What are the treatment options for a crunching sound in the shoulder?

Crunching Sound in Left Shoulder

A crunching sound (crepitus) in the shoulder without pain typically requires no treatment, but if accompanied by pain or functional limitation, conservative management with NSAIDs, physical therapy focusing on rotator cuff strengthening and scapular stabilization, and activity modification should be initiated first. 1

Initial Diagnostic Approach

Obtain plain radiographs first with a minimum of three views: anteroposterior (AP), Grashey, and axillary or scapular Y projections to rule out structural abnormalities, arthritis, or calcifications that could cause mechanical symptoms. 1, 2

Key Clinical Features to Assess

• Age-based risk stratification: Patients under 35 years are more likely to have labral pathology or instability, while those 35 and older typically have rotator cuff disease or subacromial impingement. 1
• Pain characteristics: Night pain, pain with overhead activities, or weakness with external rotation/abduction suggests rotator cuff pathology. 1, 3
• Range of motion: Measure active and passive forward flexion, abduction, and external rotation using a goniometer to identify restrictions. 2
• Mechanical symptoms: Clicking, catching, or "dead arm" sensation suggests labral tears or instability. 1

Red Flags Requiring Urgent Evaluation

• Fever with joint effusion (septic arthritis)
• Acute neurologic deficits
• Progressive weakness
• Suspected cardiac or pulmonary pathology 1

Conservative Management Algorithm

First-line treatment for non-urgent crepitus with or without pain:

• NSAIDs: Ibuprofen 400-800 mg three to four times daily for pain control 1, 4
• Structured exercise program: Focus on rotator cuff strengthening, scapular stabilization, and postural training 5, 3
• Activity modification: Avoid repetitive overhead activities and positions that provoke symptoms 1, 3
• Positioning strategies: Proper shoulder positioning during rest and sleep to minimize stress on rotator cuff structures 5

Duration of conservative trial: 60% of patients with subacromial impingement achieve satisfactory results within 2 years of conservative management. 4

Advanced Imaging Indications

If symptoms persist after 6-12 weeks of conservative management or if clinical examination suggests structural pathology:

• MRI without contrast or ultrasound are equivalent first-line studies for suspected rotator cuff tears, with choice depending on local expertise. 1, 2
• MR arthrography is the reference standard for labral tears in subacute/chronic settings, particularly in patients under 35 years. 1, 2
• CT without contrast should be ordered if radiographs show fracture or when bone loss assessment is critical for instability. 1

Important Caveat

Approximately 10% of rotator cuff tears are asymptomatic, so imaging findings must be correlated with clinical presentation—do not treat images, treat patients. 2

Interventional Options After Failed Conservative Management

Consider these in stepwise fashion:

• Subacromial corticosteroid injections: Can be used when pain is thought to be related to subacromial bursa or rotator cuff inflammation, though evidence is limited. 5, 1
• Botulinum toxin injections: Into subscapularis and pectoralis muscles if spasticity is contributing to symptoms. 5
• Suprascapular nerve blocks: For refractory pain with sensory changes. 1

Surgical Referral Indications

Refer to orthopedic surgery when:

• Adequate conservative management (minimum 3-6 months) has failed
• Progressive neurological deficits develop
• Severe restrictions in range of motion with muscle contractures
• Full-thickness rotator cuff tears in appropriate surgical candidates
• Recurrent instability affecting quality of life 1, 4

Surgical Timing Consideration

Decompressive surgery is performed when symptoms persist despite conservative treatment, as long as rotator cuff continuity is preserved and there is pathological abnormality of the bursa. 4

Common Pitfalls to Avoid

• Do not perform aggressive passive range-of-motion exercises without proper technique, as this can cause more harm than good in the complex shoulder joint. 5
• Avoid overhead pulley exercises in patients with suspected rotator cuff pathology or impingement. 5
• Do not rely solely on imaging findings: Shoulder instability can mimic rotator cuff pathology, and asymptomatic pathology is common. 2
• Ultrasound is highly operator-dependent: Ensure local expertise is available before choosing this modality over MRI. 2