Shoulder Injuries, Part 4: Treatment, Exercise and Rehabilitation
In Part 4, we bring the shoulder series together by examining how treatment and rehabilitation can be adapted to the individual. Shoulder pain and injury can vary considerably between patients, so management should be guided by the diagnosis, symptoms, functional limitations, physical examination, activity demands, and goals of the individual.
Some presentations may primarily involve the shoulder itself, while others may be influenced by strength, mobility, neurological factors, previous injury, or the demands placed on the shoulder by the trunk and lower extremities. This can be particularly relevant in activities such as throwing, swimming, racquet sports, lifting, and other movements that require coordinated force production throughout the body.
Effective rehabilitation is rarely based on a single technique. Education, appropriate activity, progressive exercise, and gradually rebuilding strength, endurance, coordination, and load tolerance form the foundation of recovery. Manual therapy may be incorporated when clinically appropriate to help manage symptoms, improve movement, and support participation in active rehabilitation.
Before examining specific treatment and exercise strategies, it is important to consider situations in which manual therapy may be inappropriate or require modification.
Article Index:
Contraindications and Precautions To Manual Therapy
Before applying manual therapy, the clinician should determine whether the presentation is appropriate for conservative musculoskeletal management. Screening should consider the patient's history, mechanism of injury, examination findings, medical history, and any signs suggesting serious or non-musculoskeletal pathology.
Manual therapy should be avoided, postponed, or appropriately modified when the potential risks outweigh the expected benefits.
Conditions Requiring Further Investigation or Referral
Manual therapy should generally not be performed over or around a region when there is suspicion of:
Acute fracture or unreduced dislocation
Septic arthritis or other active infection
Malignancy or destructive bone disease affecting the region
Significant acute trauma requiring further investigation
Progressive or significant neurological deficit
Acute neurovascular compromise
Symptoms suggesting cardiac, vascular, visceral, or other serious non-musculoskeletal pathology
Suspicion of infection, tumour, neurological pathology, unreduced dislocation, or an acute traumatic rotator cuff tear may require urgent assessment or referral rather than routine conservative shoulder treatment.
Conditions Requiring Caution or Modification
Other findings do not necessarily prohibit manual therapy but may require modification of the technique, intensity, or treatment plan. These can include:
Known or suspected joint instability
Acute inflammatory conditions
Significant pain or swelling
Recent surgery or tissue injury
Osteoporosis or reduced bone strength
Bleeding disorders or anticoagulant medication
Neurological symptoms
Cervical spine involvement
Connective-tissue disorders or generalized joint hypermobility
The presence of one of these factors does not automatically mean that manual therapy is inappropriate. The clinician should consider the specific diagnosis, tissue involved, severity of the condition, type of manual procedure being considered, patient preference, and potential benefit versus risk.
Clinical Judgment Comes First
Contraindications are not simply a checklist. A gentle soft-tissue technique, joint mobilization, and high-velocity manipulation involve very different mechanical forces and therefore do not necessarily share the same contraindications.
When the presentation is uncertain, symptoms are inconsistent with a routine musculoskeletal disorder, or significant red flags are present, further investigation or appropriate referral should take priority over manual treatment.
Joint Mobilization and Manipulation
Joint mobilization and manipulation may be incorporated into the management of selected shoulder conditions when limitations in movement, pain, or other examination findings suggest that manual therapy could be useful.
Assessment should not be limited to the glenohumeral joint. Depending on the patient's presentation, the clinician may also consider the acromioclavicular and sternoclavicular joints, scapulothoracic movement, and the cervical and thoracic spine. In some patients, mobility or symptoms in adjacent regions may be relevant to shoulder function.
This does not mean that a restriction in one joint automatically causes dysfunction elsewhere. The clinical significance of any mobility finding should be determined by the patient's symptoms, functional limitations, examination findings, and response to treatment.
