What are the recommended management strategies for shoulder pain?

Shoulder Pain Management

For shoulder pain, begin with conservative multimodal therapy including exercise, education, and NSAIDs, reserving imaging for suspected serious pathology or failed conservative treatment, and consider surgery only after 3 months of unsuccessful non-surgical management.

Initial Assessment and Imaging Strategy

Avoid routine imaging unless specific criteria are met. Radiological imaging should be discouraged unless: (1) serious pathology is suspected (fracture, dislocation, "red flag" conditions), (2) there has been unsatisfactory response to conservative care or unexplained progression, or (3) imaging is likely to change management 1.

For acute traumatic shoulder pain:

• Radiographs are the preferred initial diagnostic modality and should include minimum 3 views: AP views in internal and external rotation plus an axillary or scapula-Y view 1
• Axillary or scapula-Y views are vital as glenohumeral and acromioclavicular dislocations can be misclassified on AP views alone 1
• CT without contrast is advantageous for identifying subtle nondisplaced fractures and characterizing complex fracture morphology when radiographs are indeterminate 1
• CT can affect clinical management in up to 41% of patients with proximal humeral fractures 1

First-Line Conservative Management

Exercise and activity modification form the cornerstone of treatment. All high-quality guidelines consistently recommend activity/exercise as primary therapy 1.

Physical Therapy Components

• Range of motion exercises (passive and active-assisted) should be performed with the upper limb in various safe positions within the patient's visual field 2
• Gentle mobilization and stretching should focus on increasing external rotation and abduction 2
• Active range of motion should be progressively increased in conjunction with restoring alignment and strengthening weak scapular girdle muscles 2
• Rotator cuff strengthening exercises are recommended to protect the glenohumeral joint 3

Pharmacological Management

NSAIDs are recommended as first-line pharmacological therapy for pain reduction and inflammation control 3.

• Acetaminophen or ibuprofen can be used for pain relief if no contraindications exist 2
• Naproxen dosing for musculoskeletal conditions: 250-500 mg twice daily for chronic conditions; for acute pain, start with 500 mg followed by 500 mg every 12 hours or 250 mg every 6-8 hours (initial daily dose should not exceed 1250 mg) 4
• Oral vitamin C and vitamin D supplementation may help slow cartilage degeneration 3
• Opioids should be used cautiously, for the shortest period possible, and not routinely 1

Manual Therapy

If manual therapy is used, it must be combined with other treatments—never as standalone therapy. Manual therapy should be applied only in conjunction with exercise, education, and activity advice as part of multimodal care 1.

Interventional Options

Corticosteroid Injections

Subacromial or glenohumeral corticosteroid injections provide short-term pain relief and are commonly used, though long-term benefits remain unverified 1.

• Injections result in superior short-term pain reduction compared with standard care 1
• Select patients with verified shoulder joint pathology on ultrasonography for optimal results 1
• Use cautiously in athletes due to potential adverse effects 3

Specialized Interventions

• Suprascapular nerve blocks are superior to placebo in reducing shoulder pain for up to 12 weeks 1
• Botulinum toxin injections into subscapular and pectoral muscles can treat shoulder pain related to spasticity, though results are mixed for general shoulder pain 1, 2
• Neuromuscular electrical stimulation (NMES) may be considered for shoulder pain 2

Biologics

Platelet-rich plasma, bone marrow aspirate concentrate, and mesenchymal stem cells show promise for decreasing pain but do not stop progression or improve underlying pathology—further evidence is needed 3.

Surgical Considerations

Surgery should only be considered after failed conservative management. Unless specifically contraindicated (e.g., unstable/significantly displaced fractures, joint instability), offer evidence-informed non-surgical care prior to surgery 1.

Timing and Indications

• Trial non-surgical management for at least 3 months before surgical review 1
• Unstable or significantly displaced fractures and joint instability are injuries most likely requiring acute surgical treatment 1
• Soft tissue injuries including labral tears and rotator cuff tears may undergo conservative management first 1
• Important exception: Traumatic massive rotator cuff tears may require expedited surgical timeline to achieve optimal functional outcomes 1

Surgical Options

When conservative treatment fails after 3-6 months, surgical options depend on specific diagnosis and include arthroscopic subacromial decompression, rotator cuff repair, excision of distal clavicle, and shoulder arthroplasty 5, 6.

Critical Pitfalls to Avoid

• Do not order routine imaging without meeting specific criteria—explain to patients that imaging may not be needed 1
• Do not use manual therapy alone—it must be part of multimodal treatment 1
• Do not delay surgical referral for acute injuries with unstable fractures or joint instability 1
• Do not overlook psychosocial factors—assess mood, anxiety, and recovery expectations as these impact outcomes 1
• Patient age, comorbidities, and activity level all influence appropriate management strategy 1