What are the treatment options for common shoulder injuries?

Treatment Options for Common Shoulder Injuries

For acute traumatic shoulder injuries, begin with upright three-view radiographs (AP internal rotation, AP external rotation, and axillary or scapula-Y view), followed by conservative management with pain control, sling immobilization, and early physical therapy for most non-displaced fractures and soft tissue injuries, reserving surgery for unstable fractures, dislocations with recurrent instability, and massive rotator cuff tears requiring expedited repair. 1, 2, 3

Initial Diagnostic Approach

Imaging Strategy

• Obtain upright radiographs as the first-line imaging modality with minimum three views: anteroposterior in internal and external rotation, plus axillary or scapula-Y view 1, 2, 3
• The axillary or scapula-Y view is critical because acromioclavicular and glenohumeral dislocations are frequently missed on AP views alone 2, 3
• Standing radiographs are essential as supine positioning underestimates shoulder malalignment 2, 3

Advanced Imaging Indications

• MRI without contrast is the preferred modality for soft tissue injuries including rotator cuff tears, labral tears, and bone loss assessment 3
• CT is superior for characterizing complex fracture patterns when surgical planning is needed 3
• CT angiography is indicated immediately if vascular compromise is suspected (diminished pulses, expanding hematoma, ischemia signs) 3

Treatment Algorithm by Injury Type

Clavicle Fractures

• More than 80% can be managed conservatively with sling immobilization, pain control, and early mobilization 4, 5
• Surgical referral is required for significantly displaced or unstable fractures 1, 2

Proximal Humerus Fractures

• 85% can be managed nonoperatively using sling immobilization, early range-of-motion exercises, and progressive strength training 4, 5
• These injuries predominantly occur in elderly patients after low-energy falls 5
• Unstable or significantly displaced fractures require acute surgical management 1, 2

Acromioclavicular Joint Injuries

• Types I and II injuries are treated conservatively with pain management, short-term sling use, and physical therapy 4, 5
• Types IV through VI require surgical intervention 4
• Type III injuries remain controversial regarding optimal management approach 4

Glenohumeral Dislocations

• 80% are anterior dislocations that can be reduced using nonsurgical techniques with intra-articular lidocaine or intravenous analgesia 4, 5
• Patients with shoulder instability or recurrent dislocations should be referred for surgical evaluation 2
• Post-reduction management includes brief sling immobilization followed by rehabilitation 5

Rotator Cuff Tears

Conservative Management (Initial Approach)

• Most rotator cuff tears can undergo conservative management initially before considering surgery 1, 3, 4
• Treatment includes gentle stretching and mobilization techniques, focusing on increasing external rotation and abduction 1
• Active range of motion should be increased gradually while restoring alignment and strengthening weak shoulder girdle muscles 1
• Rehabilitation should focus on strengthening the rotator cuff, periscapular muscles, and core musculature 2

Pharmacologic Management

• Ibuprofen (400-800 mg every 6-8 hours) is superior to acetaminophen for improving pain severity and functional activity in rotator cuff-related pain 6
• Acetaminophen (500 mg every 6-8 hours) can be used if NSAIDs are contraindicated 1, 6

Injection Therapy

• Subacromial corticosteroid injections can be used when pain is related to injury or inflammation of the subacromial region (rotator cuff or bursa) 1
• The American Academy of Orthopaedic Surgeons suggests corticosteroid injections may be considered for subacromial conflict 2
• Botulinum toxin injections into subscapularis and pectoralis muscles can treat pain related to spasticity 1

Surgical Indications

• Massive traumatic rotator cuff tears require expedited surgical referral for optimal functional outcomes 1, 2
• Surgery is considered after 3-6 months of failed conservative treatment 7, 8

Labral Tears

• Labral tears without instability can be managed conservatively with physical therapy and activity modification 3
• Surgical referral is indicated for persistent symptoms or associated instability 3

Critical Pitfalls to Avoid

• Never rely on AP views alone as this leads to missed dislocations and AC joint injuries 2, 3
• Always perform upright rather than supine radiographs to avoid underestimating malalignment 2, 3
• Document neurovascular examination thoroughly, particularly in high-energy trauma 3
• Recognize that open fractures and vascular compromise require immediate surgical referral 3

Special Considerations for Post-Stroke Hemiplegic Shoulder

• Patient and family education on range of motion and positioning is essential for pain management 2
• Active, active-assisted, or passive range of motion exercises should be used to prevent Complex Regional Pain Syndrome 1
• Suprascapular nerve blocks may reduce hemiplegic shoulder pain for up to 12 weeks 2