Understanding the Effects of Joint Mobilization and Manipulation
Historically, manual therapy was often explained primarily through mechanical models, such as restoring joint position, breaking adhesions, lengthening shortened capsules, or correcting abnormal biomechanics. Current research suggests that the effects of manual therapy are more complex.
Mechanical forces are certainly applied to joints and surrounding tissues during mobilization and manipulation, but treatment may also produce responses involving the peripheral and central nervous systems, sensory processing, muscle activity, autonomic responses, and the patient's expectations and treatment context.
Effects on Pain and Movement
Joint mobilization and manipulation can reduce pain and improve movement in appropriately selected patients. These changes can be clinically valuable, particularly when pain or restricted movement is limiting exercise, daily activities, or progression through rehabilitation.
Manual therapy can also influence pain sensitivity, muscle activity, and sensory processing. Research has demonstrated changes in measures such as pressure-pain thresholds following some manual therapy interventions, although the magnitude and duration of these responses vary between individuals.
What remains less certain is exactly why these effects occur. Current evidence suggests that the response is not explained by a single mechanical event, such as realigning a joint or breaking adhesions. Instead, mechanical input to the joint and surrounding tissues interacts with neurological, sensory, contextual, and other physiological processes.
From a clinical perspective, the most important question is whether the intervention produces a meaningful change in pain, movement, confidence, or function that allows the patient to progress more effectively into active rehabilitation.
Manual Therapy as Part of Rehabilitation
When joint mobilization or manipulation is used, it should generally be considered one component of a broader rehabilitation strategy rather than the primary method for restoring shoulder function.
A temporary reduction in pain or improvement in movement may create an opportunity to introduce or progress:
Active range-of-motion exercises
Rotator cuff strengthening
Scapular and shoulder-girdle strengthening
Progressive resistance exercise
Functional and sport-specific loading
Activities important to the individual
Exercise remains an important component of conservative management for rotator cuff-related shoulder pain, although current evidence does not establish one universally superior exercise program.
The objective is therefore not simply to create greater passive joint motion. The longer-term goal is to help the patient develop the mobility, strength, endurance, coordination, confidence, and load tolerance required for meaningful activity.
Joint Treatment Demonstrations
The following videos demonstrate several joint mobilization and manipulation procedures that may be incorporated into the management of shoulder conditions. The specific techniques selected should be based on the patient's examination findings, symptoms, clinical presentation, treatment goals, and preferences.
Click Image to Watch Video
MSR 5 Point Shoulder Joint Mobilization
In this video, Dr. Brian Abelson, developer of Motion Specific Release (MSR), demonstrates the MSR 5-Point Shoulder Joint Mobilization. These procedures are designed to address shoulder joint mobility and can be incorporated into a broader rehabilitation program when clinically appropriate.
Chiropractic Adjustment
Joint manipulation may be considered when examination findings indicate that mobility in a particular region is relevant to the patient's symptoms or function.
Depending on the individual presentation, treatment may involve the shoulder girdle, thoracic spine, or other clinically relevant regions.
Manipulation should be selected according to the patient's presentation, contraindications, potential benefits and risks, and individual preferences.
Cervical Joint Mobilization
In this video, Dr. Abelson demonstrates examples of cervical joint mobilization techniques. The cervical spine may be considered during a shoulder assessment when the patient's history and examination indicate that cervical mobility or symptoms are relevant to the presentation.
The decision to use mobilization, manipulation, or neither should be based on the individual examination, contraindications, clinical judgment, and patient preference.
Myofascial Treatment for Shoulder Injuries
Muscles, tendons, and fascia form an interconnected system of tissues that transmit and respond to mechanical forces. The fascial system includes collagen-containing connective tissues that surround, connect, support, and separate muscles and other structures throughout the body. Rather than functioning simply as passive wrapping, fascia is a biologically active tissue involved in mechanical force transmission, sensory function, and adaptation to loading.
For clinicians using myofascial techniques, several characteristics of fascia are particularly relevant.
