What is the treatment for pain and numbness in the shoulder, arm, and fingers?

Treatment for Pain and Numbness in Shoulder, Arm, and Fingers

Start with ibuprofen 400-800 mg every 6-8 hours as first-line treatment for pain, combined with physical therapy focusing on range of motion exercises, particularly external rotation and abduction movements. 1, 2

Initial Assessment and Diagnosis

Before initiating treatment, evaluate the following specific findings:

• Assess muscle tone, strength, soft tissue changes, joint alignment of the shoulder girdle, pain levels, and orthopedic changes 3, 4, 1
• Look specifically for instability signs: pain during movement, decreased velocity or precision of movement, and clicking/displacement sensations 3
• For numbness and tingling: Ask specifically about symptoms in hands and feet, their characteristics, distribution, and timing 5
• Consider potential causes: adhesive capsulitis, traction/compression neuropathy, complex regional pain syndrome, shoulder trauma, bursitis/tendonitis, rotator cuff tear, or heterotrophic ossification 1
• Obtain radiographs: anteroposterior views in internal and external rotation plus axillary or scapula-Y view to assess alignment and fractures 1

First-Line Treatment Algorithm

For Pain Management:

Ibuprofen is superior to acetaminophen for shoulder pain, providing better improvement in pain severity and functional activity. 6

• Ibuprofen 400-800 mg every 6-8 hours (maximum 3200 mg/day) 1, 2
• Acetaminophen 500 mg every 6-8 hours can be used if NSAIDs are contraindicated, though it provides less functional improvement 1, 6
• Critical caveat: Acetaminophen has limited efficacy for chronic pain conditions and reaches a ceiling effect at 1000 mg 7, 8

For Physical Rehabilitation:

• Range of motion exercises (passive and active-assisted) focusing on external rotation and abduction 3, 4, 1
• Gentle mobilization and stretching exercises to prevent frozen shoulder 3, 1
• Gradually increase active range of motion while restoring alignment and strengthening weak shoulder girdle muscles 3, 4
• AVOID overhead pulley exercises - these encourage uncontrolled abduction and increase pain risk 4, 1

For Numbness and Neuropathic Symptoms:

If numbness and tingling persist after addressing mechanical shoulder issues:

• Duloxetine is first-line for neuropathic pain, numbness, and tingling 5
• Physical activity has proven efficacy for neuropathy (Level IA evidence) 5
• Gabapentin or pregabalin (calcium channel α2-δ ligands) are alternative first-line options 5, 9
• Tricyclic antidepressants (nortriptyline or desipramine) are also first-line, though anticholinergic side effects limit tolerability 5

Second-Line Interventions

If first-line treatments provide inadequate relief after 4-6 weeks:

• Subacromial or intra-articular corticosteroid injections when pain relates to rotator cuff or bursa inflammation 1
• Botulinum toxin injections into subscapularis and pectoralis muscles if spasticity is contributing to pain 3, 4, 1
• Functional electrical stimulation (FES) or neuromuscular electrical stimulation (NMES) may be considered 4, 1
• Suprascapular nerve blocks as adjunctive treatment for persistent pain 1

Advanced Treatment Options

For refractory neuropathic symptoms:

• Transcranial direct current stimulation (tDCS) as adjunct therapy (Evidence Level A) 4
• Repetitive transcranial magnetic stimulation (rTMS) may be considered (Evidence Level B) 4
• Topical lidocaine for localized peripheral neuropathic pain 5

Special Considerations for Complex Regional Pain Syndrome

If you identify pain and tenderness of metacarpophalangeal and proximal interphalangeal joints with dorsal finger edema, trophic skin changes, hyperesthesia, and limited range of motion:

• Oral corticosteroids 30-50 mg daily for 3-5 days, then taper over 1-2 weeks to reduce swelling and pain 3, 4, 1
• Active, active-assisted, or passive range of motion exercises are mandatory to prevent CRPS progression 3, 4

Critical Pitfalls to Avoid

• Never delay treatment - shoulder pain can mask motor function improvement, inhibit rehabilitation, and contribute to depression, insomnia, and reduced quality of life 3, 4
• Do not use overhead pulleys - they increase pain risk through uncontrolled abduction 4, 1
• Do not assume acetaminophen and ibuprofen are equivalent - ibuprofen provides superior functional outcomes for shoulder pain 6
• Do not ignore numbness and tingling - these neuropathic symptoms require specific pharmacologic treatment beyond simple analgesics 5
• Ibuprofen causes fewer side effects than acetaminophen with codeine (28% vs 65% side effect rate) in soft tissue injuries 10

Treatment Timeline

• Week 1-2: Initiate ibuprofen and range of motion exercises; assess for neuropathic component
• Week 2-4: If numbness persists, add duloxetine or gabapentin; continue physical therapy
• Week 4-6: If inadequate response (<30% pain reduction), consider corticosteroid injections or switch to alternative first-line neuropathic agent
• Beyond 6 weeks: Consider botulinum toxin, nerve blocks, or referral to pain specialist 5