What are the treatment options for shoulder pain?

Treatment Options for Shoulder Pain

The most effective treatment for shoulder pain includes NSAIDs for pain relief, physical therapy with gentle stretching and mobilization techniques, and targeted injections for specific conditions, avoiding overhead pulley exercises and complete immobilization. 1

First-Line Conservative Management

Medication Options

• NSAIDs (First-line pharmacological therapy):

  • Use the lowest effective dose for the shortest duration (400-800mg ibuprofen 3-4 times daily) 2
  • Consider topical NSAIDs for fewer systemic side effects 1
  • Take with meals or milk if gastrointestinal complaints occur 2
  • Caution: Increased risk of cardiovascular events and GI bleeding, especially in older adults 2

• Acetaminophen: Alternative for patients with contraindications to NSAIDs 1

Physical Therapy Interventions

• Avoid: Overhead pulley exercises and complete immobilization 1

• Recommended exercises:

  • Gentle stretching focusing on external rotation and abduction 1
  • Eccentric strengthening exercises combined with thermal therapy 1
  • Gradually increase active range of motion exercises 1

• Timing is crucial: Early intervention is important; consider intensive therapy if full function isn't achieved by 6-8 weeks 1

Thermal Therapy

• Ice application: Apply through a wet towel for 10-minute periods to reduce pain and swelling in acute inflammatory conditions 1
• Heat therapy: Can be combined with stretching exercises 1

Second-Line and Advanced Interventions

Injection Therapies

• Corticosteroid injections:

  • Intra-articular triamcinolone for significant pain 1
  • Methylprednisolone acetate 40mg with lidocaine 1% for more rapid pain relief 1
  • Target injections to specific areas (intra-articular or subacromial) rather than intramuscular 1

• Alternative injections:

  • Suprascapular nerve blocks for non-neuropathic shoulder pain (pain relief up to 12 weeks) 1
  • Botulinum toxin into the subscapularis and pectoralis muscles for shoulder stiffness with spasticity 1

Diagnostic Imaging

• Initial imaging: Plain radiography (anteroposterior in internal/external rotation, axillary or scapula-Y view) 1
• Advanced imaging (only if needed after plain films):
  • Ultrasound: Highly rated for suspected bursitis or rotator cuff evaluation 1
  • MRI: For evaluating rotator cuff quality, fatty degeneration, and muscle atrophy 1
  • Avoid CT as initial study for frozen shoulder 1

Condition-Specific Approaches

For Glenohumeral Osteoarthritis

• Focus on rotator cuff strengthening exercises to protect the glenohumeral joint 3
• Consider vitamin C and D supplementation to potentially slow cartilage degeneration 3

For Adhesive Capsulitis (Frozen Shoulder)

• Identify and target specific soft tissues responsible for ROM loss 3
• Physical therapy focusing on gentle stretching and mobilization 1

Surgical Considerations

• Referral timing: Consider surgical referral if conservative management fails after 3-6 months 1, 4
• Surgical options based on specific diagnosis:
  • Arthroscopic subacromial decompression for impingement
  • Rotator cuff repair
  • Shoulder arthroplasty for advanced osteoarthritis
  • Tenotomy of pectoralis major, latissimus dorsi, teres major, or subscapularis for severe cases with restricted range of motion 1

Prognosis

• Approximately 80% of patients recover completely within 3-6 months with appropriate conservative treatment 1
• Factors affecting outcomes:
  • Age (patients over 50 have higher rates of full-thickness rotator cuff tears)
  • Workers' compensation status may correlate with less favorable outcomes
  • Rotator cuff muscle quality affects healing potential 1

Common Pitfalls to Avoid

• Delaying physical therapy intervention
• Using advanced imaging before plain radiographs
• Complete immobilization of the shoulder
• Overhead pulley exercises
• Using CT as initial study for frozen shoulder
• Prolonged NSAID use without monitoring for side effects