What is the treatment for shoulder pain when reaching behind?

Treatment for Shoulder Pain When Reaching Behind

Start with conservative management including physical therapy focused on range of motion exercises (especially external rotation and abduction), NSAIDs for pain control, and consider corticosteroid injections if symptoms persist beyond 4-6 weeks. 1, 2

Initial Diagnostic Approach

The pain you describe when reaching behind typically indicates rotator cuff pathology, posterior capsule tightness, or internal impingement. Before initiating treatment, obtain standard shoulder radiographs (AP views in internal/external rotation plus axillary or scapular-Y view) to rule out fracture, dislocation, or glenohumeral arthritis 3. Radiographs should be performed upright as malalignment can be missed on supine films 3.

First-Line Conservative Treatment (0-6 Weeks)

Pain Management

• Use acetaminophen or ibuprofen as first-line analgesics to enable participation in physical therapy 1, 4
• NSAIDs serve dual purpose: pain reduction and inflammation control 4

Physical Therapy Protocol

• Begin with gentle passive and active-assisted range of motion exercises, specifically targeting external rotation and abduction deficits 1
• Progress exercises gradually while monitoring pain response—therapy is more effective for motion-related pain than rest pain 4
• Incorporate rotator cuff strengthening exercises to protect the glenohumeral joint and restore scapular mechanics 1, 4
• Position the arm within the patient's visual field during exercises for better motor control 1

Second-Line Interventions (4-12 Weeks)

If conservative measures fail after 4-6 weeks:

Corticosteroid Injections

• Consider glenohumeral or subacromial corticosteroid injection for persistent pain 3, 4
• Injections provide superior short-term pain reduction compared to standard care alone 3
• Use ultrasound guidance to verify joint pathology before injection for optimal outcomes 3
• Start with 30-50 mg oral corticosteroids for 3-5 days if injection not immediately available, then taper over 1-2 weeks 1

Botulinum Toxin (If Spasticity Present)

• Inject botulinum toxin into subscapularis and pectoralis major muscles if examination reveals spasticity contributing to pain 3, 1
• This is particularly effective when pain is associated with restricted joint mobility from muscle hypertonicity 3

Advanced Interventions (Beyond 12 Weeks)

Neuromuscular Electrical Stimulation

• Consider surface or intramuscular NMES as adjunctive therapy, though compliance can be variable 3, 1
• Intramuscular NMES (6 hours/day for 6 weeks) shows better efficacy than surface stimulation 3

Suprascapular Nerve Block

• Perform suprascapular nerve block if pain has both nociceptive and neuropathic components 3
• Provides pain relief for up to 12 weeks and is as effective as glenohumeral steroid injections 3

Neuropathic Pain Management

• Prescribe neuromodulating medications (gabapentin, pregabalin, or tricyclic antidepressants) if clinical signs suggest neuropathic pain: sensory changes in shoulder region, allodynia, or hyperpathia 3, 1

Surgical Referral Criteria

Refer to orthopedic surgery if conservative treatment fails after 3-6 months 5, 6. Surgery requires clear structural diagnosis from advanced imaging (MRI preferred for soft tissue evaluation) 3. Note that traumatic massive rotator cuff tears may require expedited surgical timeline for optimal functional outcomes 3.

Critical Pitfalls to Avoid

• Do not rely solely on AP radiographs—axillary or scapular-Y views are essential as glenohumeral dislocations can be missed on AP views alone 3
• Do not inject corticosteroids without confirming underlying pathology, as efficacy is significantly better when specific joint pathology is verified by ultrasound 3
• Do not delay treatment—shoulder pain can inhibit rehabilitation, contribute to depression and insomnia, and reduce quality of life 1
• Avoid excessive rest—early range of motion exercises prevent complex regional pain syndrome and frozen shoulder 1

Expected Outcomes

Patients with chronic shoulder pain can expect significant decreases in pain and improvements in function with conservative treatment, regardless of whether stiffness accompanies the pain 2. Long-term outcome is not predicted by hand dominance, clinical history duration, or initial severity 2.