What are the treatment options for shoulder issues?

Treatment Options for Shoulder Issues

The treatment of shoulder issues should focus on addressing the specific underlying cause, with a combination of non-pharmacological approaches, medications, and in some cases, surgical interventions, tailored to the type and severity of the condition.

Assessment and Diagnosis

• Evaluate for specific signs including pain during movement, decreased velocity or precision of movement, and popping/shifting sensations 1
• Assess tone, strength, changes in soft tissues, and alignment of joints in the shoulder girdle 1
• Ultrasound can evaluate the acromioclavicular joint, rotator cuff tendons, and long head of biceps tendon 2
• MRI is the procedure of choice for evaluating occult fractures and shoulder soft tissues, including tendons, ligaments, muscles, and labrocapular structures 2
• MRI and MR arthrography are preferred for patients under 35 years with shoulder pain and in patients with instability or labral pathology 2

Common Shoulder Conditions

Rotator Cuff Disorders

• Most common source of shoulder pain, accounting for over two-thirds of cases 3
• Presents with difficulty performing overhead activities or pain that awakens the patient from sleep 4
• On examination, patients may be unable to hold the affected arm in an elevated position 4

Shoulder Instability

• Generally presents with a history of dislocation or subluxation events in patients younger than 40 years 5
• Positive apprehension and relocation tests are consistent with the diagnosis 5

Adhesive Capsulitis

• Can be associated with diabetes and thyroid disorders 5
• Presents with diffuse shoulder pain and restricted passive range of motion 5

Shoulder-Hand Syndrome (CRPS)

• Characterized by pain and tenderness of joints, edema over the dorsum of the fingers, trophic skin changes, hyperaesthesia, and limited range of motion 6

Hemiplegic Shoulder Pain

• Up to 72% of stroke patients experience at least one episode of shoulder pain during the first year after stroke 2
• Can delay rehabilitation and functional recuperation 2

Treatment Options

Non-Pharmacological Management

Rest and Activity Modification

• Complete rest from aggravating activities until symptoms resolve 1
• Return to normal activities only after achieving pain-free motion and strength 1

Physical Therapy and Exercise

• Rotator cuff and scapular stabilizer strengthening exercises 1
• Restore range of motion through gentle stretching and mobilization techniques, focusing on external rotation and abduction 2, 1
• Gradually increase active range of motion while restoring alignment and strengthening weak muscles 6, 1
• Avoid overhead pulleys, which encourage uncontrolled abduction and may increase risk of developing shoulder pain 2, 1

Modalities

• Ice, heat, and soft tissue massage to reduce pain and inflammation 2, 1
• Electrical stimulation may improve shoulder lateral rotation and reduce pain 2
• Ultrasound may be considered as a diagnostic tool for shoulder soft tissue injury 2

Support and Positioning

• Shoulder strapping or sling for comfort and to prevent subluxation 2
• Protect the hemiplegic limb from trauma and injuries to reduce the frequency of shoulder-hand syndrome 2, 6

Pharmacological Management

First-line Treatment

• Non-opioid analgesics such as acetaminophen or NSAIDs if not contraindicated 6, 3
• Topical NSAIDs for mild to moderate pain 6
• Topical capsaicin may be effective for hand involvement in shoulder-hand syndrome 6

Injections

• Intra-articular corticosteroid injections for shoulder pain 2
• Botulinum toxin injections for shoulder spasticity and pain associated with spasticity-related joint mobility restrictions 2, 6
• Suprascapular nerve blocks may be considered as an adjunctive treatment for hemiplegic shoulder pain 2

Surgical Interventions

• Consider surgery for:
  • Middle third clavicle fractures and type III acromioclavicular sprains in active individuals 7
  • First-time glenohumeral dislocation in young athletes 7
  • Full-thickness rotator cuff tears 7
  • Displaced or unstable proximal humerus fractures 7, 4
• 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 2

Special Considerations for Athletes

• Implement a progressive throwing program emphasizing proper mechanics 1
• Duration typically 1-3 months depending on injury severity 1
• Return to competition only after completing a functional, progressive throwing program without symptoms 1
• For baseball pitchers: adhere to age-appropriate pitch counts and rest periods 2, 1

Common Pitfalls to Avoid

• Returning to activity too soon before adequate healing and strengthening 1
• Using overhead pulleys in rehabilitation, which can worsen instability 2, 1
• Failing to address the entire kinetic chain (including scapular mechanics and core strength) 1
• For throwing athletes: ignoring proper mechanics and overuse factors 2, 1