Sensory Innervation
Deep and muscular fascia are well innervated. Histological research has identified free nerve endings as well as Ruffini and Pacinian corpuscles within fascial tissues, providing anatomical support for roles in nociception and proprioception. The density and distribution of these nerve endings vary considerably between different fascial tissues.
This sensory capacity provides one plausible reason why mechanical input applied to fascia and surrounding soft tissues may influence pain perception and movement.
However, the clinical response to myofascial treatment should not be attributed to one receptor or neurological mechanism alone.
Mechanical Adaptation and Remodeling
Connective tissues continually adapt to the mechanical environment in which they function. Fibroblasts can detect mechanical forces through mechanotransduction, converting mechanical signals into cellular responses that influence gene expression and extracellular matrix production.
This process is important for normal tissue maintenance and adaptation. Injury, immobilization, repetitive loading, aging, inflammation, and other biological factors can also influence the organization and mechanical properties of connective tissues.
This is where I think we can preserve part of what you were trying to communicate with “our fascia contains our history,” but make it scientifically defensible. The tissues we examine today have been shaped, at least in part, by their previous mechanical and biological environment. I just would not describe fascia literally as a stored record of every previous injury.
Force Transmission and Fascial Continuity
Fascial tissues form continuous anatomical relationships between muscles and adjacent regions. These connections provide pathways through which mechanical forces can be distributed beyond an individual muscle or tendon.
This does not mean that a restriction identified in one fascial region necessarily causes symptoms somewhere else. Anatomical continuity demonstrates the potential for mechanical interaction, but clinical relevance must still be established through the patient's history, examination, symptoms, movement, and response to treatment.
Addressing Myofascial Restrictions
MSR incorporates a variety of soft-tissue procedures intended to address clinically relevant myofascial findings around the shoulder. The procedures selected depend on the patient's presentation and may be directed toward the rotator cuff, surrounding shoulder musculature, and other regions identified during examination.
As with joint mobilization, the objective is not simply to locate and “release” every area of perceived tissue restriction. Myofascial treatment can be used as part of a broader strategy to reduce symptoms, improve movement, and help the patient progress into active rehabilitation.
Stop Rotator Cuff Pain Now
In this video, Dr. Brian Abelson, developer of Motion Specific Release, demonstrates the MSR 6-Point Rotator Cuff Protocol. The protocol combines several soft-tissue procedures directed toward structures associated with the rotator cuff and surrounding shoulder region.
These procedures can be incorporated when clinically appropriate as part of a broader rehabilitation program that includes progressive mobility, strengthening, and functional loading.
MSR Fascial Expansion:
MSR Fascial Expansion procedures integrate concepts from fascial anatomy and regional anatomical relationships with selected principles and points derived from acupuncture and traditional Chinese medicine.
When incorporated into shoulder management, Fascial Expansion is used as one component of the overall treatment approach. Technique selection is guided by the individual's symptoms, examination findings, and response to treatment, with the broader goal of supporting movement and active rehabilitation.
Conclusion
Effective shoulder rehabilitation begins with understanding the individual rather than applying the same treatment approach to every shoulder problem. The patient's diagnosis, symptoms, mobility, strength, neurological findings, functional limitations, activity demands, and personal goals all help determine which interventions are most appropriate.
Manual therapy, including joint mobilization and myofascial techniques, can be useful when clinically indicated, particularly when reducing pain or improving movement helps the patient participate more effectively in rehabilitation. However, treatment should progressively emphasize active movement, strengthening, endurance, coordination, and increasing the shoulder's ability to tolerate the loads required for work, recreation, and sport.
Progression should be guided by the individual's response rather than by a rigid timeline. For one person, the goal may be comfortably reaching overhead or performing daily activities. For another, it may involve returning to heavy occupational demands, swimming, throwing, racquet sports, or high-level athletic performance. The rehabilitation program should evolve as the patient's capacity improves.
