you wouldn’t need to read it.

Bill’s progress was better than average—his pain settled quickly in the postoperative period. By the time the surgeon allowed him to stop using the sling 5 weeks after surgery, his range of shoulder movement was improving rapidly. Importantly, he had coped well at home with his arm in a sling for 5 weeks. At 3 months he had almost full range of movement; by 6 months he was doing a “return to golf” rehabilitation exercise program.

Jim however was struggling. He refused to take the pain and anti-inflammatory medication that had been prescribed by his orthopedic surgeon, and so his pain levels were much higher than Bill’s. As he was only occasionally doing his home exercise program, and was experiencing significant pain, his shoulder was getting very stiff. He was taking advice from acquaintances rather than his health professionals, and so was attempting to overcome the stiffness by doing his exercises more aggressively but infrequently.

At five weeks when he was advised to stop wearing his sling, he experienced a spike in his pain level. At this point he had very poor active range of motion with marked pain at the limit of movement.

By six months after surgery Jim was still experiencing quite a lot of discomfort over the shoulder and could not sleep on that side. His active range of movement was still restricted in every direction.

At 12 months post-operatively he still had not reached the level of recovery that Bill had at six months.

Why I Was Driven To Write This Book

Cases like Bill and Jim, and countless others in the 20 years since then, have made me realize that it is the patient who controls their recovery, not me as their physical therapist.

Several years ago, as a guest of that same orthopedic surgeon who operated on Bill and Jim, I attended a conference for orthopedic surgeons who specialize in the shoulder. On the last day of the conference, at a panel discussion in front of the 450 delegates, a professor of orthopedic surgery from the UK said:

“Your orthopedic surgery of the shoulder is only as good as the post-operative physiotherapy program.”

I would take that one step further and say:

“The post-operative recovery from orthopedic surgery of the shoulder is only as good as the patient makes it.”

When I can help patients make the right decisions about their shoulder rehabilitation and provide them with the knowledge and tools to have a speedy and effective recovery, then I am a happy Physiotherapist!

As I have publicly stated on LinkedIn:

“My purpose is to make a significant positive impact on the physical health of the clients who attend my physiotherapy clinic or consult with me online.”

This book allows me to do this on a grander scale, reaching far more people than I could in several lifetimes individually. I won’t now be so frustrated by those who refuse to be helped. And so, I set out to make a positive and meaningful difference with my words. And this book helps me reach more people and achieve that mission.

To take control of your recovery from shoulder surgery, you need to understand the basics of your surgery rehabilitation, and the process of healing. This will help you lose your anxiety and focus your attention and energies on getting well fast and efficiently. Recovery from shoulder surgery is a process, and it takes time. This timeline can be accelerated by avoiding complications, appreciating your physical limitations through each phase of the recovery process, and following the right steps in the process to promote faster healing.

Why You Should Read This Book

So, who could benefit from reading this book?

This book will help if you or a loved one:

◆ Have been referred to an orthopedic surgeon with a view to surgery for a shoulder problem.

◆ Have already seen an orthopedic surgeon and are considering shoulder surgery based on the surgeon’s advice.

◆ Have booked in for shoulder surgery.

◆ Have recently had shoulder surgery.

Once you understand the basics of the preparation for surgery, the surgery itself, and the rehabilitation program, there is much less fear and anxiety about the whole process. The predictability of the process becomes reassuring, allowing you to focus your entire attention and energy on rehabilitating your shoulder back to full pain-free function.

The knowledge and tools in this book help you make a speedy recovery, with less anxiety and pain, and ultimately a better return to full function of your shoulder.

This is a conversation space exclusively for subscribers—kind of like a group chat or live hangout. I’ll post questions and updates that come my way, and you can jump into the discussion. Feel free to share your shoulder experiences, whether they be about unresolved problems, things that have helped, or your experience with shoulder surgery.

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2. Open the app and tap the Chat icon. It looks like two bubbles in the bottom bar, and you’ll see a row for my chat inside.

3. That’s it! Jump into my thread to say hi, and if you have any issues, check out Substack’s FAQ.

Shoulder pain and stiffness can start insidiously or with a bang—you wake with it one morning, or a sudden movement leaves you gasping.

Whether your shoulder pain was caused by a long history of football injuries, or by simply reaching over into the back seat of the car to pick something up, shoulder pain can dramatically affect your quality of life, and make even simple everyday tasks a major chore.

So what I’ve given you here is a list of simple remedies to ease this pain.

