What treatment options are available for chronic bilateral shoulder joint pain exacerbated by overhead movements and full rotation with no known injury?

Management of Chronic Bilateral Shoulder Pain Without Known Trauma

Begin with standard shoulder radiographs (AP views in internal and external rotation plus axillary or scapula-Y view) to rule out structural pathology, followed immediately by a structured 6-12 week conservative management program combining NSAIDs, activity modification, and progressive physical therapy before considering advanced imaging or surgical consultation. 1

Initial Diagnostic Workup

Obtain standard three-view shoulder radiographs bilaterally to exclude fractures, dislocations, arthritis, or bony abnormalities that could explain your chronic symptoms. 2 The series must include:

• Anteroposterior views in both internal and external rotation
• Axillary or scapula-Y view (critical because certain pathologies are missed on AP views alone) 2

Do not proceed to MRI initially unless conservative management fails after 3 months or there is clinical suspicion for massive rotator cuff tear requiring urgent surgical evaluation. 1 CT is inferior to MRI for soft-tissue diagnosis and should not be used for non-traumatic shoulder pain evaluation. 2

First-Line Conservative Management (Weeks 1-12)

Pain Control

• Start ibuprofen 400 mg every 4-6 hours as needed (maximum 3200 mg daily, though most patients respond adequately to 1200-2400 mg daily). 3 Take with food to minimize gastrointestinal side effects. 3
• Apply ice during acute flare-ups and heat for chronic stiffness. 1
• Consider subacromial corticosteroid injection if pain significantly limits participation in physical therapy, particularly if rotator cuff or bursal inflammation is suspected. 1 However, evidence for injections in rotator cuff pathology is inconclusive. 2

Activity Modification

• Completely avoid overhead movements and full rotation activities that reproduce your pain until acute symptoms resolve. 1 This is non-negotiable for healing.
• Modify work, sports, and daily activities to stay below the pain threshold. 4

Physical Therapy Protocol (Critical Component)

Phase 1: Gentle Mobilization (Weeks 1-4)

• Begin with gentle stretching focusing specifically on increasing external rotation and abduction range of motion. 1
• Use active-assisted or passive range of motion exercises performed within pain-free ranges. 1
• CRITICAL PITFALL TO AVOID: Do NOT use overhead pulleys as they encourage uncontrolled abduction and can worsen underlying pathology. 1

Phase 2: Progressive Strengthening (Weeks 4-8)

• Strengthen rotator cuff muscles (supraspinatus, infraspinatus, teres minor, subscapularis) with resistance bands and light weights. 1, 4
• Strengthen scapular stabilizers (serratus anterior, rhomboids, trapezius) to restore proper shoulder mechanics. 1
• Re-establish proper alignment and mechanics of the shoulder girdle and spine. 1

Phase 3: Dynamic Stabilization (Weeks 8-12)

• Progress to dynamic stabilization exercises that challenge shoulder control during movement. 1
• Incorporate core and lumbopelvic strengthening as part of the kinetic chain. 1
• Gradually return to functional activities as pain allows. 1

When to Escalate Care

If symptoms persist or worsen after 3 months of appropriate conservative management, obtain MRI bilaterally to evaluate for rotator cuff tears, labral pathology (including SLAP tears), or other soft-tissue injuries requiring surgical intervention. 1 Given your bilateral presentation and young age (symptoms since 8th grade), consider evaluation for:

• Multidirectional instability
• Labral pathology
• Rotator cuff pathology (though less common in younger patients without trauma)
• Glenohumeral or acromioclavicular arthritis 5, 4

Refer to orthopedic surgery if:

• Conservative management fails after 6-12 weeks of directed treatment 5
• MRI reveals full-thickness rotator cuff tears with significant symptoms 2
• Recurrent instability or dislocation occurs 6
• Structural abnormalities requiring surgical correction are identified 7

Expected Timeline and Return to Activity

• Most patients respond to conservative management within 1-3 months. 1
• Return to overhead activities and full rotation only after achieving pain-free motion and adequate strength. 1
• Common pitfall: Returning to aggravating activities too soon before adequate healing leads to chronic pain and dysfunction. 1

Special Considerations for Bilateral Presentation

Your bilateral presentation without known injury suggests either:

• Overuse/repetitive strain pattern
• Underlying anatomical variant or instability
• Systemic condition affecting both shoulders

The bilateral nature makes conservative management even more important as the first-line approach, as surgery on both shoulders would significantly impact function during recovery. 2 The American Academy of Orthopaedic Surgeons emphasizes that surgery should not be performed for asymptomatic pathology, and even symptomatic chronic tears warrant a trial of conservative management first. 2