What are the appropriate next steps in managing a patient with left shoulder pain, previously diagnosed as musculoskeletal and treated with a ketorolac (Toradol) injection, cyclobenzaprine (Flexeril), and ibuprofen, who denies trauma, performs housework, and is now presenting for follow‑up?

Next Steps for Persistent Musculoskeletal Shoulder Pain After Initial Treatment

Order shoulder radiographs (AP views in internal and external rotation plus axillary or scapula-Y view) as the next step, even without trauma history, to rule out occult fracture or other bony pathology before continuing conservative management. 1

Imaging First, Despite "Musculoskeletal" Diagnosis

While the outside clinic diagnosed musculoskeletal pain, the persistence of symptoms after appropriate initial treatment (ketorolac injection, cyclobenzaprine, and ibuprofen) warrants baseline imaging. The 2025 ACR guidelines are clear: radiographs are the preferred initial diagnostic modality in cases of acute shoulder pain because they can identify shoulder malalignment and most fractures 1.

Critical Point About "No Trauma"

The patient performs housework, which involves repetitive overhead activities and potential for unrecognized microtrauma or stress injuries. The absence of a recalled fall or acute injury does not exclude:

• Occult fractures (especially in older patients or those with osteoporosis)
• Stress fractures from repetitive activity
• Subtle malalignment
• Acromioclavicular joint pathology

The standard trauma series should include minimum 3 views: AP in internal rotation, AP in external rotation, and axillary or scapula-Y view 1. The axillary or scapula-Y views are vital because acromioclavicular and glenohumeral joint dislocations can be missed on AP views alone 1.

Medication Duration Concerns

Cyclobenzaprine (Flexeril) should not be continued beyond 2-3 weeks 2. Since the patient received this on Thursday and is presenting for follow-up (presumably within days), verify she understands this time limitation. The FDA labeling explicitly states that use for periods longer than two or three weeks is not recommended 2.

If Radiographs Are Normal: Conservative Management Algorithm

Assuming radiographs exclude fracture, dislocation, or significant arthritis, proceed with:

1. Continue NSAIDs with proper dosing

• Ibuprofen 400-600 mg every 6-8 hours as needed (not the ceiling dose used in acute ED settings)
• Continue for 2-4 weeks with food to minimize GI effects
• Recent evidence shows oral ibuprofen provides comparable pain relief to IM ketorolac for musculoskeletal pain 3

2. Activity Modification Specific to Housework

• Avoid overhead reaching activities
• Modify lifting techniques (keep loads close to body, avoid reaching)
• Limit repetitive shoulder movements
• This is NOT complete rest—gentle range of motion within pain tolerance should continue

3. Consider Corticosteroid Injection if Pain Persists Beyond 2 Weeks

Moderate evidence supports a single corticosteroid injection with local anesthetic for short-term improvement in both pain and function 4. This is superior to repeating ketorolac injections. Recent 2026 data shows ketorolac injections are non-inferior to corticosteroids at 3 months for subacromial impingement 5, but corticosteroids remain the standard of care with more robust long-term data.

4. Physical Therapy Referral

• Initiate after acute pain subsides (typically 1-2 weeks)
• Focus on rotator cuff strengthening and scapular stabilization
• Most patients with subacromial pain fully recover with minimal intervention 6

Red Flags Requiring Urgent Specialist Referral

Reassess for these features that would mandate immediate orthopedic consultation:

• Fever or systemic symptoms (infection, malignancy)
• Unexplained weight loss (malignancy)
• Significant weakness or neurologic deficit (nerve injury, massive rotator cuff tear)
• Night pain that prevents sleep (may indicate rotator cuff tear or other serious pathology)
• Progressive worsening despite treatment (consider alternative diagnosis)

Timeline for Specialist Referral

Refer to orthopedics if pain persists beyond 6-8 weeks of appropriate conservative management 7. The natural history of most shoulder pain is favorable, and early surgical referral leads to overdiagnosis and overtreatment 6. However, if imaging reveals significant pathology (displaced fracture, dislocation, large rotator cuff tear), refer immediately.

Common Pitfall to Avoid

Do not assume "musculoskeletal" diagnosis from outside clinic is definitive without imaging. The 2026 JAMA review emphasizes that early imaging is not indicated in the absence of significant trauma OR suspicious features 6, but persistent pain after appropriate treatment constitutes a suspicious feature warranting radiographic evaluation. The outside clinic may have appropriately deferred imaging initially, but persistence changes the clinical picture.