Why Your Shoulder Pain Might Not Be a Shoulder Problem

As performance-based physical therapists, we see a steady stream of active adults frustrated by persistent shoulder pain that doesn’t respond to typical shoulder treatments. They’ve stretched their rotator cuff, strengthened their scapular stabilizers, maybe even had a few cortisone injections—all with little to no relief. Many arrive in our office with a folder full of clean X-rays and MRIs, only to hear, “Your shoulder looks fine.”

Here’s what many don’t realize: not all shoulder pain comes from the shoulder itself. In fact, some of the most stubborn cases we’ve treated were actually rooted in the thoracic spine and rib cage—more specifically, in how the muscles and fascia in these regions influence shoulder mechanics and pain referral patterns.

Muscles You Should Know: Levator Scapulae and Serratus Posterior

Two of the biggest culprits are levator scapulae and serratus posterior superior.

•   Levator scapulae originates from the upper cervical spine and attaches to the superior angle of the scapula. When this muscle becomes overactive, shortened, or burdened by poor posture (think desk work, Jiu-Jitsu, cycling, or any forward-head activity), it can tug relentlessly on the upper ribs and cervical spine, also causing your scapula to lift and tilt forward on the rib cage, causing irritation.
•   Serratus posterior superior lies deep under the rhomboids and runs from the upper thoracic spine to ribs 2–5. Dysfunction here can restrict rib mobility and irritate intercostal nerves, referring pain that feels deceptively like a deep, hard-to-pinpoint ache in the posterior shoulder, scapular region, or lateral shoulder.

Both of these muscles influence rib mechanics and fascial tension that radiate toward the shoulder complex.

The Missing Link: Fascial Connections

What ties all of this together is fascia. The thoracolumbar fascia, cervical fascia, and scapular fascia form a continuous network that transmits tension across distant regions. Fascial restrictions and densifications around the thoracic spine, ribs, and upper cervical region can radiate stress into the shoulder girdle, subtly altering mechanics and creating what feels like local shoulder dysfunction. 

This is why isolated rotator cuff strengthening or scapular retraction work often falls flat. If the underlying thoracic or rib dysfunction isn’t addressed, the shoulder will continue to bear the brunt of the compensation.

Why Imaging Falls Short

Standard imaging—X-rays and MRIs—focuses on structural anomalies like joint degeneration, disc herniation, rotator cuff tears, or fractures. But these tools don’t visualize muscle tone, joint mobility, fascial restrictions, or subtle rib dysfunction. You could have a perfectly clean MRI and still experience significant pain because the dysfunction lies in soft tissue tension and movement—not structural damage.

This is where skilled manual assessment comes in.

The Power of Manual Assessment

A thorough hands-on assessment can uncover:

•   Thoracic joint stiffness or hypermobility
•   Rib fixations or restrictions
•   Fascial adhesions pulling on surrounding tissues
•   Trigger points in levator scapulae, serratus posterior, rhomboids, or intercostals
•   Asymmetries in thoracic rotation or rib excursion with breathing

These are findings that no image will reveal but are obvious under trained hands. We often see immediate changes in shoulder mobility and pain simply by mobilizing the thoracic spine, releasing rib restrictions, or addressing fascial pulls—without ever directly touching the glenohumeral joint.

What This Means for You

If you’re dealing with stubborn shoulder pain that hasn’t responded to traditional approaches, it’s worth expanding the search. Your thoracic spine, rib cage, and fascial system may hold the answer.

As movement specialists, performance-based PTs are uniquely trained to spot these relationships and treat them with manual therapy, targeted mobility work, and integrative movement retraining. The goal isn’t just to chase the site of pain but to correct the true source of dysfunction.

Key Takeaway

If your shoulder pain seems mysterious or unresponsive, don’t settle for a clean MRI as the final word. Get assessed by someone who understands the interconnectedness of the thoracic spine, ribs, and fascial system. The solution may lie just outside the joint you’re trying to fix.

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Interested in learning how we assess these patterns? Book a one-on-one session to see how a comprehensive manual assessment can help uncover what imaging can’t.

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