What is the recommended treatment for several months of shoulder pain?

Treatment for Several Months of Shoulder Pain

For chronic shoulder pain lasting several months, begin with a structured physical therapy program focused on gentle stretching and range of motion exercises (particularly external rotation and abduction), combined with NSAIDs like ibuprofen for pain relief, and escalate to corticosteroid injections or advanced interventions only if conservative measures fail after 6-12 weeks. 1, 2

Initial Assessment and Diagnosis

Evaluate the shoulder systematically for:

• Muscle tone, strength, and soft tissue changes 1
• Joint alignment of the shoulder girdle 1
• Pain levels and orthopedic changes 1
• Signs of instability (pain during movement, decreased velocity/precision, clacking sensations) 3
• Potential causes including adhesive capsulitis, rotator cuff pathology, bursitis/tendonitis, or complex regional pain syndrome 1

Obtain radiographic evaluation with anteroposterior views in internal and external rotation plus an axillary or scapula-Y view to assess alignment and rule out fractures. 1 Ultrasound can be used as a diagnostic tool for soft tissue injuries. 4

First-Line Conservative Treatment (Weeks 0-6)

Start with multimodal conservative therapy combining:

• Range of motion exercises focusing specifically on external rotation and abduction to prevent frozen shoulder 1, 2

  • Increase active range of motion gradually while restoring alignment and strengthening weak shoulder girdle muscles 1, 3
  • Avoid overhead pulley exercises as they encourage uncontrolled abduction and may worsen pain 1

• NSAIDs for pain control such as ibuprofen if no contraindications exist 1, 5, 6

  • Use at the lowest effective dose for the shortest duration needed 5
  • Be aware of GI bleeding risk, especially with prolonged use, corticosteroids, anticoagulants, alcohol, or in elderly patients 5

• Physical modalities including ice, heat, and soft tissue massage 1

• Low-level laser therapy which has evidence for shoulder pain of any duration 2

Second-Line Interventions (Weeks 6-12)

If conservative measures provide insufficient relief after 6 weeks:

• Subacromial or intra-articular corticosteroid injections when pain is related to inflammation of the subacromial region (rotator cuff or bursa) 1, 7, 8

  • Both anterior and posterior injection routes are equally effective for subacromial impingement 8
  • Provides pain reduction and functional improvement for up to 6 months 8

• Shoulder strapping or slings for support, particularly if subluxation is present 1

• Neuromuscular electrical stimulation (NMES) may be considered as an adjunctive treatment 4, 1

For chronic shoulder pain exceeding 3 months specifically:

• Stretching and strengthening exercises become more important 2
• Laser acupuncture may be considered 2
• General physician care with information, advice, and pharmacological pain management 2

Advanced Interventions (After 12 Weeks)

For persistent pain despite adequate conservative treatment:

• Botulinum toxin injections into subscapularis and pectoralis muscles if pain is related to spasticity 1, 3

• Suprascapular nerve blocks as an adjunctive treatment for refractory shoulder pain 4, 1

• Referral to orthopedic surgery for patients who fail 6-12 weeks of directed conservative treatment 9, 7

Special Considerations

For Complex Regional Pain Syndrome (CRPS):

• Diagnose based on pain/tenderness of metacarpophalangeal and proximal interphalangeal joints, edema over dorsum of fingers, trophic skin changes, hyperesthesia, and limited range of motion 1, 3
• Treat with oral corticosteroids 30-50 mg daily for 3-5 days, then taper over 1-2 weeks 1, 3

Patient education on proper positioning and range of motion exercises is essential throughout treatment, particularly before any transitions in care. 4, 1

Common Pitfalls to Avoid

• Do not use overhead pulley exercises—they worsen pain and encourage poor mechanics 1
• Do not continue ineffective conservative treatment beyond 12 weeks without specialist referral 7
• Reassess at each visit for worsening symptoms, new physical/psychological symptoms, or satisfactory recovery 2
• Be cautious with prolonged NSAID use due to cardiovascular and GI risks 5