What are the recommended treatments for shoulder pain?

Recommended Treatments for Shoulder Pain

For most shoulder pain conditions, conservative management including physical therapy, education, and appropriate pain medication should be attempted for 3-6 months before considering surgical interventions. 1

Initial Assessment and Diagnosis

Proper treatment begins with accurate diagnosis:

• Radiography: Standard initial imaging for traumatic shoulder pain, including:

  • Anteroposterior (AP) views in internal and external rotation
  • Axillary or scapula-Y view (crucial for detecting dislocations) 1
  • Perform upright radiographs as malalignment can be underrepresented on supine views

• Clinical assessment:

  • Musculoskeletal evaluation
  • Evaluation of spasticity
  • Identification of any subluxation
  • Testing for regional sensory changes 1

• Advanced imaging when needed:

  • MRI or MR arthrography for soft tissue injuries (gold standard) 1
  • CT for complex fracture patterns 1
  • Ultrasound may be considered as a diagnostic tool for shoulder soft tissue injury 1

Treatment Algorithm

First-Line Treatments

1. Education and Self-Management

   • Patient education about positioning, range of motion exercises, and shoulder care 1
   • Activity modification to reduce pain-provoking movements 2

2. Physical Therapy

   • Active and passive range of motion exercises 1
   • Gentle stretching and mobilization techniques, particularly increasing external rotation and abduction 1
   • Rotator cuff strengthening exercises to protect the glenohumeral joint 2
   • Correction of scapular motion and posture 2, 3

3. Pharmacological Management

   • NSAIDs as first-line therapy for pain and inflammation 2
   • Acetaminophen or ibuprofen for pain relief if no contraindications 1
   • Oral vitamin C and D supplementation may help slow cartilage degeneration 2

Second-Line Treatments

1. Injection Therapies

   • Corticosteroid injections:

     • Subacromial or glenohumeral injections for inflammation 1
     • Methylprednisolone acetate (4-80mg depending on joint size) for intra-articular administration 4
     • Caution: Limited evidence for long-term effectiveness 1

   • Botulinum toxin injections:

     • Effective for shoulder pain related to spasticity 1
     • Target muscles: subscapularis, pectoralis major, infraspinatus 1

   • Nerve blocks:

     • Suprascapular nerve blocks may be considered for hemiplegic shoulder pain 1
     • Can provide relief for up to 12 weeks 1

2. Neuromuscular Electrical Stimulation (NMES)

   • May be considered for shoulder pain, particularly in post-stroke patients 1

Third-Line Treatments

1. Biologic Therapies

   • Platelet-rich plasma, bone marrow aspirate concentrate, or mesenchymal stem cells 2
   • Note: These may help decrease pain but don't stop OA progression 2

2. Surgical Interventions

   • Consider only after 3-6 months of failed conservative management 5
   • Requires clear diagnosis and structural information from imaging 5
   • For hemiplegic patients with severe restrictions, surgical tenotomy of pectoralis major, latissimus dorsi, teres major, or subscapularis muscles may be considered 1

Special Considerations

Hemiplegic Shoulder Pain (Post-Stroke)

• Positioning and supportive devices/slings for subluxation 1
• Avoid overhead pulley exercises (not recommended) 1
• Neuromodulating pain medications for neuropathic pain 1

Osteoarthritis

• Focus on rotator cuff strengthening to protect the joint 2
• Combined approach of activity modification and physical therapy 2
• Hyaluronic acid injections have mixed evidence for efficacy 2

Manual Wheelchair Users

• Targeted exercise programs have shown effectiveness in reducing shoulder pain 6
• Include arm ergometry, resistive strengthening, and stretching of shoulder girdle muscles 6

Common Pitfalls to Avoid

1. Premature imaging: Radiography is sufficient for initial evaluation; advanced imaging should be reserved for cases not responding to conservative treatment 1

2. Overlooking posture: Poor body posture strongly influences shoulder function and should be addressed in treatment 3

3. Rushing to surgery: Most soft-tissue injuries (labral tears, rotator cuff tears) can undergo conservative management before considering surgery 1, 5

4. Neglecting comprehensive approach: Shoulder pain often requires addressing multiple factors including muscle imbalance, joint mobility, and inflammation 3

5. Overuse of corticosteroid injections: While effective for short-term relief, these should be used judiciously due to potential long-term effects on tissue integrity 2