What are the guidelines for managing shoulder pain?

Management of Shoulder Pain

Begin with patient education on proper positioning and range of motion exercises as first-line therapy, followed by analgesics (acetaminophen or ibuprofen) if no contraindications exist, then escalate to targeted interventions based on the underlying pathology. 1

Initial Conservative Management

First-line approach:

• Educate patients on proper shoulder positioning and initiate range of motion exercises (passive and active-assisted), focusing specifically on external rotation and abduction to prevent frozen shoulder and shoulder-hand pain syndrome 2, 1
• Administer acetaminophen (up to 6 caplets per day, taken every 8 hours) or ibuprofen for pain control if no contraindications exist 1, 3
• Implement gentle mobilization and stretching techniques, emphasizing external rotation and abduction movements 2, 4

Critical caveat: Avoid overhead pulley exercises, as they encourage uncontrolled abduction and can worsen shoulder pathology 2, 1

Escalation Based on Specific Pathology

For Spasticity-Related Shoulder Pain (Hemiplegic Shoulder)

• Botulinum toxin injections into subscapular and pectoral muscles are recommended for severe hypertonicity and associated pain 1, 4
• Consider suprascapular nerve blocks as an adjunctive treatment, which can reduce pain for up to 12 weeks 1
• Apply shoulder strapping to prevent trauma and provide support 2
• Use functional electrical stimulation (FES) to improve shoulder lateral rotation and reduce pain 2

For Inflammatory/Structural Shoulder Pain

• Administer subacromial corticosteroid injections when inflammation of the subacromial region is suspected, ideally verified by ultrasonography 1, 4
• Note that intra-articular triamcinolone injections have significant effects on pain, though ROM improvements may not reach statistical significance 2
• Important limitation: Corticosteroid injections provide only short-term relief (weeks to months), and long-term pain reduction has not been verified 1

For Complex Regional Pain Syndrome (Shoulder-Hand Syndrome)

• Diagnose based on clinical findings: pain and tenderness of metacarpophalangeal and proximal interphalangeal joints, dorsal finger edema, trophic skin changes, hyperesthesia, and limited ROM 4
• Initiate early treatment with oral corticosteroids: 30-50 mg daily for 3-5 days, then taper over 1-2 weeks to reduce swelling and pain 4
• Maintain active, active-assisted, or passive ROM exercises throughout treatment 4

Adjunctive Interventions

Physical modalities to consider:

• Ice, heat, and soft tissue massage for symptomatic relief 2
• Neuromuscular electrical stimulation (NMES) for pain management 4
• Strengthening exercises for rotator cuff and scapular stabilizers once acute pain is controlled 2

Advanced neuromodulation options:

• Repetitive transcranial magnetic stimulation (rTMS) or transcranial direct current stimulation (tDCS) as adjuncts to upper extremity therapy 4
• These may be more appropriate than nerve blocks for patients with central pain components 1

Staff Education and Prevention

• Train all healthcare staff on proper handling techniques to prevent trauma to the hemiplegic or painful shoulder 2
• Implement positioning protocols to maintain proper joint alignment 2
• Use supportive devices appropriately to accompany any interventional treatments 1

Key Clinical Pitfalls

Avoid these common errors:

• Do not use overhead pulleys for rehabilitation, as they promote uncontrolled abduction and can cause further injury 2, 1
• Do not rely solely on corticosteroid injections for long-term management, as their benefits are temporary 1
• Do not delay treatment of shoulder pain, as it can mask motor function improvement, inhibit rehabilitation (limiting cane or wheelchair use), and contribute to depression, insomnia, and reduced quality of life 2, 4

When to Refer

• Patients who fail 3-6 months of appropriate conservative treatment should be referred to orthopedic surgery 5, 6
• Urgent referral is warranted for acute traumatic injuries or "red flag" diagnoses 5
• Consider multidisciplinary referral including physiotherapy, occupational therapy, and psychology as needed to optimize outcomes 5