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Referred Shoulder Pain

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I've talked about shoulder pain and rehabilitation in the past, but why does it seem the location of shoulder pain is erratic? I've had a few high level coaches tell me treating shoulder pain is nearly impossible, since the pain can jump around, described as unpredictable. This article will address this topic and uncover common areas of shoulder pain, potential cause and treatment.

Referral pain and trigger point

Muscles tightness and one may refer pain to variable locations. For example, a heart attack can refer pain all over, most notably down the left arm during a heart attack. This is an example of referred pain and the muscles of the shoulder are no different. Some of the muscles' referral patterns make sense, as many of them refer directly to the location of the muscle, but other muscles are different in fact, the suboccipital muscles and sternocleidomastoid muscle often refer to the head, commonly entitled tension headaches. Trigger points are described by Travell as a “hyperirritable locus within a taut band of skeletal muscle, located in the muscular tissue and/or its associated fascia. The spot is painful on compression and can evoke characteristic referred pain and autonomic phenomena.” These hyperirritable loci are commonly from an increase in muscle tension, causing tightness and symptoms.

Common Shoulder Trigger Points

Obviously swimming puts high levels of stress on the shoulder. This degree of stress causes many muscles to fire, unfortunately fatigue can cause improper muscle firing leading to soreness. Soreness can lead to compensations, which overwork certain muscles, often times termed postural muscles. The most common overworked shoulder muscles include:



- Upper Trapezius- trigger points are believed to occur from excessive elevation of the shoulder girdle. Trigger points can occur on the lateral neck or superior to the shoulder blade. The upper trapezius can refer pain to the bottom of the scull or anywhere along this large muscle.

- Levator Scapulae- trigger points often occur due to sustained elevation of the shoulders, causing excessive activation. The common trigger points are on the superior medial border of the scapula, along the muscle belly. This muscle can refer down the bottom of the shoulder blade or to the posterior deltoid.

- Pectoralis Minor- common trigger points are noted on the front of the shoulder and referred pain is typically seen on the anterior deltoid or down the inside of the arm. This muscle can become overworked from sustained anteriorly rolled shoulders and poor posture (does this describe any of your swimmers....I think so!)

- Subscapularis- the subscapularis typically has trigger points on the muscle belly, but it refers pain to multiple locations: posterior and middle deltoid as well as the wrist and shoulder blade.

These are the main muscles overworked, but the other rotator cuff muscles (supraspinatus and infraspinatus) can become injured from repetitive swimming. The supraspinatus is the the most commonly injured muscle in swimming and typically refers pain to the midtdle deltoid. The infraspinatus has a referral pattern down the front and back of the arm and trigger points along the muscle belly.

This dense article hopes to ensure swim coaches muscle tightness and improper firing can be from hypertonic (tight) muscles. These tight muscles can cause trigger points, referral patters and inhibit other muscles. These three items can disrupt biomechanics at the shoulder (possibly other regions) and impede swimming. If these problems are noted in a swimmer, light stretching can help, but muscle releases may be needed to completely relax the muscle since stretching still causes muscle activation. I'm working on a DVD which demonstrates some of the muscle releases which can be performed at home, but this is only advised as prehabilitation and asymptomatic people. If pain is present, see a health care professional and stop the symptoms before the symptoms progress.

Where do most of your shoulders have shoulder pain? Front of shoulder, side, back? Vote on the poll.


Travell, J. Simons, D. Myofascial Pain and Dysfunction The Trigger Point Manual. Williams and Wilkins 1983.

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