What are the treatment options for shoulder and elbow pain?

Treatment of Shoulder and Elbow Pain

For shoulder pain, begin with conservative management including rest, activity modification, physical therapy focusing on range of motion (especially external rotation and abduction), and analgesics, with corticosteroid injections reserved for refractory cases; for elbow pain, start with radiographs followed by conservative treatment including rest, physical therapy, and analgesics, with surgery considered only for severe or refractory cases. 1

Initial Diagnostic Approach

Elbow Pain

• Obtain plain radiographs as the initial imaging study for chronic elbow pain to identify intra-articular bodies, heterotopic ossification, osteochondral lesions, soft tissue calcification, occult fractures, or osteoarthritis 1
• Consider electromyography if nerve symptoms (numbness, tingling) are present 1
• Advanced imaging (MRI, CT) has limited evidence as initial studies and should be reserved for cases where radiographs are normal or nonspecific but clinical suspicion for intra-articular pathology remains high 1

Shoulder Pain

• Evaluate muscle tone, strength, soft tissue changes, joint alignment of the shoulder girdle, pain levels, and orthopedic changes 2
• Look specifically for instability signs: pain during movement, decreased velocity or precision of movement, and clicking/displacement sensations 2
• Ultrasound can detect soft tissue injuries of the shoulder 2

Conservative Treatment Protocol

Elbow Pain Management

• Rest and activity modification as first-line interventions 1
• Analgesics (acetaminophen or ibuprofen if no contraindications) for pain relief 2
• Physical therapy including stretching and strengthening exercises 1
• Corticosteroid injections for epicondylalgia and osteoarthritis that fail conservative measures 1

Shoulder Pain Management

Range of Motion Exercises

• Perform passive and active-assisted range of motion exercises with the upper limb positioned safely within the patient's visual field 2
• Focus gentle mobilization and stretching on increasing external rotation and abduction to prevent frozen shoulder and shoulder-hand-pain syndrome 1, 2
• Progress to active range of motion gradually as alignment improves and weak shoulder girdle muscles strengthen 2
• Standing on a tilt table for 30 minutes daily is useful for preventing contracture 1
• Position the hemiplegic shoulder in maximum external rotation for 30 minutes daily (either sitting or in bed) to prevent shoulder contracture 1

Pain Management Interventions

• Analgesics (acetaminophen or ibuprofen) if no contraindications exist 2
• Intra-articular corticosteroid injections (triamcinolone) into the glenohumeral joint or subacromial space for refractory pain, particularly when shoulder joint pathology is verified by imaging 1
• Ice, heat, and soft tissue massage as adjunctive modalities 1
• Botulinum toxin injections into subscapularis and pectoral muscles for hemiplegic shoulder pain related to spasticity 2

Electrical Stimulation

• Functional electrical stimulation (FES) to improve shoulder lateral rotation and reduce pain 1
• Neuromuscular electrical stimulation (NMES) may be considered for shoulder pain, though evidence is mixed 1, 2

Positioning and Support Devices

• Shoulder strapping may be considered, though evidence for efficacy is mixed; some studies show trends toward less pain at 6 weeks and better upper limb function 1
• Avoid overhead pulley exercises as they encourage uncontrolled abduction and have the highest incidence of developing hemiplegic shoulder pain 1
• For wheelchair users, lap trays and arm troughs are useful positioning devices to reduce shoulder pain and subluxation 1
• Slings may be considered during ambulation training to protect the shoulder from traction injury 1

Splinting Considerations

• Resting hand/wrist splints combined with regular stretching and spasticity management may be considered for patients lacking active hand movement 1
• Serial casting or static adjustable splints may be considered to reduce mild to moderate elbow and wrist contractures 1
• Resting ankle splints used at night and during assisted standing may prevent ankle contracture in the hemiplegic limb 1

Surgical Indications

Elbow

• Surgery is indicated for severe or refractory epicondylalgia, collateral ligament injury, biceps injury, cubital tunnel syndrome, or osteochondral abnormalities 1
• Conservative treatment should be attempted for 3-6 months before considering surgery 3

Shoulder

• Surgical release of brachialis, brachioradialis, and biceps muscles may be considered for substantial elbow contractures with associated pain 1
• Surgery is appropriate for rotator cuff tears in healthy surgical candidates after conservative measures fail 4
• For patients who are not surgical candidates or refuse surgery, peripheral nerve stimulation targeting suprascapular and axillary nerves can be considered 4

Critical Pitfalls to Avoid

• Never perform aggressive passive range-of-motion exercises on the complex shoulder joint without proper technique, as this can cause more harm than good 1
• Avoid overhead pulley exercises for shoulder rehabilitation 1
• Do not continue physical therapy indefinitely without clear functional improvement; standard post-operative rotator cuff repair typically requires 12-16 weeks of skilled therapy 5
• Ensure proper education of patients, staff, and caregivers about protecting the hemiplegic limb from trauma and injuries to reduce the frequency of shoulder-hand syndrome 1

Special Considerations

• Shoulder pain can delay rehabilitation and functional recuperation, mask improvement of motor function, or inhibit rehabilitation by limiting use of assistive devices 1, 2
• Hemiplegic shoulder pain can contribute to depression, insomnia, and reduced quality of life 2
• For adhesive capsulitis (frozen shoulder), therapeutic exercises and mobilization are strongly recommended for reducing pain, improving ROM and function in stages 2 and 3 6
• Low-level laser therapy is strongly suggested for pain relief in adhesive capsulitis but not recommended for improving ROM 6