Across this four-part series, we have moved from the anatomy and biomechanics of the shoulder complex, through muscular coordination and scapular movement, to clinical examination and diagnosis, and finally to treatment and rehabilitation. One principle connects all four parts: the shoulder should not be reduced to a single structure, test, restriction, or treatment technique.
The goal is to identify the factors that are meaningful for the individual, address those factors appropriately, and progressively rebuild the mobility, strength, endurance, confidence, and load tolerance needed to return to the activities that matter to them.
References - Part 4
Abelson B, Abelson K, Mylonas E. A Practitioner's Guide to Motion Specific Release: Functional, Successful, Easy to Implement Techniques for Musculoskeletal Injuries. 1st ed. Rowan Tree Books; 2018.
Bialosky JE, Bishop MD, Price DD, Robinson ME, George SZ. The mechanisms of manual therapy in the treatment of musculoskeletal pain: A comprehensive model. Manual Therapy. 2009;14(5):531-538.
Keter DL, Bialosky JE, Brochetti K, et al. The mechanisms of manual therapy: A living review of systematic, narrative, and scoping reviews. PLoS One. 2025;20(3):e0319586.
Lafrance S, Charron M, Dubé MO, et al. The efficacy of exercise therapy for rotator cuff-related shoulder pain according to the FITT principle: A systematic review with meta-analyses. Journal of Orthopaedic & Sports Physical Therapy. 2024;54(8):499-512.
Lin I, Wiles L, Waller R, et al. What does best practice care for musculoskeletal pain look like? Eleven consistent recommendations from high-quality clinical practice guidelines: Systematic review. British Journal of Sports Medicine. 2020;54(2):79-86.
Paraskevopoulos E, Plakoutsis G, Chronopoulos E, Papandreou M. Effectiveness of combined program of manual therapy and exercise vs exercise only in patients with rotator cuff-related shoulder pain: A systematic review and meta-analysis. Sports Health. 2023;15(5):727-735.
Suarez-Rodriguez V, Fede C, Pirri C, et al. Fascial innervation: A systematic review of the literature. International Journal of Molecular Sciences. 2022;23(10):5674.
Tena-Portilla A, Martín-San Agustín R, Gacto-Sánchez M, Escriche-Escuder A. Effectiveness of exercise in rotator cuff-related shoulder pain: A systematic review with meta-analysis. Physiotherapy Theory and Practice. Published online August 17, 2026:1-30.
Vermeulen HM, Rozing PM, Obermann WR, le Cessie S, Vliet Vlieland TPM. Comparison of high-grade and low-grade mobilization techniques in the management of adhesive capsulitis of the shoulder: Randomized controlled trial. Physical Therapy. 2006;86(3):355-368.
Wu D, Wen Z, Ke H, et al. Specific modes of exercise to improve rotator cuff-related shoulder pain: Systematic review and meta-analysis. Frontiers in Bioengineering and Biotechnology. 2025;13:1560597.
Disclaimer:
The articles and embedded videos on the MSR website are provided for educational and informational purposes only. They are not a substitute for individualized assessment, diagnosis, or treatment by an appropriately qualified healthcare professional.
Some videos demonstrate clinical examination and manual therapy procedures intended for licensed or regulated healthcare professionals with appropriate training. These procedures should be performed only within the practitioner’s legal scope of practice and should not be attempted as self-treatment.
Viewing or using this content does not establish a practitioner-patient relationship. If you have questions about a medical condition or symptoms that are new, severe, or worsening, consult an appropriately qualified healthcare provider.
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DR. BRIAN ABELSON DC - The Author
Dr. Brian Abelson is a chiropractor, author, and educator with more than 30 years of clinical experience in musculoskeletal care, rehabilitation, and sports performance. His educational work focuses on musculoskeletal conditions, human movement, sports biomechanics, and evidence-informed approaches to treatment and rehabilitation.
He is the developer of Motion Specific Release (MSR) and Clinical Director of Kinetic Health in Calgary, Alberta, Canada.
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