What is the recommended treatment for overhead shoulder pain?

Treatment of Overhead Shoulder Pain

Start with range of motion exercises focusing on external rotation and abduction combined with NSAIDs, while strictly avoiding overhead pulley exercises that can worsen pain. 1

Initial Assessment Priorities

Evaluate the following specific parameters to guide treatment:

• Muscle tone, strength, and soft tissue integrity 1
• Joint alignment of the shoulder girdle and pain levels 1
• Potential causes: adhesive capsulitis, rotator cuff pathology, bursitis/tendonitis, or complex regional pain syndrome 1
• Radiographic evaluation should include anteroposterior views in internal and external rotation plus an axillary or scapula-Y view 1

First-Line Treatment Algorithm

Exercise Therapy (Primary Intervention)

• Begin range of motion exercises immediately, emphasizing external rotation and abduction to prevent frozen shoulder and shoulder-hand pain syndrome 1, 2
• Gradually increase active range of motion while simultaneously restoring alignment and strengthening weak shoulder girdle muscles 1, 2
• Critical pitfall to avoid: Never use overhead pulley exercises as they encourage uncontrolled abduction and increase pain 1, 3
• Exercise is the most effective intervention for subacromial shoulder pain based on current evidence 4

Pharmacological Management

• NSAIDs (ibuprofen or naproxen) as first-line medication for pain relief 1, 5, 6
• For naproxen: start with 500 mg twice daily, adjustable based on response; use lowest effective dose for shortest duration 5
• Acetaminophen can be used if NSAIDs are contraindicated 2, 3
• Consider lower doses in elderly patients due to increased unbound plasma fraction 5

Adjunctive Modalities

• Ice, heat, and soft tissue massage to complement exercise therapy 1

Second-Line Interventions (When First-Line Fails)

Corticosteroid Injections

• Subacromial corticosteroid injections when pain relates to rotator cuff or bursa inflammation 1, 3
• Intra-articular corticosteroid injections for patients with inflammation or subacromial region injury 1, 3

Additional Interventions

• Shoulder strapping or slings for support, particularly with subluxation present 1
• Neuromuscular electrical stimulation (NMES) may be considered as adjunctive therapy 1, 2

Advanced Interventions (Refractory Cases)

For Spasticity-Related Pain

• Botulinum toxin injections into subscapularis and pectoralis muscles when shoulder pain relates to spasticity 1, 2, 3

For Persistent Pain

• Suprascapular nerve blocks as adjunctive treatment for persistent shoulder pain 1

Special Clinical Scenarios

Complex Regional Pain Syndrome Prevention

• Active, active-assisted, or passive range of motion exercises must be performed to prevent CRPS development 2, 3
• If CRPS develops: oral corticosteroids 30-50 mg daily for 3-5 days, then taper over 1-2 weeks to reduce swelling and pain 2, 3
• Diagnosis requires: pain/tenderness of metacarpophalangeal and proximal interphalangeal joints, dorsal finger edema, trophic skin changes, hyperesthesia, and limited range of motion 2, 3

Critical Pitfalls and Caveats

• Untreated shoulder pain delays rehabilitation and can mask motor function improvement 2, 3
• Overhead pulley exercises are contraindicated as they encourage uncontrolled abduction and worsen pain 1, 3
• Shoulder pain contributes to depression, insomnia, and reduced quality of life if inadequately treated 2, 3
• NSAIDs should be used at the lowest effective dose for the shortest duration due to cardiovascular and gastrointestinal risks 5
• Avoid NSAIDs in patients with moderate to severe renal impairment (creatinine clearance <30 mL/min) 5