What are the treatment options for shoulder pain?

Treatment of Shoulder Pain

Start with patient education on proper positioning and range of motion exercises, followed by gentle stretching focusing on external rotation and abduction, combined with NSAIDs for pain relief. 1, 2

Initial Assessment and Diagnosis

Before initiating treatment, perform a targeted clinical evaluation:

• Assess tone, strength, soft tissue length changes, joint alignment of the shoulder girdle, pain levels, and orthopedic abnormalities 1, 2
• Identify the underlying cause: adhesive capsulitis, rotator cuff pathology, bursitis/tendonitis, complex regional pain syndrome, traction/compression neuropathy, shoulder trauma, or heterotrophic ossification 1, 2
• Evaluate for spasticity if post-stroke or neurological etiology is suspected 1
• Test for regional sensory changes, allodynia, or hyperpathia to identify neuropathic pain components 1
• Consider ultrasound imaging to identify soft tissue injuries 1

First-Line Treatment Approach

Range of Motion and Physical Therapy

• Implement gentle stretching and mobilization techniques emphasizing external rotation and abduction to prevent frozen shoulder 1, 2
• Progress active range of motion gradually while simultaneously restoring joint alignment and strengthening weak shoulder girdle muscles 1, 2
• Avoid overhead pulley exercises as they encourage uncontrolled abduction and may worsen pain 1, 2

Pharmacological Management

• Prescribe NSAIDs (such as ibuprofen) or acetaminophen for initial pain control 1, 2
• Apply modalities including ice, heat, and soft tissue massage as adjunctive pain relief 1, 2

Positioning and Support

• Educate patients and families on proper positioning techniques and shoulder care, particularly before discharge or care transitions 1
• Consider shoulder strapping or slings for support, especially when subluxation is present 1, 2
• Note that evidence for positioning and strapping is conflicting—some studies show benefit while others show no significant difference in pain or function 1

Second-Line Interventions (If First-Line Fails After 6-12 Weeks)

Corticosteroid Injections

• Administer subacromial corticosteroid injections when pain relates to rotator cuff or bursa inflammation 1, 2
• Use intra-articular glenohumeral injections (triamcinolone) for joint-related inflammation 1, 2
• Evidence is mixed: some studies show significant short-term pain reduction, while others show no benefit 1
• Best results occur when ultrasound confirms specific shoulder joint pathology before injection 1

Neuromuscular Electrical Stimulation (NMES)

• Consider NMES (surface or intramuscular) as an adjunctive therapy, particularly for improving pain-free lateral rotation 1, 2
• Surface NMES has variable compliance and tolerability; intramuscular NMES (6 hours/day over 6 weeks) shows better efficacy in some studies 1
• Most effective in acute settings (<6 months) when combined with regular therapy 1

Third-Line Interventions for Refractory Pain

Spasticity-Related Pain

• Inject botulinum toxin into subscapularis and pectoralis muscles when shoulder pain is clearly related to spasticity 1, 2
• Evidence shows mixed results: effective for spasticity-related mobility restrictions but insufficient for general shoulder pain 1

Nerve Blocks

• Consider suprascapular nerve blocks as adjunctive treatment for persistent shoulder pain 1, 2
• Blocks are superior to placebo and as effective as glenohumeral steroid injections for up to 12 weeks 1
• Effective for both nociceptive and neuropathic pain mechanisms 1

Neuropathic Pain Component

• Trial neuromodulating pain medications (such as amitriptyline or lamotrigine) when clinical signs suggest neuropathic pain with sensory changes, allodynia, or hyperpathia 1

Surgical Considerations

• Consider surgical tenotomy of pectoralis major, latissimus dorsi, teres major, or subscapularis for severe cases with marked restrictions in shoulder range of motion 1
• Surgery is generally reserved for patients who fail 3-6 months of conservative treatment 3

Special Considerations for Complex Regional Pain Syndrome (CRPS)

• Prevent CRPS with active, active-assisted, or passive range of motion exercises 1
• Diagnose based on pain/tenderness of metacarpophalangeal and proximal interphalangeal joints, edema over dorsum of fingers, trophic skin changes, hyperesthesia, and limited ROM 1
• Treat with early oral corticosteroids: 30-50 mg daily for 3-5 days, then taper over 1-2 weeks to reduce swelling and pain 1, 2

Critical Pitfalls to Avoid

• Never use overhead pulley exercises—they consistently worsen outcomes by encouraging uncontrolled abduction 1, 2
• Staff education to prevent trauma to the affected shoulder is essential, as trauma increases risk of shoulder-hand syndrome 1
• Do not rely solely on positioning protocols or strapping without other interventions—evidence shows no significant difference compared to no positioning 1
• Recognize that botulinum toxin is not a universal solution for shoulder pain—it specifically targets spasticity-related pain, not general shoulder pain 1