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The difference is what reaches the dermis

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I also still have fatigue and an ache in my upper back that I have never experienced before

The following are common causes: Overuse: Repetitive overhead motion in sports (e.g., tennis, swimming) or occupations (e.g., painters, mechanics) Impingement syndrome: Compression of rotator cuff tendons under the acromion during arm elevation Age-related degeneration: Reduced blood flow and tendon elasticity in individuals over 40 Poor posture: Forward head and shoulder positioning increases stress on shoulder stabilizers Previous shoulder injuries: Dislocations or fractures can alter shoulder mechanics and increase risk How Is Rotator Cuff Tendinopathy Diagnosed