What are the treatment options for shoulder pain?

Treatment Options for Shoulder Pain

The most effective treatment for shoulder pain includes a combination of physical therapy, medication, and interventions targeting specific underlying causes, with treatment selection based on the etiology of pain.

Initial Assessment and Diagnosis

• Radiography is the preferred initial imaging study for traumatic shoulder pain, with standard views including anteroposterior views in internal and external rotation and an axillary or scapula-Y view 1
• Clinical assessment should include musculoskeletal evaluation, evaluation of spasticity, identification of any subluxation, and testing for regional sensory changes 1
• Ultrasound may be considered as a diagnostic tool for shoulder soft tissue injury 1

Conservative Management

Physical Therapy

• Range of motion exercises focusing especially on external rotation and abduction are recommended to prevent frozen shoulder and shoulder-hand-pain syndrome 1
• Avoid overhead pulley exercises, which encourage uncontrolled abduction and can increase the incidence of developing hemiplegic shoulder pain 1
• Rotator cuff strengthening exercises are recommended to protect the glenohumeral joint 2

Medications

• Non-steroidal anti-inflammatory drugs are recommended as first-line pharmacological therapy for reduction of pain and inflammation 2
• Supplementation of oral vitamin C and vitamin D can help slow down cartilage degeneration in osteoarthritic conditions 2
• Neuromodulating medications may be considered for patients with central pain components associated with sensory changes, allodynia, and hyperpathia 1, 3

Interventional Treatments

Injections

• Intra-articular corticosteroid injections (Triamcinolone) have been found to have significant effects on pain reduction 1
• Suprascapular nerve blocks are effective in reducing shoulder pain through reduction of both nociceptive and neuropathic pain mechanisms for up to 12 weeks 1, 3
• Botulinum toxin injections can be useful to reduce severe hypertonicity in shoulder muscles and may decrease pain associated with spasticity-related joint mobility restrictions 1, 3

Electrical Stimulation

• Functional electrical stimulation (FES) may be considered for shoulder pain and has been shown to improve shoulder lateral rotation 1
• Neuromuscular electrical stimulation (NMES) may be considered (surface or intramuscular) for shoulder pain 1

Supportive Measures

• Shoulder strapping (sling) is recommended to prevent shoulder pain in the involved upper extremity 1
• Positioning and use of supportive devices are reasonable to consider for shoulder subluxation 1
• Modalities including ice, heat, and soft tissue massage can be used to reduce pain/swelling and improve circulation, tissue elasticity, and range of motion 1

Surgical Options

• Surgical tenotomy of pectoralis major, lattisimus dorsi, teres major, or subscapularis may be considered for patients with severe hemiplegia and restrictions in shoulder range of motion 1
• Most soft-tissue injuries (such as labral tears and rotator cuff tears) can undergo a period of conservative management before considering surgery 1, 4
• Surgical interventions are typically considered when symptoms persist or worsen after 6-12 weeks of directed conservative treatment 5

Treatment Algorithm Based on Etiology

For Hemiplegic Shoulder Pain

1. First-line: Patient education on positioning and range of motion exercises 1, 3
2. Second-line: Electrical stimulation and shoulder strapping 1
3. Third-line: Intra-articular injections (Triamcinolone) or suprascapular nerve blocks 1
4. Fourth-line: Botulinum toxin injections for spasticity-related pain 1, 3
5. Fifth-line: Surgical tenotomy for severe cases with restricted motion 1

For Inflammatory/Structural Shoulder Pain

1. First-line: NSAIDs and physical therapy focusing on ROM and strengthening 2, 5
2. Second-line: Corticosteroid injections (subacromial or glenohumeral) 1, 5
3. Third-line: Suprascapular nerve blocks 3
4. Fourth-line: Referral for surgical evaluation if no improvement after 3-6 months 4, 5

Common Pitfalls and Caveats

• Overhead pulley exercises should be avoided as they can worsen shoulder pain 1
• Corticosteroid injections provide only short-term relief and long-term pain reduction has not been verified 3
• Biologics such as platelet-rich plasma may help decrease shoulder pain but neither stop progression nor improve osteoarthritis 2
• The effectiveness of acupuncture as an adjuvant treatment for hemiplegic shoulder pain remains uncertain 1