Shoulder pain in people who train: loading and rehabilitation

Subacromial pain syndrome is a collective term for overlapping conditions in the shoulder: inflammation of the bursa, tendon inflammation and partial degenerative injuries of the rotator cuff. Experts disagree about where the boundaries lie, and the conditions are therefore treated together [1].

The pain can radiate down the arm. With acute onset it is often severe, with marked loss of function and pain at rest as well. With chronic problems the pain is usually moderate and more related to activity, particularly when the arms are loaded above shoulder height [1]. Night pain with waking and difficulty lying on the painful side are described as characteristic [1].

Overuse problems in the shoulder often develop gradually. An IOC consensus statement describes overuse injuries as cumulative and without a clear onset [4].

The examination is based on a systematic review of the shoulder. Hawkins' test, Neer's test and the painful arc test are included as a minimum, and a positive painful arc is the main criterion for the diagnosis [1]. Many of the tests can also be positive in other conditions, so the results must be interpreted with caution [1].

The strength of the rotator cuff is tested to rule out tendon damage that may need surgical assessment [1]. X-ray can be used to look for calcifications and exclude other disease, and ultrasound is valuable for excluding structural tendon damage. MRI is relevant if a torn tendon or frozen shoulder is suspected [1].

The Danish national clinical guideline gives a weak recommendation to consider supervised exercise. The exercise should last at least three months, with at least two supervised sessions. Self-training after instruction may suit those who prefer it, but the dropout is higher [2].

The Lægehåndbogen describes exercise as the best documented treatment. Long-term exercise therapy is described as being as effective as surgery, and three months is a minimum, with longer being preferable [1].

Which type of exercises works best is unclear. A summary on NHI of a Swedish systematic review with 281 patients and studies of moderate quality found that eccentric exercises reduced pain somewhat more than other exercises, but that the difference was not judged to be clinically important. It was uncertain whether they improved function more [3].

The Lægehåndbogen describes that patients can use the arm freely within the pain limit. When the arm is lifted above shoulder height the bursa is compressed, which can maintain the irritation. Periods of relief from heavy shoulder loading may have a place, but should not be the only measure, and immobilisation of the shoulder should be avoided [1].

Repeated heavy work with the arms above shoulder height should be avoided, and tasks can be varied [1]. The Danish guideline mentions that reduced shoulder-loading work is a non-surgical option that is assessed individually, without a formal recommendation [2].

The guideline gives a weak recommendation against using injection into the bursa other than after careful consideration, because the benefit is small. Injection should not be given alone, and exercise should be offered at the same time [2]. The Lægehåndbogen describes that at follow-up after six months injection has not been shown to affect the course [1].

For pain lasting less than six months it is strongly recommended not to offer surgery to create more room under the acromion. For symptoms lasting more than six months without effect from at least three months of exercise, it can be considered after careful deliberation, and the evidence is weak [2].

The course varies. The problems often improve by themselves over time, but it may take a long time. Possible complications are rupture of the rotator cuff or the biceps tendon, stiffness in the shoulder and long-lasting pain [1].

Acute onset often gives severe pain and marked loss of function [1], and such problems should be assessed by a healthcare professional, among other things to clarify whether there is tendon damage. The same applies if the diagnosis is uncertain, if the pain cannot be controlled, or if supervised exercise has had no effect [1].

A chiropractor can examine the shoulder, assess what triggers the pain and together with you make a plan for loading and rehabilitation. When the diagnosis is uncertain, diagnostic ultrasound can be used. You can read more about chiropractic with us.

What is subacromial pain syndrome?

It is a collective term for overlapping conditions in the shoulder, such as bursa inflammation, tendon inflammation and partial degenerative injuries of the rotator cuff. The pain is often related to activity with the arms above shoulder height [1].

Should I rest the shoulder?

The Lægehåndbogen describes that the arm can be used freely within the pain limit and that immobilisation should be avoided. Relief from heavy loading may have a place, but should not be the only measure [1].

How long should one exercise the shoulder?

The Danish guideline describes supervised exercise for at least three months [2], and the Lægehåndbogen describes that longer is preferable [1].

Does the shoulder need surgery?

The guideline strongly recommends not offering surgery for pain lasting less than six months. With longer duration and no effect from at least three months of exercise it can be considered after careful deliberation [2].

Are eccentric exercises best for the shoulder?

This is unclear. A Swedish review found a small pain effect compared with other exercises, but the difference was not judged to be clinically important, and it was uncertain whether function improved [3].

You can read more about rotator cuff problems, supraspinatus tendinitis and frozen shoulder. You can find more articles in the overview of articles.

This article was written by Dr.Dropin Fysikalske and is based on the sources listed below. It gives general information and does not replace an examination by a healthcare professional.

The websites were accessed and read on 22 October 2026.

1. Olsen BS, Jensen AN, Hansen TB, Søndergaard A. Subacromielt smertesyndrom (Subacromial pain syndrome). Lægehåndbogen, sundhed.dk. Updated 16 December 2021. Link

2. Sundhedsstyrelsen. Nationale kliniske retningslinje for behandling af patienter med subakromielt smertesyndrom i skulderen (National clinical guideline for treatment of patients with subacromial pain syndrome of the shoulder). 2021. Link

3. Johannessen T. Eksentriske øvelser ved subakromialt impingement syndrom (Eccentric exercises in subacromial impingement syndrome). NHI.no. 1 November 2019. Summarises Larsson R, Bernhardsson S, Nordeman L. BMC Musculoskelet Disord. 2019. Link

4. Soligard T, Schwellnus M, Alonso JM, Bahr R, Clarsen B, Dijkstra HP, Gabbett T, Gleeson M, Hägglund M, Hutchinson MR, van Rensburg CJ, Khan KM, Meeusen R, Orchard JW, Pluim BM, Raftery M, Budgett R, Engebretsen L. How much is too much? (Part 1) International Olympic Committee consensus statement on load in sport and risk of injury. Br J Sports Med. 2016;50:1030-1041. doi:10.1136/bjsports-2016-096581. Link