Why most shoulder pain after 45 never settles, and what one British orthopaedic surgeon does differently.

You sleep on your back, or on the good side, because rolling onto the bad one wakes you at four in the morning. You brace before you reach for the kettle. Getting a coat on has turned into a negotiation. Lifting the grandchildren, the one thing you assumed you would always be able to do, is now something you think twice about.

And you have already had a go at the obvious things.

Heat packs. Voltarol. A course or two of physio at £55 a session that loosened it for a few days before it locked up again. Perhaps a steroid injection that worked beautifully for six weeks and then stopped. Perhaps your GP has quietly mentioned a referral.

So now you are in the worst place of all. Too sore to live normally, not far gone enough to hand over four to six months of your life to a rotator cuff repair and the rehab that follows.

I have sat opposite this patient hundreds of times.

Susan said that to me last winter. Three GPs, two physiotherapists and one steroid injection before she finally got the referral.

I told her what I tell most people sitting in that chair.

Surgery for chronic rotator cuff pain after 45 is the last option, not the first. And in her case, as in most cases, the underlying problem was never a tear that needed cutting.

It was a blood supply problem.

I want to walk you through what I mean, because if your shoulder has been giving you grief for a year or two, what follows has probably never been put to you. Not by your GP. Not by your physio. Not by anyone selling you an injection.

Once you understand it, the reason none of it worked makes complete sense.

The rotator cuff, the four muscles and tendons that hold the shoulder together, is one of the most poorly supplied tissues in the whole body when it comes to blood flow.

Even in a healthy 25-year-old it sits right at the edge of its blood supply. The capillaries feeding it are sparse compared with almost any other major muscle group.

After 40, those capillaries begin to disappear.

The tissue is still there. The structure is still there. But the supply line that keeps it repairing itself has largely dried up: the oxygen, the nutrients, the cellular machinery that clears inflammation and rebuilds damaged fibres.

This is what clinicians call hypovascular degeneration. In plain English: the tissue is starving.

When you make a movement that microscopically tears the rotator cuff (and we all do, dozens of times a day, simply reaching and lifting), the tissue at 30 repairs itself within hours. The blood flow is there. The machinery turns up. Job done.

The same micro-tear at 60? The blood doesn't turn up. The repair doesn't happen. The damage compounds. Inflammation lingers because there is no flow to flush it away. And what was a healthy shoulder slowly becomes a tender, stiff, painful one.

Once you understand the blood supply problem, the reason every common treatment falls short becomes obvious.

The reason these fall short is not that they were done badly. It is that the tissue was already starving, and none of them feed it.

The answer to chronic rotator cuff pain after 45 isn't to stitch the tear. It is to restore blood flow to the tissue so it can do what it is biologically designed to do: repair itself.

There are three known ways of getting deep, sustained blood flow back into degenerated rotator cuff tissue at home.

Each of these three is well established in physiotherapy and rehabilitation medicine. Heat therapy, compression therapy and therapeutic vibration are standard tools in any sports medicine clinic in the country.

But here is what is new, and what we had been missing.

Heat alone opens the vessels but doesn't flush waste or break adhesions. Compression alone moves fluid but can't open vessels that have been shut for years. Vibration alone reaches the deep tissue, but the tissue isn't ready to receive it if there is no blood flow.

Run all three at once, for twelve minutes, daily, and the shoulder finally gets what it has been starved of for the last decade.

About eighteen months ago, after watching too many people sit in my clinic hoping I could undo what biology had quietly been doing for twenty years, I began working with a small team of biomedical engineers on something that could deliver all three therapies (heat, compression and vibration) in a single twelve-minute session at home.

It is a wrap that straps over the shoulder. One control unit, one button to start. It runs all three at once for exactly twelve minutes, then switches itself off. Once a day, in your own front room, with the telly on or a cup of tea in hand.

I started suggesting it last year to the people I genuinely believed should not be rushed into theatre. People like Susan.

Susan used it once a day for six weeks before her next appointment with me.

When she came back she didn't say anything for a moment. Then she lifted her arm above her head, slowly but completely, and looked at me.

She hasn't booked it since.

She is not the only one. Of the people I have suggested it to over the last twelve months, people who came in expecting to go on a surgical list, most have not gone on to have an operation. Some still will. Some genuinely need surgery and no device is going to change that. But for the rest, the chronic-pain patients in their fifties and sixties who simply needed the shoulder fed again, it has done what physio and steroid injections never could.

It has restored the tissue.

MAEVEN Shoulder is not a cure. It is not a replacement for surgery where surgery is genuinely needed. It is not a magic device.

It is a clinical tool: three established therapies delivered together, daily, at home, for chronic rotator cuff and frozen shoulder cases where the underlying issue is degenerative rather than acute.

For the people I see, men and women in their fifties, sixties and seventies with the slow-onset, won't-go-away shoulder pain that physio can't quite fix and injections only mask, it has changed how I practise.

It ships tracked and insured to your door, and it comes with a 90-day money-back guarantee.

If you have been told surgery is the next step and you haven't booked it yet, this is what I would ask you to try first.

It is the option that goes before the operating theatre. It gives the tissue a chance to repair itself, while you still have that chance.

Most of my patients tell me they wish they had known about it eighteen months earlier.

If that is where you are right now, here is where to look.