What is the best treatment for shoulder pain and tenderness?

Treatment of Shoulder Pain and Tenderness

For shoulder pain and tenderness, begin with analgesics (acetaminophen or ibuprofen if no contraindications) combined with gentle stretching and mobilization exercises focusing on external rotation and abduction, progressing active range of motion gradually while strengthening the shoulder girdle muscles. 1, 2

Initial Assessment

Evaluate the painful shoulder systematically to guide treatment:

• Assess muscle tone, strength, soft tissue length changes, joint alignment of the shoulder girdle, pain levels, and orthopedic changes 1, 2
• Test for regional sensory changes, allodynia, or hyperpathia to identify neuropathic pain components 1
• Identify any subluxation and evaluate spasticity 1
• Consider ultrasound as a diagnostic tool to detect soft tissue injuries 1, 2

First-Line Treatment Approach

Pharmacological Management

• Start with analgesics such as acetaminophen or ibuprofen if no contraindications exist 1, 2, 3
• Consider topical NSAIDs as first pharmacological treatment for mild to moderate pain 3
• Naproxen (375-750 mg twice daily) reduces joint pain and tenderness while increasing range of motion, with onset of pain relief within 1 hour and effects lasting up to 12 hours 4

Exercise Therapy

• Perform gentle stretching and mobilization techniques, specifically targeting increased external rotation and abduction 1, 2, 3
• Use active, active-assisted, or passive range of motion exercises, placing the upper limb in various appropriate and safe positions within the patient's visual field 2, 3
• Increase active range of motion gradually while simultaneously restoring alignment and strengthening weak shoulder girdle muscles 1, 2, 3
• Therapeutic exercise demonstrates positive effects on pain and function superior to other interventions 5

Positioning and Support

• Consider positioning and use of supportive devices for shoulder subluxation 1
• Evaluate need for adaptive devices on an individual basis, with periodic reassessment to determine if equipment can be discontinued 1

Second-Line Interventions

For Spasticity-Related Pain

• Inject botulinum toxin into the subscapularis and pectoralis muscles when pain is thought to be related to spasticity 1, 2, 3
• Botulinum toxin injection is useful to reduce severe hypertonicity in shoulder muscles 1

For Subacromial Pathology

• Use subacromial corticosteroid injections when pain is related to injury or inflammation of the subacromial region (rotator cuff or bursa) 1, 3
• Short-term pain reduction is superior with corticosteroid injection compared to standard care, though long-term benefits are not verified 1

For Neuropathic Pain

• Trial neuromodulating pain medications for patients with clinical signs of neuropathic pain (sensory changes, allodynia, hyperpathia) 1

Adjunctive Therapies

• Consider neuromuscular electrical stimulation (NMES), either surface or intramuscular, for shoulder pain 1, 2
• Functional dynamic orthoses may facilitate repetitive task-specific training 1, 2
• Repetitive transcranial magnetic stimulation (rTMS) and transcranial direct current stimulation (tDCS) may be considered as adjuncts to upper extremity therapy 1, 2

Important Clinical Considerations

Common Pitfalls to Avoid

• Avoid overhead pulleys, which encourage uncontrolled abduction and may increase risk of developing shoulder pain 3
• Do not combine naproxen with aspirin, as aspirin increases naproxen excretion rate and the combination may result in higher frequency of adverse events 4

Impact on Recovery

• Shoulder pain can delay rehabilitation and functional recovery by masking motor function improvement or inhibiting participation in rehabilitation activities 1, 2, 3
• Untreated shoulder pain may contribute to depression, sleeplessness, and reduced quality of life 1, 2, 3

Patient Education

• Provide patient and family education on range of motion exercises, positioning, and shoulder care, particularly before discharge or care transitions 1

When Conservative Treatment Fails

• If conservative strategies fail after 3-6 months, surgical options may be considered, though the proportion requiring surgery is small 6
• Surgery requires clear diagnosis and structural information from imaging 6