What is the initial management for a patient experiencing shoulder pain when pushing up?

Initial Management of Shoulder Pain When Pushing Up

The initial management for shoulder pain when pushing up should include gentle stretching and mobilization techniques, focusing on increasing external rotation and abduction, along with gradual active range of motion exercises to restore alignment and strengthen weak muscles in the shoulder girdle. 1

Assessment of Shoulder Pain

When evaluating shoulder pain during pushing movements, consider these key elements:

• Evaluate tone, strength, changes in soft tissue length, alignment of shoulder girdle joints, pain levels, and orthopedic changes 1
• Assess for possible causes including:
  • Adhesive capsulitis
  • Traction/compression neuropathy
  • Complex regional pain syndrome
  • Shoulder trauma
  • Bursitis/tendonitis
  • Rotator cuff tear
  • Heterotrophic ossification 1

Treatment Algorithm

First-Line Interventions

1. Pain Management

   • If no contraindications exist, use analgesics such as acetaminophen or ibuprofen 1
   • Apply modalities including ice, heat, and soft tissue massage 1

2. Range of Motion Exercises

   • Implement gentle stretching and mobilization techniques
   • Focus on increasing external rotation and abduction to prevent frozen shoulder 1
   • Gradually increase active range of motion while restoring alignment 1
   • Place the upper limb in various appropriate positions within the patient's visual field 1

3. Strengthening

   • Target weak muscles in the shoulder girdle 1
   • Implement rotator cuff and scapular stabilization exercises 2

Important Cautions

• Avoid overhead pulleys which encourage uncontrolled abduction and can increase the incidence of shoulder pain 1
• Avoid aggressive passive range of motion exercises that may cause more harm than good 2

Advanced Interventions (if first-line fails)

1. Electrical Stimulation

   • Consider functional electrical stimulation (FES) for pain management 1
   • Particularly effective for improving shoulder lateral rotation 1

2. Injection Therapy

   • Consider intra-articular injections (Triamcinolone) which have significant effects on pain 1
   • Subacromial corticosteroid injections when pain is related to injury or inflammation of the subacromial region 1
   • Botulinum toxin injections into the subscapularis and pectoralis muscles if pain is related to spasticity 1

3. Supportive Devices

   • Consider shoulder strapping or sling to prevent trauma to the shoulder 1
   • Evaluate need for adaptive devices on an individual basis 1

Patient Education

Educate patients on:

• Proper positioning and handling of the affected arm 2
• Home exercise program focusing on gentle range of motion 2
• Activity modification to avoid exacerbating movements 2

When to Refer

Consider referral to a specialist if:

• No improvement after 3-6 months of conservative treatment 2
• Significant functional limitations despite therapy 2
• Evidence of instability or acute injury 2, 3

The evidence strongly supports that early intervention with appropriate exercises and pain management can significantly improve outcomes and prevent chronic shoulder pain. Physical therapy approaches focusing on restoring neuromuscular control have been shown to be effective in improving shoulder function in patients experiencing pain 4, 5.