What People Believe About Shoulder Pain, and What the Evidence Says

The SparkNotes

• 810 people with shoulder pain were asked what they understood about their condition. Structural explanations dominated. Psychological and emotional factors ranked second-to-last of eleven — despite nearly 4 in 10 having had pain for over a year.

• Out of 26 treatments named, education and advice was mentioned by around 1 in 100 people.

• Set against that: a large randomized trial found six sessions of progressive exercise was not superior to a single session of best-practice advice over 12 months.

• Structural findings show up on scans in people with pain and people without. Imaging correlates poorly with symptoms — which is why chasing a picture to find “the cause” often leads nowhere.

• What ultrasound is actually for: making the explanation concrete, narrowing things down alongside the physical exam, and screening for the rare finding that would change the plan. Not finding the cause of your pain — no imaging can do that.

The Whole Story

In 2026, researchers published something unusual: rather than testing a treatment, they asked 810 people with rotator cuff-related shoulder pain what they understood about their own condition, based on the advice they remembered receiving from health professionals.

The results are worth looking at, both for what people believe and for where those beliefs came from.

One thing to be clear about first

This study measured what patients recalled, not what clinicians said. The authors are careful about this: they couldn’t determine whether beliefs were resistant to change, shaped by selective memory or misinterpretation, or whether the advice itself was inconsistent or incomplete. They also didn’t record which type of professional gave the advice, and some participants were recalling conversations from years earlier.

So none of what follows is an accusation aimed at anyone’s doctor or therapist. It’s a picture of what people walk away holding onto — which, from a patient’s perspective, is the thing that actually shapes what they do next.

What people thought was causing it

The most common explanations were structural or anatomical — a tendon, a muscle, a bursa, something identifiable and physical. Close behind were lifestyle and activity factors: overwork, repetitive tasks, heavy lifting. Then trauma or acute injury. Then posture.

Near the very bottom, second to last out of eleven categories, sat psychological and emotional factors.

That last one stands out given that nearly 4 in 10 participants had been dealing with shoulder pain for more than a year.

Why the structural explanation is incomplete

A structural story is intuitive and often partly correct. Tissue does get injured and tissue does matter.

The difficulty is that structural findings are extremely common in people with no pain at all. The research underpinning the modern approach to rotator cuff-related shoulder pain notes that structural abnormalities appear frequently on imaging in people both with and without shoulder pain, and that the correlation between imaging findings and symptoms is poor. This is precisely why the umbrella term “rotator cuff-related shoulder pain” exists — it acknowledges genuine uncertainty about which structure is responsible, because often nobody can say.

Purely biomedical explanations struggle in three common situations: pain with no clear pathology, pain persisting long past normal tissue healing timeframes, and pain far more severe than any identified damage would predict.

Why this matters for what people do next

Beliefs drive decisions. Someone convinced their pain comes from a torn tendon is reasonably going to want that tendon repaired. Someone who believes their shoulder is weak is going to want to strengthen it. Same shoulder, different path.

There’s experimental evidence on this: a randomized study found that the diagnostic label used and the advice given influenced how strongly people felt they needed surgery. The words change the trajectory.

What people thought would fix it

The most-endorsed treatment was strengthening exercise, which is genuinely encouraging — current clinical practice guidance supports active exercise-based rehabilitation as the initial treatment for reducing pain and disability. The message is landing.

After that came medication, then rest or time off work, then physiotherapy, then hot and cold. The study’s authors suggest that how highly the passive options ranked may reflect people associating movement with further damage, making the idea of exercising a painful shoulder feel counterintuitive.

And near the bottom of a list of twenty-six: education and advice, mentioned by around 1 in 100 people.

The finding that should change how care is delivered

That last one deserves attention, because of what sits next to it in the literature.

A large randomized trial compared up to six sessions of progressive exercise with a physiotherapist against a single session of best practice advice for rotator cuff disorders. Across twelve months, the progressive exercise program was not superior on pain and disability.

A single well-delivered conversation performed comparably to six treatment sessions.

That isn’t an argument against exercise or against physical therapy. It’s evidence that understanding your condition — what’s happening, what it means, what to expect, what to do — is a genuinely powerful intervention that almost nobody counts as treatment, including the people receiving it.

What better explanation looks like

The study’s authors suggest clinicians should normalize pain, put imaging findings in context, set clear recovery expectations, and actively promote self-management.

In practice that means being told that most shoulder pain is not serious. That pain severity isn’t a reliable measure of how much structural damage exists. That recovery doesn’t require every finding on a scan to disappear. And that gradually using a painful shoulder is usually both safe and effective.

None of that is reassurance for its own sake. It’s accurate, and it’s what determines whether someone loads their shoulder or protects it for six months.

What I’ve built around this

Resurgo appointments are 60 minutes, and a meaningful part of that is explanation. Not as a preamble before the real treatment, but because the evidence suggests it may be one of the more effective things happening in the room.

Real-time ultrasound is part of how that explanation happens. You see your own tissue moving while your shoulder moves, which turns an abstract description into something you can watch. Used alongside the physical examination, it helps narrow down where symptoms are more likely coming from — the useful signal is when what appears under the probe agrees with what the hands-on testing already suggested, and when it doesn’t agree, that’s worth knowing too. It also screens for the small number of findings that would mean a different approach or another opinion, and it puts a previous scan report into context.

What it doesn’t do is find the single cause of your pain. The research above is exactly why no imaging can promise that.

If that sounds like where you are, book a Discovery Call and we’ll talk it through.

Sources

Wong E, Ferreira G, Muller RD, Sousa F, Malliaras P, West CA, O’Keeffe M, Bejarano G, O’Neill H, Maher CG, Zadro JR (2026). Patients’ perceptions of the causes and treatments for rotator cuff-related shoulder pain: a content analysis of patient responses and implications for clinician communication. Musculoskeletal Science and Practice 84:103557.

Hopewell S, Keene DJ, Heine P, et al. (2021). Progressive exercise compared with best practice advice, with or without corticosteroid injection, for the treatment of patients with rotator cuff disorders (GRASP). Lancet 398(10298):416-428.

Desmeules F, Roy JS, Lafrance S, et al. (2025). Rotator cuff tendinopathy diagnosis, nonsurgical medical care, and rehabilitation: a clinical practice guideline. J Orthop Sports Phys Ther 55:235-274.

Zadro JR, O’Keeffe M, Ferreira GE, et al. (2022). Diagnostic labels and advice for rotator cuff disease influence perceived need for shoulder surgery. J Physiother 68:269-276.

Buchbinder R, Staples MP, Shanahan EM, et al. (2013). General practitioner management of shoulder pain in comparison with rheumatologist expectation of care and best evidence. PLoS One 8:e61243.

A note on the evidence: the Wong study asked patients what they understood about their own condition. It measured recall and belief, not what any clinician actually said. The proportions above are broad patterns rather than precise measurements — the authors are explicit that their coding categories overlapped and that their interpretation focused on the shape of the responses, not exact percentages.

Read next

Why Avoiding the Painful Movement Stops Working — what happens to a shoulder you protect, and why it usually gets worse.

What Actually Gets You Better — the beliefs are one half; this is the other.