Shoulder pain rehabilitation - it takes time!!

One of the first questions a person with shoulder pain will ask you (physical therapist) is, "HOW LONG WILL IT TAKE TO GET BETTER"? This is a perfectly reasonable question to ask, as it will allow the person in pain to plan their future and take some ownership over their situation. An accurate timeline can also lead to the formulation of a mind map of what their pain means to them, and is an undervalued factor in persistent pain (read about it here). This may be important for preventing acute pain from progressing to persistent pain.

So how do we answer this question? Is it indeed answerable? Whilst every presentation will be different (individuals differ, remember) and at the mercy of many biological, psychological, and social factors that are all inter-related, we may be able to provide an evidence based timeline of when to expect significant improvement in clinical signs and symptoms. Now, before I go on, what one person thinks is improvement will be different from the next person. One individual may expect 100% complete resolution of symptoms before admitting improvement, whereas another person may be overwhelmed with excitement in gaining 10 degrees in pain free shoulder elevation. I recommend you clarify this in your subjective history. Ask about beliefs, expectations, and past experiences with this or previous episodes of shoulder pain. This will allow a clear picture of what the person in pain expects and you can correct any aberrant or mal-adaptive beliefs where necessary.

The vast majority of shoulder pain trials concerning the rotator cuff include a 12 week rehabilitation regime. This period of time seems to be where the bulk of meaningful improvement takes place, thereafter improvement plateaus. In fact, most people who end up getting surgery for rotator cuff pain get it within the first 12 weeks of pain developing. So, this 12 week mark appears to be significant as a rough estimation of time to notice significant improvement in signs and symptoms. An interesting systematic review published in 2019 (HERE) suggests that conservative management (physical therapy) should be persisted with for at least 12 months before considering escalation of management to surgery in rotator cuff related shoulder pain. While this may be objectively true, it is very hard for a person in pain to endure 12 months of consistent shoulder pain without tangible improvement. This will have to be resolved in collaboration between the patient, physical therapist, and potentially GP and surgeon.

I find it absolutely vital to be open and upfront about timelines. This helps patient expectations and the development of therapeutic alliance. If you are promising miracle-like improvements within days, you are likely setting you and your patient up for failure. This will threaten your rapport and lead to disillusionment by the patient, and for good reason too! The very nature of pain; a multi-factorial, complex, and emergent experience, lends itself to being a challenge to 'treat'. Therefore, trying to modify this by changing behaviour, morphology, strength, or beliefs about pain will likely take time. Try and communicate this in a simple and digestible way. Avoid fear-mongering, quick escalation of management (imaging, injections, surgery), and over-reliance on passive coping strategies.

In summary, be honest about expected recovery timelines. Every case will vary, so always adapt and modify prognosis based on individual factors. However, if you suggest at least 3 months and up to 12 months of conservative management before any conversation of surgery, this is in alignment with evidence. It then falls on you as a clinician to educate the person in front of you why this is the case and develop a plan to achieve their desired goals in a timeline that is suitable to them, but also reflective of the scientific literature.

P.S. if you're a person with shoulder pain and someone is promising INSTANT RESULTS with a SECRET METHOD, please disregard this and look elsewhere.