1. Avoid sustained overhead activities

When your arms are raised there is increased pressure on the bursa and tendons in the shoulder. This may increase your pain (later perhaps) by increasing the reaction of the bursa & tendons.

2. Rest

If playing that game of tennis causes shoulder pain that lasts the next 24 hours, it’s probably time to put down that racket for a few days and let the shoulder settle. Your shoulder will not improve by “playing through the pain”. You may find that avoiding the aggravating activities is the best way you have of controlling and in fact settling your shoulder pain. I often tell my patients with shoulder pain:

You will get 50% of the improvement in your pain from avoiding the things I tell you not to do, and 50% of the improvement from doing things that I tell you to do.

3. Ice

For a recent injury or after shoulder surgery applying an ice pack for 20 minutes 2 to 3 times daily will help reduce both pain and swelling. If you are still playing sport, ice the shoulder after playing to minimize inflammation. Remember to wrap the ice pack in a dry cloth to protect the skin from damage.

4. Heat

For chronic conditions, or for arthritic pain, local hot packs can offer significant pain relief and relax tight muscles. Apply a comfortable warmth for 20 minutes, and repeat as often as necessary. Don’t use heat for new acute injuries – ice is more appropriate here. Local hot packs applied to the shoulder before exercise will often make those exercises both more comfortable and more effective.

5. Movement & stretching

Our bodies thrive on movement and our shoulders are no exception. But don’t move into painful positions, and avoid overhead activities. Shoulder pain is often considerably less after gentle pain free exercise. Tightness in the shoulder can contribute to pain on activity, so the correct exercises can help ease pain.

A very helpful simple exercise:
Pendular exercise: Bend forward supporting your weight on your unaffected arm, keeping your spine straight, and letting your affected arm hang relaxed straight down. Let your arm swing in small circles, x10 in each direction. Also swing the arm gently back and forth by your side, x10.

6. Posture

Our modern lifestyle unfortunately sees us sitting in front of a computer, our spine slumped forward and our arms and shoulders hunched forward. This position places the shoulders under stress, and contributes to impingement in the shoulder where the tendons and bursa are pinched between the bones. Improving your posture will reduce the pressure and irritation of the tendons and bursa, leading to a gradual reduction in shoulder pain.

Posture exercise: This exercise counteracts the tendency that we all have when sitting (eg in front of a computer) of adopting a “chin forward” posture. Sitting up straight in a chair against a backrest, pull your neck and upper back up straight by gliding your head backwards. Your face should remain vertical, and you should have the feeling of sitting tall and creating “double chins.” Hold for five seconds. Repeat x10.

7. Shoulder Blade Squeeze Exercise

Repeat this movement often, especially if you work with your arms forward for much of the day eg in front of a computer.

If you would like more articles and videos about your shoulders:

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Who this is for

TheShoulderPhysio is for adults over 40 with persistent shoulder pain, stiffness, weakness, or loss of function who want clear, practical guidance to allow them to return to all the activities they are missing out on.

Who is TheShoulderPhysio?

Bruce Paulik, a multiple-degree-qualified Musculoskeletal/Shoulder Physiotherapist, who, over the past forty years, has helped thousands of clients achieve excellent outcomes for their shoulder problems.

What happens when you subscribe:

Free subscribers receive posts about shoulder recovery - emailed to you and available here on TheShoulderPhysio, and selected Freedom Friday videos.

Paid subscribers receive:
— in-depth articles from our archive about building a stronger, more functional, pain free shoulder, emailed to you or available here on TheShoulderPhysio.
— chapters from my Shoulder Recovery Series books added each month to our archive.
— my Freedom Friday 3 to 5 minute videos with bite-sized nuggets of advice to help your shoulders.
— join our community discussions about shoulders and post comments.

— Over time, paid subscribers will gain access to deeper guidance, mini-courses, workshops, and structured resources designed to help you better understand and manage your shoulder recovery pathway.

— Annual paid subscription tiers include a one-on-one 30-minute video session with me to discuss your shoulder situation, clarify your current strategy, and help you think through your next steps.

Foundation Members receive:
Our Foundation Members receive all of these things, plus two extra one-on-one 30-minute video sessions with me to continue the discussion of your shoulder situation, clarify your current strategy, and help you plan your next steps.

Our Community

We are building a community here where members can share the trials, tribulations, and successes of shoulder recovery. I will be active in this community. Join the Chat!

BEGIN YOUR JOURNEY TO
A HEALTHY STRONG SHOULDER NOW!