The 4 Neurocentric Hidden Drivers of Shoulder Pain

Why Most Assessments Miss the Mark: Clients show up, follow the plan, and yet the pain sticks—or comes right back.
--> Here’s what to look for, ask, and do instead.

Shoulder pain is everywhere.

It’s one of the most common complaints therapists and coaches receive, yet so many clients never get lasting relief, even when they “do everything right.”

You assess mobility.
You prescribe the right exercises.
You check range, posture, and scapular control.
And still…

That ache creeps back in.

What gives?

We’ve been taught to look at the joint, the muscle, the scapula mechanics. Maybe even upstream or downstream.
But here’s the truth:

If you’re not assessing the brain’s perception of threat, you’re missing the real driver of pain. 

What If Your Assessments Are Asking the Wrong Questions?

You’re using your screens.
You’re checking mobility.
You’re following the protocol.

But what if the problem isn’t what you’re testing?
…it’s what you’re not asking?

Because not all shoulder pain is mechanical.
Not all movement dysfunction is visible.
And not all nervous system threat shows up in range-of-motion charts or MMT scores.

The Missing Link

One of the most overlooked tools in shoulder pain assessment?

The client’s story. 

In applied neurology, we don’t just ask where it hurts. We dig for patterns:

• “What makes it worse? What makes it better?”
• “Do you ever feel this pain when you're not moving?”
• “Does the pain travel, tingle, or burn?”
• “Do certain foods, stressors, or positions seem to set it off?”
• “What else has changed in your body since this pain started?”

These questions do more than fill out an intake form.
They guide us toward the brain’s map of safety — and tell us which system might be driving the alarm.

Because shoulder pain is rarely “just” shoulder pain.

We have always said the brain is the body's GPS, and time and again, your story, the client's story, proves right. 

A Neurology-Informed Framework: The 4 Types of Pain

According to applied neurology principles, most shoulder pain falls into one of four neurocentric categories, and each demands a different input to calm the system.

Let’s break them down.

1. Somatic Pain (Muscle & Joint)

This is what most functional movement systems are built to identify.

It’s sharp, achy, and reproducible with movement or pressure.
Subacromial impingement, biceps tendonitis, or tight pec minors all live here.

BUT—if your client’s shoulder screen clears but they still hurt, something else is likely going on. 

Applied neurology tip: Even somatic pain is filtered through the brain’s perceived threat. Sensory drills, balance inputs, or vision work can often resolve pain faster than local tissue loading.

2. Visceral Pain (Organ Referral)

This pain is dull, vague, and not linked to movement.
You can’t recreate it with shoulder screens.

It may relate to digestion, breathing, or other systemic patterns.

Example: Gallbladder or diaphragm irritation can refer pain to the shoulder.

Neuro lens: Visceral organs share sensory highways with musculoskeletal regions.

The brain often misinterprets these signals. Movement screens won't find this, but a detailed client history and visceral threat screening can.

3. Neurogenic Pain (Nerve-Driven)

Sharp. Burning. Shooting. Maybe numb or tingling.
Often runs down the arm. Sometimes triggered by head or neck position.

This is not a rotator cuff issue, and you’ll miss it if you only look at the glenohumeral joint.

Clues: Positive Spurling’s, nerve tension tests, dermatomal patterns.

Neuro fix: Focus on neural glides, breath retraining, and sensory-motor integration. Add visual and vestibular drills to reduce the global threat.

4. Sympathetic Pain (Autonomic Nervous System)

This is the one that really throws people off.

Pain that’s out of proportion. Sensitive to light touch. Maybe discolored skin, sweating, swelling.
Could be post-injury, post-stroke, or from chronic stress overload.
Clients may avoid using the limb altogether.

Applied neurology focus: Desensitization. Graded exposure. Vagus nerve input. Safety and predictability. This is where applied neuro shines—calming an inflamed threat bucket.

Read more about the threat bucket here.  

Why Categorization Changes Everything

Let’s say a client presents with shoulder pain:

• They pass your movement screen
• Orthopedic tests are inconclusive
• They say the pain sometimes flares up at night for “no reason”

Now what?

If you’ve only trained in biomechanical models, you might go back to more soft tissue work or scapular stability drills.

But if you think neuro-first?

You ask:

• Could this be a visceral referral?
• Could it be nerve-based?
• Is the nervous system stuck in protective mode?
• Can I find a sensory mismatch that’s driving this?
• Could their lifestyle be a major cause? 

And now you’re playing the right game. 

Because the goal isn’t just to stretch the pec or activate the serratus — it’s to calm the system.

And you can't calm what you don't understand.

Calm the Threat, Reclaim the Shoulder

How to Treat Persistent Shoulder Pain Using the Brain’s GPS 

Step 1: Don’t Guess. Assess.

In applied neurology, assessment goes far beyond ortho tests.
We test inputs that the brain uses to map the body and move safely:

•  Sensory mapping: Can the client feel light touch clearly across dermatomes?
•  Visual control: Can their eyes converge, track, and stabilize?
•  Vestibular system: Can they balance with eyes closed? Do they tolerate head turns?
•  Breath and vagal tone: Are they chest breathers? Does exhalation reduce tension?

These inputs tell us how “safe” the brain feels — and where threat might be hiding.

Free masterclasses for the assess/reassess process here.

Step 2: Apply a Targeted Drill

Based on the results of the assessment, we apply a neuro drill—a small, precise input aimed at restoring the brain’s sense of safety.

Examples:

•  Oculomotor drills to reduce upper trap overactivity
•  Balance drills to downregulate global threat
•  Breath drills to restore vagal tone and reduce guarding
•  Neural glides to address nerve compression
•  Sensory mapping drills to enhance proprioception

Case Example:
A client with anterior shoulder pain and limited internal rotation performs a 30-second visual convergence drill. Immediate reassessment shows +10° IR and less pain with overhead motion.

Step 3: Reassess

Every drill must be followed by a reassessment.
Why? Because the brain will tell you if it liked the input.

• Did ROM improve?
• Did the pain reduce?
• Did the movement smooth out?

If yes—great.
If no—change the input and test again.

The nervous system gives instant feedback. --> This is the greatest gift to the therapy and fitness world.  You get INSTANT feedback to know if your choice worked or not.  Not 2 weeks, next session, next month, INSTANT.

This model removes guesswork.
You stop treating symptoms. You start finding solutions that stick. 

Those FREE masterclasses again. 

The Brain Drives the Shoulder

Most therapists have been trained to think:
“Pain = tissue issue.” 

But applied neurology teaches us this:

Pain = perception of threat.
Movement = permission from the brain.
Progress = reducing threat, not just increasing strength.

If you want shoulder rehab that sticks. 

Not just temporarily improving range of motion ---> you have to go deeper.

Ask better questions.
Use functional screens as data, not diagnosis.
And always consider the brain first.

The brain is the governor of the body, and if used as the GPS to what's going on, your biomechanical training will only be enhanced. 

You don’t have to keep guessing.

When clients don’t respond to conventional shoulder rehab, it’s not because you missed the exercise. It’s because the nervous system is still on high alert.

By asking better questions, using smarter inputs, and respecting how pain truly works, we stop chasing the shoulder…

…and start listening to the brain.

 If you want to learn more about how our mentorship can help you enhance your practice, book a call to talk about it here. We don't do sales, but we will teach you what you need to know.